Regulatory posture: the 38 CFR 17.38(c)(4) "gender alterations" exclusion is left intact and no VA rulemaking is pending

Records what became of the only rulemaking track ever opened on the regulatory exclusion of transition-related surgery from VA's medical benefits package. RIN 2900-AP69, "Removing Gender Alterations Restriction From the Medical Benefits Package," appeared in the Spring 2016 and Fall 2016 Unified Agendas at the proposed-rule stage; no NPRM was ever issued and the item is listed in the Fall 2016 agenda as a completed action, withdrawn 08/17/2016, with VA citing the availability of appropriated funding. VA separately published a Federal Register notice on July 9, 2018 soliciting public comment on the May 9, 2016 petition for rulemaking to remove the exclusion, stating it would "consider the comments received, and then determine whether to propose a regulatory change"; no responsive decision document followed. In the current (2026) Unified Agenda, VA lists no regulatory action whose title concerns gender, sex, transgender care, or the medical benefits package. The practical consequence is that the exclusion at 38 CFR 17.38(c)(4) remains in force by inertia, and every 2025-2026 VA action narrowing transgender veterans' care — the Directive 1341 rescission, the hormone-initiation bar, the June 2026 program elimination — was taken sub-regulatorily, outside notice-and-comment, and therefore without a rulemaking record, comment docket, or reasoned-explanation obligation of the kind the APA imposes on rules.