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Hospitals and doctors around the country are facing harassment and even death threats over the medical care they offer to transgender kids. In many cases, they have been the subject of posts by a Twitter account called Libs of TikTok, as well as stories in conservative media outlets casting gender-affirming care as child abuse and mutilation.

Which raises the question: where should social networks draw the line with accounts promoting narratives that spark harassment campaigns on their platforms and beyond?

Children's National Hospital in Washington, D.C. became the most recent target this week when Libs of TikTok posted an audio recording in which hospital staff appeared to say that gender-affirming hysterectomies had been performed on minors. The hospital said that claim was incorrect and that none of the people recorded deliver care to patients.

"The information in the recording is not accurate. We do not and have never performed gender-affirming hysterectomies for anyone under the age of 18," Children's National said in a statement to NPR. "The operator speaking provided wrong information."

The statement continued: "Since the spreading of misinformation on Twitter, we have been the target of a large volume of hostile and threatening phone calls and emails."

Childrens' hospitals in Boston, Seattle, Chicago, and Portland, Oregon, have also been targeted. Last week, Boston Children's Hospital warned it was receiving "a large volume of hostile internet activity, phone calls, and harassing emails including threats of violence toward our clinicians and staff" after false claims it performs genital surgeries on minors.

The U.S. Justice Department even weighed in, with the U.S. Attorney for Massachusetts calling the attacks "disturbing."

False claims, out-of-context videos

These false narratives about pediatric gender-affirming care are rooted in fundamental "misperceptions," said Dr. Angela Kade Goepferd, a pediatrician and director of the Gender Health Program at Children's Minnesota.

"People have misperceptions that we're doing surgery on young kids. People have misperceptions that we are changing kids from boys into girls at a very young age," they said.

They said care for transgender kids is wide-ranging, from efforts to help children socially transition to puberty-blocking medications, and is undertaken with the input of pediatric psychologists, clinical social workers, hormone experts and endocrinologists, as well as families. Gender-affirming surgeries are not a routine part of pediatric gender care, they said, and Children's Minnesota does not perform any such surgeries.

Some of the claims about Children's National, Boston Children's and other hospitals were pushed by the Libs of TikTok account, which regularly reposts videos and social media posts from LGBTQ people, teachers, schools and other institutions. The clips are sometimes taken out of context and framed to fuel outrage or ridicule of LGBTQ and anti-racist causes, in what the account owner has described as "exposés" of "the crazies."

For example, a short clip about gender-affirming hysterectomies from a video originally posted by Boston Children's that Libs of TikTok reposted makes no mention of patients' ages. But Libs of TikTok tweeted alongside the clip the false claim that the hospital offers the surgery "for young girls."

Libs of TikTok, run by a Brooklyn woman named Chaya Raichik, has 1.3 million followers on its biggest platform, Twitter. It's gained prominence and influence in right-wing circles over the last year as conservatives increasingly try to use anti-LGBTQ sentiment to gain support.

NPR reached out to Raichik for this story. She initially responded and agreed to an interview, but did not respond to a follow-up message. Raichik frequently condemns criticism of her online activities as efforts to "cancel and silence" her. She has said that she has also been targeted with death threats.

Platforms struggle with harassment networks

Twitter and Facebook prohibit bullying and harassment, coordinated mass attacks, and incitement to violence. Both companies ban the use of the word "groomer" as a smear against LGBTQ people under their rules against hate speech.

The platforms have taken down some of the threats against the hospitals. But it's less clear how much accountability the companies can or will put on accounts that draw attention to the targets that end up getting harassed.

Twitter has previously temporarily suspended Libs of TikTok for breaking its rules. The company declined to comment on the account. Following Boston Children's Hospital's reported threats, Libs of TikTok said it had been permanently suspended by Facebook for violating the platform's community standards. But that was quickly reversed, and the account returned to posting on Facebook, saying the social network said that was an error. Facebook declined to comment on the suspension.

Libs of TikTok appears to have evaded outright bans by coming right up to the edge of the platforms' rules but not breaking them. The account does not explicitly encourage followers to threaten anyone, and typically uses its target's own words, sometimes stripped of context, to imply wrongdoing.

But while its individual posts may stick to the letter of the platforms' rules, their cumulative effect is what worries researchers like Joan Donovan, who studies online extremism, media manipulation and disinformation at Harvard's Shorenstein Center on Media, Politics and Public Policy.

"We've reached this phase in social media where people know what to do when an account like Libs of TikTok calls out another account or a person or institution," she said. Call-outs can spark harassment campaigns known as "brigading," where commenters pile on a common target.

In the case of the children's hospitals, "the threats have moved from insulting people or targeted accounts online into more direct threats," Donovan said. "The online threat escalates very quickly into offline violence when we start to see these patterns of attack."

For social networks to deal with what Donovan calls "networked incitement," she says effectively tracking those threats means looking beyond single posts on specific platforms.

"The precipitating comments may not be that incendiary, but if that creates a pattern of attack that is recognizable, which it is with an account like Libs of TikTok, then these companies are well within their jurisdiction to warn and then ban the account."

Right-wing groups target LGBTQ events, education and healthcare

Pediatricians and children's hospitals are just the latest targets of right-wing outrage, in a new iteration of decades-old smears of gay, lesbian and transgender people as pedophiles or "groomers."

"The Libs of TikTok account has been a major actor in driving a lot of the harassment campaigns that we've seen over the past year," said Ari Drennen, LGBTQ program director at Media Matters for America, the liberal advocacy group.

In some cases, events and figures publicized by Libs of TikTok have been targeted offline by far-right extremists known for brawling.

On a single day this summer, for example, men with ties to the white nationalist group Patriot Front were arrested outside a Pride event in Coeur D'Alene, Idaho, and alleged members of the far-right Proud Boys crashed a drag queen story hour at a library in San Lorenzo, Calif. Libs of TikTok had tweeted about both events, although there's no conclusive link between the posts and the extremist groups' activities.

As the Washington Post reported in April, the account's subjects and posts are regularly featured and promoted by other conservative influencers and media figures, including podcaster Joe Rogan. Raichik has appeared on Tucker Carlson's prime time Fox News show.

The escalating stigmatization of transgender medical care has doctors worried.

"This is a developmentally appropriate, team-based approach that allows kids time to figure out their identities," said Dr. Goepferd of Children's Minnesota.

Threats to hospitals ripple out, affecting not only hospital staff but also patients and families seeking all kinds of care, as well as longer-term research needed in the field. "I worry that this type of false narrative would make research institutions or funders nervous to fund more research into finding out what is the best possible care we could be providing right now," Goepferd said.

"The fact that somewhere the message has gotten through that it's okay to attack physicians, pediatricians, children's hospitals in this way is just a really disturbing societal trend," they said.

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