gender reassignment bitlife

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BitLife How-to Get the Cunning Ribbon Guide

Our BitLife How-to Get the Cunning Ribbon Guide will walk you through the steps you need to obtain this ribbon! We're going to need to do a dastardly deed, get caught, and then make our escape if we're going to be able to collect this prize. Our guide will walk you through exactly how to get it done.

How-to Get the Cunning Ribbon

First, we just need to get through the infant, child, and teenage years. These really don't matter, however, I wouldn't really let yourself get too low on any of your percentages if you can help it. You can decide to make some money during these years by getting a part time job or doing some of the freelance gigs, but they aren't necessary.

Once you've turned 18, you'll want to head to the Activities tab and go to Plastic Surgery. We're looking for the Gender Reassignment surgery option. Choose a doctor and see how much it is going to cost to get it done. There should be two doctor options, so check both and note the amount of money you need to get it. You'll need to save up enough money to afford the surgery in the future. For me, it was in the range of $35,000 - $45,000 dollars. Get a job and start saving up the money you'll need for the surgery. I'd try to get a bit more than you might need just to be safe.

Now that you have the cash, it's time to commit a crime! It doesn't matter what crime you commit, you just need to get caught doing whatever it is. Pick a Public Defender so you don't spend any money on a lawyer, and head on to prison. Now you will need to escape! Lucky for you, we have a pretty detailed guide on how-to escape any of the prisons in BitLife .

Once you've escaped from jail, go back to the Plastic Surgery tab and get the Gender Reassignment surgery. You can sometimes die from this, but that's a risk you'll need to take! If the surgery is a success, you'll now need to live your life without being caught. You can attempt to emigrate to another country, but that doesn't always work.

IF you get caught and are on an iPhone or iPad, you can immediately close the game by double tapping your home button and sliding the app upwards. Open it back up, and it should be like you were never caught at all. Keep pressing through the years until you croak at some point and you should be rewarded with the Cunning Ribbon!

Keep in mind that sometimes you can get the Mediocre Ribbon and occasionally some of the others. Obtaining Ribbons in BitLife isn't always an exact science unfortunately.

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BitLife: How to Complete the Barbie Challenge

With Barbie now in theaters, why not learn how to complete the Barbie Challenge in BitLife ? This is listed as an easy challenge, but you’ll find that RNG can make it frustrating. The plus side is that you don’t have to spend real money on any game packs, but you could use God Mode to increase your Looks if you wanted.

How to Complete the Barbie Challenge in BitLife

The Barbie Challenge requires you to meet the following criteria:

• Be a female.
• Undergo all plastic surgeries except gender reassignment.
• Become a model.
• Live in a mansion (or similar).

How to be Born a Female

Your first step is to start a custom life and select female as your gender. You can choose any country for this challenge. I decided to use Sweden, but location won’t make much difference here.

How to Get Plastic Surgery

If you go to Activities > Plastic Surgery, you’ll find quite a few options. For this challenge, you need to get every plastic surgery except Gender Reassignment , but you can get them in any order. 

The cost here adds up, but you don’t need to do them all in one year . I had my character work a part-time job in high school for a bit of money, but you can also gather money from a full time job after graduation. Don’t bother going to college for this one.

I focused on getting the Nose Job and Eyelid Surgery first to improve my Looks since you’ll need to get a job as a model. Depending on your Stat, you might need to grab another surgery early on.

Related: BitLife: How to Get a Sugar Daddy

How to Become a Model in BitLife

Becoming a model goes well with getting a ton of plastic surgery since you’ll need a high Looks stat. Generally, you can get the job once you hit 80% in Looks , but the higher your stat is, the better.

Once your character is 18, you’ll go into Jobs and search full-time listings for Foot Model, which is the entry level job for modeling. However, you might not see it since the jobs are subject to RNG. I took whatever job I could for the sake of building money for surgeries, and checked for Foot Model each year.

If Foot Model isn’t listed, your only choice is to age up and try again.

How to Purchase a Mansion (or Similar)

Finally, you need to purchase a mansion or similar home , but you have to live in it while still being a model. If you wait until retirement, the challenge will not be completed.

For this go to Assets or Activities > Go Shopping and check the Real Estate Broker options for a mansion. I was able to check this requirement off by purchasing a castle.

You might find that your salary hasn’t accumulated enough money to afford a mansion. To solve this, I went into Activities > Fame every time I aged up and selected Book, Photo Shoot, and Commercial to earn extra money. You won’t be able to do all three every year, but doing what you can will add a lot of money to your account.

Now you know how to complete the Barbie challenge in BitLife , and you can view more guides like how to achieve inner peace in India , which is part of the Eat Pray Love challenge.

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How to Join a Fraternity or Sorority in BitLife

BitLife fraternities and sororities are surprisingly beneficial for your character, especially once you’re out working and ready to get your first full-time career. Here are the exact requirements for joining a fraternity and sorority and the difference between the two.

Joining a fraternity or sorority in BitLife requires entering university , making some friends , and having knowledge of Greek mythology . Male characters can join fraternities, while females have access to sororities; you can’t reverse this unless your character undergoes gender reassignment.

Once your character enrolls in university, search your classmate list until you find someone in a fraternity or sorority before befriending them. If your character is a male looking to join a frat, look at male classmates for fraternities. Likewise, look at female character profiles for sorority options.

After you find a classmate to befriend, rush the fraternity of your classmate and answer the Greek mythology question correctly to join officially. Unlike job interviews, the answers are not random, so you’ll need some knowledge of mythology to pass.

What Does a Fraternity and Sorority Do in BitLife?

Fraternities and sororities allow you to bypass full-time job interviews in BitLife. By applying for a job, you can receive a pop-up message telling you your interviewer was in your fraternity or sorority and that they’re hiring you on the spot.

Aside from this, joining a fraternity or sorority appears occasionally as a challenge or achievement task. For example, the Legally Blonde challenge asks you to join a sorority, while the Gimme Gimme challenge requires you to get a job using a fraternity.

BitLife is available on iOS and Android. Do you want to explore more school-related content? Check out  how to qualify for nursing school in BitLife , or click the tag below to browse our growing article list.

• View history
• Birth Control (if born female)- A player can decide whether to have their character get on or go off birth control. If they decide to go off birth control, they can choose whether to tell their partner (if they have one) or keep it a secret. Sometimes their lover may argue if they told them that they are not on birth control. After they turn old, it will no longer matter if they are on or off birth control. Birth control is very effective when you are dating someone, but hook-ups who claim they are on birth control may be lying or misusing it and could still get pregnant if your character does not use protection. Babies who start a new life can sometimes have "I was born after the birth control failed" as their conception method at the start of their life. The minimum age for birth control is 14. If your character was born male, usually when the couple turns 18, their partner, if born female, may usually go on birth control. After age 55, AFAB people will no longer need birth control.
• Artificial Insemination - (Only available for AFAB people) you will be artificially inseminated. If successful, the player becomes pregnant. This also gives a much higher chance to have twins/triplets. If you have a partner, getting a successful artificial insemination will likely cause an argument with your partner unless you are in a same-sex relationship. After age 50, you will be considered too old for artificial insemination. This option is not available for AMAB people as they cannot become pregnant themselves, regardless of age.
• IVF - If you and your partner are having trouble reproducing, you can ask them for IVF. They likely will not accept, but, if they do, it can be successful or fruitless. If successful, the female will become pregnant. This will also give a much higher chance of twins/triplets. If fruitless, you & your partner will have to wait until the next year to try IVF again. After age 50, AFAB people will be considered too old for IVF.
• Tubal Ligation/Vasectomy - If you do not want any offspring, you can be sterilized by clicking Tubal Ligation (if AFAB) or Vasectomy (if AMAB). But this is not always efficient as in some rare cases, people can still reproduce after a successful sterilization procedure. Babies who start a new life can sometimes have "I was born after a botched vasectomy/tubal litigation procedure" as their conception method at the start of their life.
• Sperm Donation - (Only available for AMAB people) If you were born male, the option to be artificially inseminated will be replaced with the choice to donate your sperm. You will get a cash reward of 40 - 80$. You can only donate to one fertility lab a year. If you try to donate again after you just donated you will be told to "cum back later". Your sperm will be rejected if your smarts and/or looks are under 30%, if you are too old, if you already donated your sperm in the same year, or if it says “Unspecified”. Unspecified reasons may include having a disease, having a criminal record, having too many children, or having donated too many times in a lifetime. Sometimes the reasoning will simply show up as "No Sperm Needed".
• Surrogate - If you don't wanna adopt, you can ask a surrogate. When you press Surrogate, a menu will pop up and present you with different women. You can check their stats and choose whether to use their eggs for the baby. Once you decide who will be your surrogate you press "ask her". They might reject you. Married people tend to be more likely to be accepted by a surrogate, but being unmarried or single can still get a surrogate. If they accept, you will have to choose whose eggs to use. Once you do, you will have to wait one year, then you will have your baby (You can name it, of course). If a surrogate fails at getting pregnant, your character can be reimbursed half of the expenses. Some surrogate mothers will keep the baby for themselves and dishonor your contract; should this happen, your character may file a Lawsuit against them, but sadly they never get the baby back even if they win the suit. In some Nations , the option may be unavailable as it is not legal in all countries.
• Meditation - Sometimes when you choose the Meditate option under "Mind & Body," there's a chance that your fertility will raise or drop.
• You cannot visit a fertility clinic if you are transgender. However, this can still work if you are a transgender male.
• You cannot impregnate females if you are a transgender male; you also cannot get pregnant with a male if you are a transgender female. This used to be possible prior to being patched.
• To get pregnant you must not use birth control and certain diets or it will prevent pregnancy for females. This does not apply for transgender females.
• When pregnant, women may not have certain types of Plastic Surgery and may get Pregnancy massages. Other massages can be done, but run the risk of miscarriage, with Pregnancy the only one fully safe. Pregnancy massages are only available to characters who are female and pregnant.
• If you’re a homosexual male and have a transgender male as a partner, it is possible for the transgender male to become pregnant like any female (except transgender females).
• When the character you play as is born, it also might say "I was born/conceived after the fertility doctor told mum she wasn't doing it right."
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How To Get All Ribbons in BitLife: Complete Bitlife Ribbons List

BitLife features all sorts of activities, challenges, achievements and walks of life you can pursue. No Bitizen lives forever though, and when your character inevitably dies, they’ll be judged. Not in a deific manner, but a tombstone marked with a special ribbon. You’ll collect quite a few the more you play, like trading cards. If you’re a completionist, then take this guide on how to get all Ribbons in BitLife and capture them all!

How to Get All Ribbons in BitLife

Academic ribbon.

If you’re hoping to get the Academic Ribbon, you need to be the biggest nerd in school and beyond. Focus all your time on increasing your brain power.

• Be born with an intelligent character (not required, but it helps)
• Spend every year studying as much as possible and visit the library
• Graduate high school, college, and attend graduate school

To ensure you get the Academic Ribbon at the end of your life, pursue a career in education. It isn’t required, but it does increase the likelihood of earning the ribbon.

Addict Ribbon

Earning the Addict Ribbon is one of the easiest tasks to complete in BitLife, and likely to end in a quick death, too. Your sole goal in life is to get addicted to everything you can, such as drugs, gambling, and alcohol. Essentially, roleplay as an addict.

It’s pretty straightforward: Simply visit the casino and go clubbing, as much as humanly possible. Both are found in the Activities tab under Casino and Nightlife. It’s important to also note that you should intentionally lose when you’re gambling. For example, if you’re playing Blackjack and you get close to 21, have the dealer give you another card so you go over.

Bandit Ribbon

In order to obtain the Bandit Ribbon, all you have to do is rob a train , which is easier said than done. Doing it is the easy part, but waiting for the train is tedious. Long story short, you have to rob a train at the same time as the times listed in BitLife. For example, one of the options is 4:20pm, but to be successful, it has to be 4:20pm your time , too.

Barbie Girl Ribbon

Another easy one is the Barbie Girl Ribbon, which is all about plastic surgery. It boils down to the following requirements:

• Get plastic surgery (except Gender Reassignment)

Of course, plastic surgery isn’t cheap, so you should have a job that pays enough to cover the costs. You can get the work done by choosing Plastic Surgery under the Activities tab.

Big Boss Ribbon

The Big Boss Ribbon is all about being the CEO of a company and dying in BitLife with a net worth of $20 million. That last bit comes with the territory and won’t be hard to obtain. To become a CEO:

• Graduate high school and attend a university
• Major in something business related (like Finance or Information Systems)
• Attend business school
• Work your way up the corporate ladder to become CEO

When you’re the big dog in business, make sure your business does well so you die with a high enough net worth.

Cat Lady Ribbon

To earn the Cat Lady Ribbon, you should be a woman and do nothing else but spend time with your cats. Take care of them, spend your money on them, even invest in a bigger home to adopt more cats. If you manage to own at least 30 cats in your lifetime, you’ll die happy as a cat lady.

Cunning Ribbon

The Cunning Ribbon isn’t exactly hard, but might take a few attempts to get right. To earn this ribbon:

• Earn enough money for gender reassignment surgery (more on that later)
• Commit a crime, get sent to prison, then break out of prison
• Now go for gender reassignment surgery and emigrate to a new country

The goal here is to commit a crime, escape, and be in hiding for the rest of your life. By emigrating to another country, you’ll drastically reduce the odds of being caught. Don’t sweat it if you’re caught before you die. You can simply escape and emigrate to another country again.

Deadly Ribbon

In order to earn the Deadly Ribbon in BitLife, you need to murder a lot of people. At least five unfortunate souls need to be murdered by your hands to get the ribbon. It’s a lot harder than it sounds considering a single murder can and will get you sent straight to a maximum security prison. Try doing a drive-by to reduce the odds of getting caught.

Family Guy Ribbon

Despite the name, you need to be the exact opposite of Peter Griffin to earn the Family Guy Ribbon. Where he’s a terrible drunk, you need to be a good, honest father towards your children.

• Have at least three kids
• Maintain their happiness as high as possible
• Maintain a middle-class income

Keep in mind that if you have more than three kids, you may end up with the Fertile Ribbon. Maintain two or three and keep them happy!

Famous Ribbon

The Famous Ribbon is yet another ribbon with easy requirements. All you have to do is become famous in BitLife . The following careers come with fame:

• Being royalty (married or born into it)
• Writer (as an author or reporter)
• Social Media Star

Becoming a famous writer is quite easy as it doesn’t require a college degree or any other secondary school. However, marrying into royalty is a load of fun, too.

Fertile Ribbon

If you want to die with the Fertile Ribbon as your greatest accomplishment, just have a lot of kids and take good care of them. You need to have at least four children to gain the ribbon, but you should certainly go for more to counteract other ribbons.

Generous Ribbon

As this ribbon would suggest, you need to be a generous person throughout life. This means gifting your loved ones with small and larger gifts, from flowers to houses. You need to start early, so having a part-time job is always helpful. When you’re an adult, it’d be wise to have a high-paying salary as well in order to buy homes and cars as gifts, too.

Geriatric Ribbon

The Geriatric Ribbon is awarded to Bitizens that live beyond 100 years old. To make that happen, you need to take care of yourself, both in health and happiness. Try these activities::

• Visit the doctor when you’re ill
• Exercise, meditate, and maintain a healthy diet
• Go on vacations
• Spend time with your family, friends, and pets
• Maintain a garden

Stay away from drinking, drugs, and avoid sleeping around without protection.

Globetrotter Ribbon

If you want to add the Globetrotter Ribbon to your belt, you need to travel a lot, at least 20 countries. Your life should be all about working and traveling every single year, in addition to emigrating to other countries, too. Stick to a middle-class salary in order to have the income to go on vacation every year, but too much that you end up with something like the Rich Ribbon.

Gold Digger Ribbon

To earn the Gold Digger Ribbon in BitLife, your life should only be about marrying sugar moms and sugar dads . To be specific:

• Don’t have a job, but freelancing and stealing is okay
• Keep your Looks stat as high as possible
• Use the dating app to look for rich folks over 80 (so they die sooner)

The goal here is to inherit your lover’s money, so maintain a good relationship with them, marry, and do not sign a prenup. Once you’ve made $1.5 million from doing this, you’ll earn the Gold Digger Ribbon when you die.

Hero Ribbon

The Hero Ribbon is another easy ribbon to earn. You’ll want to be a generally good person, maintain a career as a doctor, nurse, or be in the military, and risk your life for others. Being a doctor is an easy way of saving lives, as is being in the military. If you join the military, dying to save others can fasttrack you to earning the Hero Ribbon.

Highroller Ribbon

Your goal for getting the Highroller Ribbon is to do nothing but gamble and win big. Blackjack is one of the better ways of earning a lot of money as opposed to the racetracks. You have to get at or close to 21 to win at Blackjack. As long as you earn over a million in earnings but less than five million, you’ll get the Highroller Ribbon.

Houdini Ribbon

You need to make Houdini blush with the number of times you’ve escaped prison. To earn the Houdini Ribbon, successfully escape prison at least 10 times. Do be mindful of how much time you spend there or dying in prison as this could award you with the Jailbird Ribbon instead.

Influencer Ribbon

For the Influencer Ribbon, join as many social media platforms as possible and spend your days making viral posts. When you have enough followers, don’t forget to get verified, too. Also, sponsorships are free game, but do take care not to buy followers. It’s a risky move that can get you kicked off social media and lose out on the Influencer Ribbon.

Jailbird Ribbon

Similar to the Houdini Ribbon, spend your life in prison, escaping, and ultimately dying there for the Jailbird Ribbon. Don’t escape prison more than three or four times, then age up in prison until you’re dead. A good way to ensure you spend the rest of your days locked up is murdering a few people.

Lazy Ribbon

To earn the Lazy Ribbon, you need to be a complete waste of space. Don’t do anything in life except age and breathe in precious air. On a side note, make sure your character’s intelligence is above room temperature or else you risk earning the Stupid Ribbon. To maximize your laziness, the easiest route is to be born with a decent Smarts stat so you don’t have to waste time improving it.

Loaded Ribbon

The Loaded Ribbon requires that you die with $20 million dollars in your name. Naturally, you’ll want to gravitate towards careers and activities that earn you the big bucks, like playing the lottery or being famous. Try out a career as a doctor, writer, or actor and you can easily make that kind of money in no time.

Lustful Ribbon

To get the Lustful Ribbon in BitLife, you need to rack up as many lovers as possible—over 20 partners, to be specific. The nightclub is a great place to get started, since one-night stands are easy to initiate. However, after 9 one-night stands, switch over to the dating app.

Additionally, you’ll want to keep your character healthy and happy. Exercise, maintain your looks, and keep a healthy diet to ensure Bitizens will take you up on your offers. Lastly, if you get an STD, it needs to be cured or else you could end up with the Wicked Ribbon instead.

Mediocre Ribbon

The Mediocre Ribbon can be a bit tricky because its requirements are similar to the Lazy Ribbon. Simply spend your entire life doing next to nothing. Hop between jobs, like being a housekeeper, stay away from college, relationships, and the military. However, you need to die a natural death, not from suicide or diseases.

Model Bitizen Ribbon

The Model Bitizen Ribbon is a balancing act due to how close it comes to the Family Guy and Generous Ribbon. Generally, you want to be a good person by keeping your karma above 50%, nor should you indulge in alcohol and drugs. On top of that:

• Have good relationships with your family
• Offer gifts, money, and compliments to at least 10 people
• Keep your net worth above $50k
• Keep yourself out of debt

If you do have children, stick to one kid in order to avoid the Family Guy Ribbon. Lastly, it’s important to maintain the listed net worth rather than exceed it so you aren’t considered “rich.”

Monopoly Ribbon

There are a myriad of ways to approach the Monopoly Ribbon. It doesn’t really matter which career you follow, as long as you are able to do the following:

• Purchase at least 10 homes
• Hold onto them for, at minimum, 5 years
• Sell them for a profit

Being wealthy certainly helps, but as long as you make over a million dollars buying and selling homes, you’ll be golden.

Mooch Ribbon

The Mooch Ribbon is one of the more goofier ribbons you can earn in BitLife. You need to essentially live off of the generosity of your family, including your wife or husband. Make a habit to ask everyone you have a relationship with for money. You’ll be eking out a living on the hard work of others, you bloodsucking vampire!

Movie Buff Ribbon

For the Movie Buff Ribbon, you can lead a fairly normal life, but much of that life should be spent watching movies. Grab yourself a decent job, maybe a date, and head to the movies as often as possible each year. If you can manage at least 20 movies in a lifetime, you’ll get the ribbon.

Rich Ribbon

As the name would suggest, you need to be quite wealthy to earn the Rich Ribbon. To be specific, your net worth should be above $2.5 million dollars by the time you die. However, don’t go past $4 million or you run the risk of earning Big Boss or Loaded. We have a handy guide on how to get rich if you’re interested!

Rowdy Ribbon

You want to essentially be an avid partygoer with an attitude to get yourself the Rowdy Ribbon. Spend your days going to the nightclub (at least 12 times), drinking alcohol, doing drugs, and throwing parties. Get into screaming matches with anyone giving you crap, but stay away from physical fights. If you end up getting addicted, go to rehab.

Scandalous Ribbon

The Scandalous Ribbon is a tough nut to crack due to its closeness to multiple ribbons. You need to spend at least 5 years in prison, but how you get there is tricky. Try to mix up the kinds of crimes you commit, but you should intentionally get caught. If you’re in prison for, say, 2 years, attempt an escape to extend your sentence.

Stupid Ribbon

If you thought the Lazy Ribbon made your Bitizen a waste of space, the Stupid Ribbon requires even less. You’re doing much of the same things—absolutely nothing—but you’re character also needs to be stupid. Drop out of school, do stupid things, and keep your Smarts stat as low as possible.

Successful Ribbon

Another ribbon that rubs elbows with Rich, Loaded, Family Guy, and Model Bitizen if you aren’t careful. For the Successful Ribbon, you have to:

• Have a net worth of $250k
• Live beyond 65 years, healthy and happy
• Stay away from drugs, alcohol, and prison
• Have strong relationships

Stick to having only one child to avoid the Family Guy Ribbon. Also, while you can give gifts, don’t be too generous to the put you end up with the Generous Ribbon.

Tarzan Ribbon

Unfortunately, the Tarzan Ribbon won’t be obtainable unless you have Bitizenship, which you pay for. This is because you need to adopt at least 20 exotic pets and commit your life to them. Additionally, you need to be:

• Have zero debt
• Have a net work just below $1 million

It’s essentially like the Cat Lady Ribbon but with extra steps. You’ll find exotic pets by visiting the Exotic Pet Dealer.

Teammate Ribbon

Did you know the developers of BitLife, Candywriter have headquarters in Tucson and Miami? Well, it’s important to know since the Teammate Ribbon revolves around said locations. Pack your bags because you’re going to be an app developer!

In your early years, you want to be a brainiac in school. Focus on academics, visit the library, and study hard. You’ll need good grades and a high Smarts stat to attend University. When you’re there, pursue a degree in Computer Science. After graduating University, get a job as an app developer and devote your life to it.

Thief Ribbon

As the name would suggest, the Thief Ribbon is all about stealing, from a little old lady’s purse to burglarizing a home. Now, keep in mind that getting caught and spending 5 years in prison will qualify you for the Scandalous or Jailbird Ribbon.

When you steal, make it quick to avoid getting caught. If you can manage stealing from 10 different marks, which should include cars, houses, and people, then you’re good to go.

Unlucky Ribbon

The Unlucky Ribbon isn’t difficult to get, per se, it’s just incredibly random. You need to die before you’re 30 by no fault of your own. It could be cancer, a random terrorist attack, an STD, or a horrific plane crash.

The best thing you can do to try and force it is to take frequent trips by plane, have one-night stands without protection, or frequent large events. Just be careful not to earn the Lustful Ribbon by accident.

Veteran Ribbon

Ready for war? Well, that’s where you’re headed. For the Veteran Ribbon, join the military and reach the rank of Admiral, General, or Sergeant Major. Additionally, you should have three deployed mines under your belt and, hopefully, live to see retirement. You can retire when you’re 62, so try and stay alive until then.

Wasteful Ribbon

The easiest ribbon to obtain in BitLife. Go into Activities and choose the surrender option. For your time and effort, you’ll be given the Wasteful Ribbon. Yes, that’s all there is to this ribbon.

Wicked Ribbon

If you want the Wicked Ribbon in BitLife, you’ll need to commit one of two actions a total of five times (you can mix the two):

• Give someone an STD
• Abandon your child and or pet

In order to avoid the Lustful Ribbon, get into a relationship with someone while infected with an STD. Adopt a pet and have a baby while you’re at it. With this strategy, you can give your lover an STD, abandon a child and pet at the same time. After that, repeat any of the three options two more times and the Wicked Ribbon is yours.

Well, folks, that was the last of the ribbons in BitLife. You now have everything you need to know on how to get all Ribbons in BitLife . Let us know which Ribbons you have in BitLife in the comments! And don’t be afraid to peruse other content using the links below!

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How to Complete The Barbie Challenge in BitLife

It’s time for another  BitLife  challenge. Bitizens will need to live their life as the most famous teenage fashion model ever created: Barbie. You’ll be taking on a job as a model, and need to save up enough money to buy a mansion and have every type of plastic surgery in the book. Here’s how to complete The Barbie Challenge in  BitLife .

Here are the Barbie Challenge requirements:

• Be a female
• Undergo all plastic surgeries except gender reassignment
• Become a model
• Live in a mansion (or similar)

Start your life as a female Bitizen to check the first requirement off the list. It’s simple enough and doesn’t need any more explanation than that. One thing to make sure of is that you have naturally high looks because this will be important when becoming a model. It also helps to have your other stats reasonably high.

Next, you’ll need to become a model at some point in your life. Like all jobs, you’ll need to work your way up from the bottom of the ranks. Graduate high school and then begin looking for jobs. Tap on the Jobs option, and look for a low-level modeling job. Some good examples are Hand Model or Foot Model. If you don’t see these on the list, you can try restarting your app or aging up a year and searching again.

Apply for the job as Foot Model or any other entry-level modeling gig. If you keep getting rejected, you may need some higher stats. When you get the job, keep working hard every year. The starting pay will probably be less than $20,000, and this isn’t enough to buy your mansion later, so do your job well to get a promotion. Eventually, you will get promoted and begin to get famous.

At that point, you can start doing photoshoots and interviews and receive anywhere north of one-million dollars for each gig. When you start getting a lot of money, you can purchase a house under the  assets  tab. Select the  Real Estate  option, and get yourself a mansion or any other massive house that someone like Barbie would buy. 

Finally, head into the activities section of  BitLife  and select the  Plastic Surgery  option near the middle of the list. You’ll need to get every single procedure on the list, except for gender reassignment surgery. Surgeries include Botox, Brazilian Butt Lift, Breast Augmentation, Eyelid Surgery, Face Lift, Liposuction, Nose Job, and Tummy Tuck. Each surgery will cost a few grand, but you should be flush with money at this point.

That’s how to complete The Barbie Challenge in  BitLife . Good luck!

BitLife 1.27 Update Guide: Everything You Need to Know About BitLife Version 1.27 aka the Mystery Update

By: Author Tim McNeil

Posted on Last updated: February 19, 2020

Even with 2019 ending in just a few weeks from now, Candywriter’s BitLife is still a massive hit on both iOS and Android platforms, a popular download more than one year removed from its debut, and a game that keeps getting better and better (for the most part) with each succeeding update. Candywriter truly changed the game with this title, which allows you to control the life of a virtual person, or a Bitizen, making numerous decisions from the cradle to the grave — it’s all up to you whether you want your Bitizen to live a long, prosperous life by doing the right thing or to waste it through the questionable choices you make! That is, of course, not to mention that there are always a few random events that could improve — or worsen — a Bitizen’s life.

Unlike with previous updates, Candywriter employed a different strategy when they rolled out version 1.27 toward the end of November. Instead of explaining in great detail what features players could expect, the company chose to “leave it to your own exploratory delight” and keep the new additions a mystery, save for one key feature — the ability to have “unlimited” Bitizens’ lives going at the same time through multiple save slots.

So what can you expect from BitLife version 1.27? How do the multiple save slots work, and how do the other new features add new twists and turns to the virtual lives of your Bitizens? Read on, as we’ve unlocked the mystery of this new update and taken the effort to detail every new feature we’ve noticed so far.

Multiple Save Game Slots — What They Can And Cannot Do

For some players, simply choosing one Bitizen’s life to control at a time could be an inconvenience. What if you, for instance, want to compare different Bitizens and see how certain decisions impact their lives? And for paid players, what if you wanted to compare different legacies from generation to generation? Allowing only one saved game to be active at a time limited things quite a bit, but with BitLife version 1.27, you can now have multiple Bitizens’ lives saved simultaneously. This appears to be the main addition, as it’s the one with the most functionality, as well as the one Candywriter specifically mentioned when discussing the mystery update.

Bored with the life you’re making one character live, but not exactly willing to start from scratch? That’s no longer a problem either, as you can toggle from one Bitizen to the next and, if need be, delete your previous saved Bitizens. Characters can be saved assuming you’ve aged them at least one year, so make sure you hit that big green Age button before exiting out of a life if you want it to be saved, with the option to go back at any time.

Related: BitLife Office Update Guide: A Complete Look at BitLife Version 1.26 aka The Office Update

Sadly, the game still does not offer the ability to duplicate an existing life so that you can play as the same character in multiple save games, seeing how varying life decisions impact the same Bitizen over time. We probably understand why — this could arguably be seen by some as cheating, and furthermore, the game comes with the Time Machine feature, where you can pay a dollar to go back to various points in your life. As an aside, we should mention that Time Machine now allows you to go as far back as 20 years (the available increments are now 1, 3, 5, 10, 15, and 20 years), only for $1 or its equivalent in local currency, regardless of how far back in time you go.

Circumcision Is Now An Option For Firstborn Males

Anybody who’s been playing for a while knows that when a Bitizen has their first child, you’ll be given the option to choose whether you want the baby vaccinated or not. The differences are subtle, but babies who aren’t vaccinated in the game tend to become sicklier adults than most. Now, there’s a new scenario that will come up when your first in-game children (males, to be specific) are born — do you want to circumcise your son or not?

In multiple playthroughs, we haven’t seen any clear benefit or disadvantage to having oldest sons (and therefore, all other sons born to a Bitizen) circumcised. It doesn’t seem to have any bearing in the world of dating — NPC dates don’t appear to care whether a male Bitizen has his foreskin cut off or not.

Neither does it have any visible effect on their general health. But your choice of whether to circumcise your character’s first son may show up on their tombstone once everything’s said and done, with a short note commenting on how friends knew the Bitizen as someone who opted (or chose not to opt) for the procedure. This may show up if the Bitizen didn’t do anything noteworthy in their lives, but we’d like to assume its effects are similar to what they are in real life — a reduced chance of acquiring STDs when having unprotected sex with NPC flings.

Doctors Come With Their Own Reputations

In previous versions of BitLife, going to the doctor was a bit of a crapshoot. All you saw was their name and the consultation fee (for countries without free healthcare), and you would only get an idea of how good (or how incompetent) the doctor would be upon seeing the fee for treating the illness itself. For example, you’d essentially be throwing $80 down the drain to treat high blood pressure, but far more likely to recover if the doctor would charge, say, more than a thousand bucks. The new update, thankfully, removes all this guesswork.

That’s right — just as we had previously teased, BitLife version 1.27 now gives doctors their own reputation bars, and that applies to the medical doctors, as well as the plastic surgeons richer Bitizens may opt to visit in adulthood. These reputation bars essentially tell you their level of expertise — are they skilled professionals or incompetent quacks? A full green bar, of course, means you’ll be dealing with the former, but that also means you’ll likely have to pay more. Meanwhile, an orange or red-colored bar suggests that the doctor probably got their degree from the internet — expect cheap and ineffective treatments with these individuals, or a botched facelift/nose lift/gender reassignment/etc.

Related: BitLife Stepfamily Update Guide (Version 1.24): Everything You Need to Know About the Stepfamily Update

In fact, you can probably say that looking for a competent doctor in the BitLife world is far easier than it is to find one in the real world. Take full advantage of this if you want your Bitizens to live happy, healthy, and long lives!

Drugs Are Dumb – A New Way To Get The Elusive ‘Stupid’ Ribbon

Prior to the new update, it was rather hard to get the Stupid ribbon. And it didn’t matter much if your Bitizen lived — and died — with a very low Smarts stat, i.e. 10 or below. Typically, this required staying unemployed for as long as possible — bouncing from one menial job to another usually resulted in a Mediocre ribbon, regardless of Smarts, so refusing to get a job was one way in which players had a chance at their Bitizen being called “Stupid” in death. Petting wild animals was also recommended as a strategy for getting the ribbon, but as any experienced player will tell you, these scenarios are still quite rare in the game.

Making questionable life decisions — choosing not to vaccinate your child, for instance — likewise helped a bit, but definitely did not guarantee the ribbon. Version 1.27, however, makes it considerably easier to earn a Stupid ribbon and add it to your collection. So how, pray tell, can this be achieved?

As we’ve observed in a few playthroughs, dying of a drug overdose could now result in a Stupid ribbon. It doesn’t matter how much Smarts your Bitizen may have — if he or she overdoses on a deadly drug like heroin, cocaine, meth, or oxycodone, their tombstone will have a Stupid ribbon draped on it, just as long as they haven’t earned enough money to be considered Rich or Loaded or haven’t become celebrities in order to be considered Famous. We guess this is Candywriter’s way of telling players that drugs are bad, but in any case, this simplifies what used to be one of the most complicated, luck-based goals in the game.

Funeral Planning – Burial, Cremation, Or Taxidermy?

Previously, the only thing you needed to decide in the event of a family member’s death was whether to attend or skip the funeral — attend it if your Bitizen is a good, responsible son or daughter, skip it if they’re estranged from their folks, or pretty much “abject and detestable” individuals. BitLife version 1.27 changes that, as you will now be tasked to plan a dead relative’s funeral and make a few additional decisions depending on a number of factors.

When parents, siblings, children, grandchildren, or nephews/nieces die, you will automatically be assigned funeral planning duties the first time it happens, and may or may not be assigned for subsequent deaths — assuming you’ve already reached adulthood. Your first choice would be whether to plan it, have someone else handle the duties, or skip the funeral. If you choose to plan the funeral, you can choose between cremation, burial, or taxidermy — this is in order of price, from lowest to highest — though you may want to disregard the cost and honor whatever your deceased relative had wanted.

You can also donate their remains to science, for no cost at all. (In most cases, the game will specify the option the dead relative wanted.) We haven’t experienced any consequences of refusing to honor a dead relative’s wishes in terms of burial options, but we’re guessing that it will increase the chances of those relatives haunting you in the event you (or your descendants, for paid players) purchase a haunted house.

In the event you opt for cremation, the game will also ask you whether you want to keep the relative’s ashes, or whether you want to sprinkle them somewhere. This doesn’t seem to have much of an effect on the game, though this could lead to some hilarious scenarios — we’ve seen playthroughs where the relative’s ashes are scattered at the location where they lost their virginity, for instance.

Related: BitLife School Update Guide (Version 1.23): Grades and Popularity, Cheating on Tests, School Bullying, Student-Teacher Interactions and College Life Explained

In addition to the above options, you now have the option to fly to your birth country if you’ve emigrated without some (or all) relatives and one of those relatives passes away — or in any circumstance where the dead relative lives in another country. This is certainly a more realistic touch, and even more so as this would naturally cost you some money in plane tickets to fly to the funeral and back home.

More New Family-Friendly (Or Unfriendly) Features

Candywriter may have released an in-depth family update a while ago, but that doesn’t mean they’re through adding family-related scenarios in BitLife. In fact, they seem to have added a few scenarios in version 1.27 that are worth noting.

The first scenario we’ve observed in our playthroughs is that it’s now possible for family members, friends, and even partners to steal from you — we’ve included an image where our Bitizen’s partner stole over $500 from him so that she and her friends could attend a concert. Yes, it’s true — these things happen in real life, and in the in-game world, we’d guess the chances of these events happening would depend on certain stats, such as a sibling’s Petulance, a parent’s Kindness (or lack thereof, to be more accurate), or a partner’s Craziness. Once this happens, you will have the option to ask the loved one not to steal again (fat chance if their Craziness is high), ask them to return the money (again, not likely if Craziness/Petulance is at red levels), or choose to keep your relationship bar intact at the expense of your Happiness by saying that it doesn’t bother you. Other options, such as breaking up with a partner, may be available, depending on the type of loved one who did the dastardly act.

On another note, we’ve seen a few instances, regardless of the Bitizen’s nationality, where parents may disapprove of their partners. This is not to be confused with arranged marriages in certain countries, but since parents all over the world have one reason or another to give pause when it comes to their child’s relationships, you may encounter scenarios where your mother or father may express concern about age difference, your partner’s work or financial status, or other hang-ups — some of them valid, some of them outright ridiculous.

Regardless, you can argue with your parent, listen to their advice but keep on dating your partner, or break up with your partner. The first two options may damage your relationship with the objecting parent, while the third will improve it, albeit result in a significant decline in Happiness.

This also appears to be a brand new scenario we’ve seen on version 1.27 — you may be asked whether you want to perform the Heimlich maneuver, call emergency services, or just sit back and watch as a relative chokes during a family dinner. The first two options can definitely help save a life and successfully performing the Heimlich could be useful in helping you earn the Hero ribbon, but neither are not guaranteed to work 100 percent of the time. Sitting back and watching, however, would invariably result in the relative choking to death, and you wouldn’t want that deceased relative haunting your house because you chose to be a horrible human being!

Finally, the game now allows you to visit relatives after you emigrate to another country. Prior to the new update, emigrating back to your birth country was the only way to reunite with any family members who didn’t join you after emigrating. This suggested much more permanency in your travels, uprooting your family and forcing you to start from the bottom at a new job.

However, you can now tap on any family member who’s not living in the same country as you are, and choose the Visit option — you will then be directed to a dialog box that includes the price of two-way tickets to and from the country where the relative is currently located. This is a good way to improve that Relationship bar, because you definitely won’t be able to choose the Spend Time option with anyone who’s living thousands of miles away from you!

A New, Slightly Tweaked Adoption Mechanic

Adoption may not be one of the more frequently-used features in BitLife, but it is nonetheless an option you should consider if, for instance, you’ve got a Bitizen who’s too old to have kids of their own, or in the case of same-sex couples. Version 1.27 added a couple new wrinkles to the adoption mechanic, so let’s look at what’s changed in the latest version of the game.

The first, and probably more obvious change is the ability to see a child’s appearance before you adopt them. Aside from viewing their Health, Smarts, and Looks, as well as their name and age, you’ll now see an avatar next to the word Adoption, thus giving you all the pertinent information you need before adopting a child.

Related: BitLife Guide (Version 1.20 Update): Military Service, Birth Control and Pregnancies, Dating Foreigners, Emigration, Time Machine Explained

The second change is the option to adopt the children of a family member in the event they pass away unexpectedly or are unable to care for them in any way. This will certainly take a toll on your finances as your family member’s kids will be grouped together with yours, but it’s another much-welcome touch of realism that makes sure any underage kids are taken care of if something bad happens to a relative.

Odds And Ends

As for the miscellaneous features Candywriter added with version 1.27, we have, for starters, seen a few changes with the virginity mechanics. On the cosmetic side of things, virginity-related scenarios now fittingly have a cherry icon on top of the dialog box. Not much has changed in terms of the actual gameplay, but we’ve heard of random events where Bitizens may lose their virginity, even if you, as the player, may want to keep them chaste until marriage, or want them to remain celibate because they’ve entered the priesthood or become a nun or a monk.

Likewise, we haven’t experienced it either, but we’ve seen quite a few Reddit members report instances where their characters got struck by lightning. Now you may be thinking that this would result in a freak, unexpected death. However, it appears that getting struck by lightning will mainly do one of two things — one, it may reset all your stats to zero, or two, you may end up with perfect 100s across the board. It’s a classic boom-or-bust scenario, and it could happen to anyone in the game.

Given how close it is to the end of 2019, we’ve seen Candywriter reference BitLife’s success as the year’s No. 5 most popular game on the Apple App Store. As that’s three spots ahead of Fortnite, which finished at No. 8, you will be asked in one scenario to choose which Fortnite dance you should perform in order to cheer up (we’d say more like troll) your friend who’s upset the latter game lost out to the former.

Just as usual, Candywriter has added a variety of new names, scenarios, and textual tweaks across the board, so you can expect to see more characters with unusual, double entendre-laden surnames, as well as one pun that particularly made us chuckle — are you down for a game of “call of booty” with that fling you met at the local club? You can also expect to lose a fair bit of Smarts if the 5-year-old child of your friend calls you a “sausage shark” and you respond with the very same insult — a classic case of the game punishing immature actions like it should.

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BitLife - Life Simulator – A Guide for All Ribbons in Game

Check out all the ribbons in bitlife - life simulator and how to collect them..

By now.gg team Sep 20, 2023

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BitLife – Life Simulator has been one of the premiere life simulator RPGs for players around the world, dictating the predictions that can happen if you choose to take certain steps in your life. Available for multiple platforms, the game has captivated millions of players by engaging them in heartwarming and intriguing text-based gameplay. It denotes that the life choices we make on a daily basis can have a significant impact on our future. Players can be whatever they want to be in the game, ranging from the likes of a Pilot to a Doctor, or an Engineer. 

Bitizens around the world, we have some amazing news for all! Enjoy playing your favorite RPG BitLife – Life Simulator (https://now.us/play/moana-games/51059/bitlife-life-simulator) right on your browser with now.gg, without the hassle of downloading additional game files and update patches! Revel in a seamless experience of interconnectivity across all your devices. Players can enjoy other games as well, or simply play together with your friends and family on a single platform.

In this article for BitLife – Life Simulator, we will be sharing details on the different Ribbons that are available to be collected by completing certain tasks in the game. These Ribbons act as Achievements, individual to each player, and can be used as proof of beating the hardest parts of the game. Ribbons are generally earned when you are successful in becoming what you want to be in life. 

Ribbon #1: Academic

Academic in BitLife – Life Simulator can be achieved by following the steps given below:

• Focus on your School life each year, trying to score higher marks in your exams.
• At age 6, start reading books. 
• At age 12, start going to a Library
• Attend a university and focus on higher-grade book reading
• Pursue medical school or go to any other graduate school with a degree in mind
• Finally, end up as a school teacher or principal

Ribbon #2: Barbie Girl

Barbie Girl in BitLife – Life Simulator can be achieved by following the steps given below:

• Start your career in a low-profile yet decent-paying industry. This is simply to afford more plastic surgeries. Avoid choosing intellectual and Academic careers.
• Get as many plastic surgeries as possible, excluding Gender Reassignment since you are required to be a Female for the entire duration of your life in order to get the Ribbon.
• Fun Fact: the game allows a Born male to have Gender Reassignment surgery and transform into a transgender female to get the Ribbon as well.

Ribbon #3: Cat Lady

Cat Lady in BitLife – Life Simulator can be achieved by following the steps given below:

• First things first, you need to be born as a Female or convert to a transgender female to achieve this Ribbon.
• To get this Ribbon, the pre-requisites are simple – adopt as many cats as possible and spend as much time with them as possible. Majority of your pets should only be cats, and avoid bringing different species. 
• For a bare minimum, experts suggest adopting 30 Cats.

Ribbon #4: Cunning

Cunning in BitLife – Life Simulator can be achieved by following the steps given below:

• You need to be involved in a Crime and sent to Jail.
• Solve a hard puzzle and escape from Jail.
• Get a Gender Reassignment surgery to escape from the eyes of the law.
• Escape from your current country to a different one. This will help you from getting caught.

Ribbon #5: Deadly

Deadly in BitLife – Life Simulator can be achieved by following the steps given below:

• The prerequisite is simple – murder people! A minimum of 5 people need to be murdered in order to get this Ribbon.
• Manslaughter will also count as a criminal offense, such as using Martial Arts or Taekwondo attacks on a person that might end up killing the person.
• Further, if Murder might not be your cup of tea, then hiring Hitmen to do the same also counts towards getting this Ribbon.

Ribbon  #6: Famous

Famous in BitLife – Life Simulator can be achieved by following the steps given below:

• Focus on your attractiveness from the get-go. Join a Gym and do not focus too much on Academics.
• Take up the role of a Theatre actor or a porn actor.
• Try working hard to get promoted and land a lead role in a movie. This will set you up to become a Movie Star
• Get low-cost surgeries if your Looks fall down below 80%. Regularly do manicures
• You can also get famous by advancing in the following careers – singer, model, chef, writer, DJ, mobile app developer, politician, reporter and magician.

Ribbon #7: Generous

Generous in BitLife – Life Simulator can be achieved by following the steps given below:

• Focus on being generous throughout your life, by gifting multiple presents to your family members and relatives
• Try to gift at least 30 items in a single year
• Have appreciation when giving gifts to others
• Avoid arguments from people, try to agree with them or simply apologize.

Ribbon #8: Hero

Hero in BitLife – Life Simulator can be achieved by following the steps given below:

• The prerequisite for this Ribbon is simple – try to save someone from dying intentionally without the help of the police or fire department.
• Saving someone but dying yourself will also fetch you this Ribbon.
• If you die in the military performing the deployment minefield puzzle, this Ribbon will also be given. 
• Successfully performing the Heimlich manoeuvre on a choking relative will also count towards this Ribbon.

Ribbon #9: Houdini

Houdini in BitLife – Life Simulator can be achieved by following the steps given below:

• Commit crimes to go to a prison, then escape it. Repeat this process multiple times by completing the mazes.
• A minimum of 10 prison escapes are recommended to get this Ribbon
• Try to not spend too much time in Jails or it will give you the JailBird Ribbon
• Escaping a Juvenile Centre multiple times also counts towards the Ribbon requirements.

Ribbon #10: Influencer

Influencer in BitLife – Life Simulator can be achieved by following the steps given below:

• Maintain a high score in the Health, Looks, and Smarts areas of life.
• Join social media networks once you reach the Age of 13.
• Post often on these social media networks to gain a following
• Try to get as many likes and followers by posting on trendy topics such as “Blog”, “Challenge”, “Dance”, “Gaming”, “Haul”, “How-to”, “Selfie”, “Sexy Pic”, “Skit”, “Story”.
• Another option is to simply buy followers
• Promote products to increase followers and gain attention
• Monetize social media accounts such as YouTube and Instagram to start earning money
• Once reach 100,000 followers, apply for verification on social media accounts to get the Social Media star badge.
• Reach a million followers across all social media accounts.

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‘Not Going To Be Silenced’: Surgeon Indicted By Biden DOJ For Blowing Whistle On Child Sex Changes Speaks Out

Screenshot/Youtube/Dr. Phil Primetime/

The Department of Justice (DOJ) recently indicted Texas surgeon Dr. Eithan Haim, who blew the whistle on a children’s hospital performing sex change procedures on minors. Haim told the Daily Caller News Foundation he will not be intimidated or silenced, vowing to fight the allegations in court.

In 2023, Haim discovered Texas Children’s Hospital was performing pediatric sex change procedures despite hospital administrators previously telling the public that their child gender program had been shut down. Haim provided documentation of the procedures to journalist Christopher Rufo, who published a May 2023 story in City Journal and on Substack exposing Texas Children’s Hospital. Shortly after the story was published, the Texas Legislature passed a bill banning pediatric sex change procedures statewide.

However, in June 2023, federal agents arrived at Haim’s home, notifying him of he may be the subject of a potential criminal investigation related to the published whistleblower documents, according to his fundraising page . The Biden DOJ was investigating Haim for alleged violations of the Health Insurance Portability and Accountability Act (HIPPA), a federal law that protects  individually identifiable health information, such as a patient’s name. (RELATED: THE WPATH TAPES: Behind-The-Scenes Recordings Reveal What Top Gender Doctors Really Think About Sex Change Procedures)

Haim has long maintained that the documents he provided Rufo did not include any such information. Rufo, who first reported Haim’s indictment in City Journal, wrote that he “can confirm that nothing in the information provided to me identified any individual; all the documents were, in fact, carefully redacted.”

I blew the whistle on @TexasChildrens secret sex change program and the @TheJusticeDept came after me for exposing the truth. After experiencing DOJ corruption we’ve decided to fight back. If you want to join the fight, donate below. https://t.co/ZMhL9LG3o1 — Eithan Haim MD (@EithanHaim) March 10, 2024

Threats of prosecution materialized this week when U.S. marshals appeared at Haim’s home and summoned him to appear in court Monday. Haim is charged with four felony counts of violating HIPPA, according to City Journal.

Haim told the Daily Caller News Foundation in an interview that he is not intimidated by the indictment.

“The most important thing is that, at this point, its game time,” Haim said. “We’re entering the arena, we have to fight back. I’m not going to be silenced, I’m not going to be intimidated. The most likely chance we have of winning, is to win this in court.”

On January 24, 2024, Haim’s legal team sent a letter to Republican Reps. Jim Jordan of Ohio and Chip Roy of Texas refuting the legitimacy of the claims made against Haim by federal prosecutor Tina Ansari.

The letter asserts the prosecution’s investigation was based on the “easily disproved falsehood” that the documents Haim provided contained children’s names.

“Yet it is obvious from a quick glance that all patient information is redacted,” Haim’s lawyers wrote. “Thus, either someone intentionally misrepresented this critical fact, or the investigation proceeded without anyone verifying the most basic facts about what happened.”

Haim estimates it will cost at least $500,000 to fight the charges in court.

“What that requires is at least $500,000 to pursue this federal trial with our attorneys,” Haim said.

His fundraising page shows he’s currently raised just over $310,000.

“Dr. Haim blew the whistle against a hospital that proclaimed it had stopped performing gender-changing surgeries and treatments on minors, when, in fact, it had not,” Haim’s lawyer Mark Lytle told the DCNF. “These surgeries are a violation of Texas law. Dr. Haim was brave in coming forward. Now the federal government is coming after him. He will strongly defend himself at trial and we expect he will be found not guilty.”

Haim maintains medical providers should be able to openly talk about procedures happening at their institutions, a sentiment core to his story.

“There’s nothing a doctor should do behind closed doors that they’re unwilling to defend in public,” Haim told the DCNF.  “That’s never how medicine should be, especially when it involves children.”

The Department of Justice did not immediately respond to a request for comment.

All content created by the Daily Caller News Foundation, an independent and nonpartisan newswire service, is available without charge to any legitimate news publisher that can provide a large audience. All republished articles must include our logo, our reporter’s byline and their DCNF affiliation. For any questions about our guidelines or partnering with us, please contact  [email protected] .

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The Biden Administration’s Final Rule on Section 1557 Non-Discrimination Regulations Under the ACA

Lindsey Dawson , Laurie Sobel , Kaye Pestaina , Jennifer Kates , Samantha Artiga , and Alice Burns Published: May 15, 2024

This brief provides an overview of the Biden Administration 2024 final rule implementing Section 1557 of the ACA, which is home to the law’s major nondiscrimination provisions. While Section 1557’s protections took effect when the ACA was enacted in 2010, much of its reach has been determined by implementation guidance issued across different Presidential administrations, often reflecting conflicting views. The final rule reinstates and expands upon many of the 2016 regulations from the Obama Administration and is a reversal from much of the 2020 Trump Administration rule. We provide a brief background on 1557 rulemaking and identify key differences between this rule and the 2020 rule. We also highlight two areas of growing interest impacted by the rule – nondiscrimination protections for pregnancy related decisions, past, present and future, including abortion, and for transgender people. Despite the issuance of the final rule, debates about 1557’s protections, and ensuing litigation, continue and will be particularly dependent on the outcome of the 2024 Presidential election.

Introduction

On April 27, 2024, the Biden Administration’s Department of Health and Human Services (HHS) finalized long-awaited revised regulations implementing Section 1557 of the Affordable Care Act (ACA). Section 1557 prohibits discrimination on the basis of race, color, national origin, age, disability, or sex and applies to health programs and activities receiving federal financial assistance (referred to as covered entities). In broad terms, it prevents covered entities from discriminating against certain protected groups in providing health care services, insurance coverage and program participation. The rule has staggered effective dates starting on July 5, 2024. In broad terms, 1557 provides nondiscrimination health care protections to individuals in protected groups, including prohibiting denial of benefits, coverage, program participation, and otherwise unequal treatment based on these factors

The administration also released a FAQ and press release . Section 1557 houses the law’s major nondiscrimination provisions by incorporating protections from existing civil rights laws. These laws include Title VI of the Civil Rights Act of 1964 (race, color, and national origin), Title IX of the Education Amendments of 1972 (sex), the Age Discrimination Act of 1975, and Section 504 of the Rehabilitation Act of 1973 (disability). Notably, Section 1557 is the first federal civil rights law to prohibit discrimination on the basis of sex in health care.

Section 1557’s protections took effect when the ACA was enacted on March 23, 2010, but much of the law’s reach has been determined by implementation guidance issued by different Presidential administrations, reflecting different interpretations  and  priorities. Across the Obama, Trump, and Biden administrations, the 1557 implementing regulations have volleyed back and forth in their interpretations, particularly related to the scope of entities covered by the law and the law’s ability to provide nondiscrimination protections based on sexual orientation and gender identity and pregnancy related conditions. These debates, and ensuing litigation, are likely to continue, and will be particularly dependent on the outcome of the 2024 Presidential election.

Most of the implementing regulations in the new rule are effective 60 days (July 5, 2024) after publication in the Federal Register (May 6. 2024). Some provisions impacting health insurance plan design won’t become effective until the plan year beginning after January 1, 2025, and other provisions where entities might need additional time to amend current practices also have later effective dates. (The rule and the FAQ provide a table of these dates.)

The FAQ accompanying the rule states it was necessary to issue this guidance “to restore and strengthen civil rights protections for individuals consistent with…the statutory text,” noting that the 2020 Trump Administration rule “covers fewer programs and services and limited nondiscrimination protections for individuals.”

Section 1557 has been subject to a wave of litigation across administrations. Litigation has both centered on rulemaking and on the statue itself. In some cases (e.g. Franciscan Alliance v. Azar ), courts have found narrowly in favor of plaintiffs who have asserted that the requirement to cover or provide certain services, such as those related to termination of pregnancy or gender affirming care, violated their sincerely held religious beliefs and thus religious freedom protections. In other cases, courts have found that Section 1557 protects access to these same services, such as by requiring state Medicaid programs to cover gender affirming care (e.g. Flack v. Wisconsin ). Courts have also weighed in on the legality of aspects of rulemaking (e.g. Whitman-Walker Clinic v. HHS ) and litigation has already been filed in the state of Florida by the attorney general and a Catholic hospital group challenging the new rule (see State of Florida et al v. HHS et al . )  In addition, litigation related to other civil rights protections ( Bostock v Clayton County, Georgia) has implications for Section 1557 and, in particular, this regulation’s interpretation of nondiscrimination based on sex. (Box 1)

Box 1: Impact of Bostock v Clayton County, Georgia on Section 1557

In June 2020, just three days after the Trump Administration rule was finalized, the Supreme Court ruled in  Bostock v Clayton County, Georgia that in the context of employment, discrimination based on sex encompasses sexual orientation and gender identity. The Bostock ruling does not directly apply to 1557 because it was based on interpretation of sex protections under Title VII and the 1557 sex protections are pulled in through Title IX. However, courts have historically looked to Title VII in interpreting Title IX, including in cases where plaintiffs challenged the Trump-era rule. As such, prior to issuing the new regulation , the Biden Administration issued guidance in May 2021 stating it would interpret and enforce 1557’s sex nondiscrimination provisions to include protections on the basis of sexual orientation and gender identity in light of and consistent with Bostock .

Summary of Major Changes

The final rule closely mirrors a proposed rule  issued by the Biden administration in July of 2022 and is, in many ways, a reversal of the final rule issued by the Trump Administration in June of 2020, which itself was a significant departure from the Obama Administration regulations issued in 2016. This  final  rule reinstates and expands upon much of those 2016 regulations. Compared to the previous rules, key changes in the Biden Administration final rule include:

• Section 1557 applies to health programs or activities that receive direct or indirect federal financial assistance from HHS, health programs and activities administered by HHS, and Therefore, covered entities include state Medicaid agencies, Medicare, many health insurance plans, and most hospitals and providers, among others. The new rule expands on the types of entities subject to 1557 compared to the Trump rule, including by determining that 1557 protections apply to products sold by issuers with plans on the marketplaces (not just the marketplace plans themselves) and by considering Medicare Part B as receiving Federal financial assistance for the first time;
• Provides nondiscrimination protections for those who experience discrimination on the basis of multiple protected characteristics. (A new protection compared to both the Obama and Trump rules);
• Explicitly provides for nondiscrimination protections based on gender identity and sexual orientation, sex characteristics (including intersex traits), and pregnancy related conditions including pregnancy termination, as well as related specific health insurance coverage protections, expanding these moderately compared to the Obama rule and completely compared to the Trump rule;
• Provides specific nondiscrimination protections for transgender people’s access to care and coverage, expanding moderately on those in the Obama rule and completely compared to the Trump rule. The rule requires people be treated consistently with their gender identity, prohibits the denial of gender affirming care when provided for other purposes, if the denial is on the basis of sex, and the categorical exclusion of gender affirming care. (See box 3 for additional details related to this provision);
• Protects patients from discrimination on the basis of actual or perceived abortions but states it is not a violation of Section 1557 if providers do not provide abortions unless the provider does not do so based on an individual’s protected status (e.g. race, age, etc.) (See box 2 for additional details related to this provision);
• Removes explicit blanket abortion and religious freedom exemptions which the Trump rule incorporated through Title IX’s religious exemptions, stating instead that robust religious freedom protections exist outside of Section 1557 and that incorporation of Title IX exemptions through the rule is not necessary;
• Adopts a new religious freedom and conscience protections exemptions process;
• The new rule reinstates explicit prohibitions on discrimination based on gender identity and sexual orientation that had existed in ten other federal regulations outside Section 1557. The protections were put in place through Obama Administration regulations and related to coverage, access, and marketing, in Medicaid, private insurance, and the Marketplaces but were eliminated in the Trump Administration’s 1557 rule.;
• Expands protections for those with limited English proficiency (including in telehealth) compared to both prior rules;
• Includes new provisions for services requirements and notices related to language access and access to auxiliary aids and services, and adopts new policies and staffing requirements for 1557 compliance;
• Reaffirms most requirements related to disability discrimination from the 2016 rule, which complement a new rule on web accessibility for public entities under the Americans with Disabilities Act and major updates to regulations implementing Section 504 of the Rehabilitation Act, which were last updated in 1977. Section 504 prohibits recipients of federal funding, including publicly-subsidized health payers and health care providers who accept Medicare or Medicaid, from discriminating against people on the basis of disability. Among other changes, the Section 504 health provisions address discrimination in medical treatment, create enforceable standards for medical equipment, address accessible web content and mobile apps, and codify the Olmstead requirement to serve people with disabilities in the most integrated setting that is appropriate.
• Reflecting emerging technologies, for the first time, addresses and applies Section 1557 nondiscrimination protections to the use of telehealth and patient care decision support tools, including in addressing bias in clinical algorithms and other tools and in the use of AI.

Box 2: Abortion – Protections from Sex Discrimination Includes Pregnancy Termination

The ACA protects providers and programs based on their willingness to provide, pay for, cover, or refer for abortion or to provide or participate in such trainings. The new final Section 1557 rule includes protections for patients on discrimination on the basis of having had actual or perceived abortions. OCR explains that a covered provider’s decision not to provide an abortion is not a violation of Section 1557 unless the provider chooses not to provide abortion for a particular individual based on a protected ground such as race. Some commenters “expressed concern that Dobbs created tension between health providers, and patients, increasing distrust in providers and that it has created chaos in the health care system. They state this has increased the risk that patients will experience discriminatory care and suffer delays in lifesaving treatment as a direct result of legal and medical uncertainty. These commenters said that discrimination in care propagates more distrust, which is a significant barrier for individuals seeking care and is precisely what section 1557 was designed to protect against.” OCR responded to these concerns noting that it is considering revisions to the HIPAA Privacy Rule to strengthen privacy protections for individuals’ protected health information related to reproductive health care.

Box 3: Care and Access for Transgender People – Protections from Sex Discrimination Include Gender Identity

Section 1557’s regulatory treatment of sexual orientation and gender identity has changed considerably over time. The 2016 Obama Administration rule interpreted sex nondiscrimination protections to include gender identity and sex stereotyping (among other identities) but not sexual orientation. At that time, HHS stated it would “evaluate complaints alleging sex discrimination … sexual orientation” on a case-by-case basis and anticipated that case law would evolve as to clarify whether sexual orientation could be covered. The Trump Administration did not define sex in the regulatory text but in the preamble suggested it would interpret sex to mean only biological sex assigned at birth. The Biden Administration interpreted sex to include sexual orientation and gender identity (among other identities), reaffirming its earlier guidance which took the same approach, in light of Bostock (see Box 1). It also extends these protections to include intersex people for the first time.

As noted above, the new rule also reinstates explicit prohibitions on discrimination based on gender identity and sexual orientation in regulations outside of Section 1557 that had been put in by the Obama Administration but eliminated through the Trump Administration’s 1557 rule.

In addition, the rule, in text and preamble, spells out specific protections for transgender people and access to gender affirming care including that entities cannot refuse gender affirming care services that would be provided to an individual for other purposes, if the limitation is based on sex or gender and that the categorical exclusions of gender affirming care is prohibited. It does not prohibit nondiscriminatory denial of services with the preamble noting “OCR has a general practice of deferring to a clinician’s judgment about whether a particular service is medically appropriate for an individual, or whether the clinician has the appropriate expertise.” OCR states any investigations will not focus on clinical judgment per se but rather whether that judgment reflects unlawful bias, The rule also does not prevent a covered entity from availing itself of religious freedom and creates new pathways for asserting such protections. (Additional details in Table 1.)

Some commenters had specific concerns regarding the rule’s application to “State laws that prohibit access to gender-affirming care…” OCR responded that “some States may have laws…that are contrary to the final rule’s nondiscrimination protections, and…section 1557 preempts those laws.” The conflict between state and federal law in this case is unresolved and the Florida Attorney General, along with a Catholic medical group, has filed suit alleging that the rule requires providers to provide gender affirming care and violates protections.

Table 2 summarizes the major provisions of HHS’s new final rule and provides a side-by-side comparison to the Obama (2016) and Trump (2020) administration rules.

• Affordable Care Act
• Women's Health Policy
• Racial Equity and Health Policy
• Consumer Protection
• Access to Care

news release

• KFF Examines New Rule Giving LGBTQ+ People More Protections Against Discrimination in Health Care

Also of Interest

• LGBTQ Health Policy
• The Trump Administration’s Final Rule on Section 1557 Non-Discrimination Regulations Under the ACA and Current Status
• Summary of HHS’s Final Rule on Nondiscrimination in Health Programs and Activities

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