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Four of the five remaining candidates for the Republican presidential nomination clashed noisily Wednesday night on a variety of healthcare issues during the final Republican debate before the 2024 primary season begins, discussing everything from gender-affirming care to fixing the healthcare system to solving the fentanyl crisis.

At the debate, which was held at the University of Alabama in Tuscaloosa and hosted by NewsNation, the transgender care question was provocatively introduced by Megyn Kelly, a SiriusXM radio host and one of three debate co-moderators.

"You came out in favor of a ban on trans medical treatments for minors, saying it's a parental rights issue," Kelly said to former New Jersey Gov. Chris Christie. "The surgeries done on minors involve cutting off body parts at a time when these kids cannot even legally smoke cigarettes. Kids who go from puberty blockers to cross-sex hormones are at a much greater likelihood of winding up sterile. How is it that you think parents should be able to OK these surgeries -- never mind the sterilization of a child -- and aren't you way too out of step on this issue to be a Republican nominee?"

Christie stood his ground. "No, I'm not," he answered. "Because Republicans believe in less government, not more ... We're out there saying that we should empower parents in education ... We should empower parents to be teaching values that they believe in, in their homes without the government telling them what those values are. And yet we want to take other parental rights away," including their decision-making ability when it comes to their underage transgender children.

Christie added that although he personally thinks gender transition surgery "is a very, very dangerous thing to do, that's my opinion as a parent, and I get to make the decisions about my children ... Every parent who is out there watching tonight, you start to turn over a little bit of this authority, the authority they're going to take from you next, you're not going to like. I'll stand up for parents each and every day."

Florida Gov. Ron DeSantis disagreed. "As a parent, you do not have the right to abuse your kids," he said to loud applause. "I signed legislation in Florida banning the mutilation of minors because it is wrong. We cannot allow this to happen in this country."

DeSantis's remarks brought a rebuke from the Endocrine Society, which said in a that his statement "contradicts mainstream medical practice and scientific evidence" and that his "comments characterizing gender-affirming care for transgender and gender-diverse youth as child abuse and genital mutilation do not reflect the healthcare landscape."

"Contrary to widespread misinformation, gender-affirming genital surgery is rarely offered to anyone under the age of 18," the society continued. "Major medical and scientific organizations including the American Medical Association, the American Psychological Association, and the American Academy of Pediatrics are in alignment with the Endocrine Society on the importance of gender-affirming care."

Former South Carolina Gov. Nikki Haley said that when she was in that position 10 years ago, the issue of whether transgender kids could use the bathroom of their preferred gender affected "maybe a handful of kids" in the state, and she said her administration agreed that "boys go into boys' bathrooms, girls go into girls' bathrooms, and if anyone has an issue with that, they use a private bathroom." On a related front, Haley added that "I also say that biological boys shouldn't be playing in girls' sports, and I will do everything I can to stop this because it's the women's issue of our time."

Tech entrepreneur Vivek Ramaswamy repeated his opinion that "transgenderism is a mental health disorder" and that procedures shouldn't be done on minors. "We don't let you have a drink of alcohol [until] age 21," he said. Just as President Reagan used federal highway money as leverage to get states to raise the drinking age to 21, "we can do the same thing when it comes to banning genital mutilation or chemical castration."

The Affordable Care Act (ACA) also came up in the discussion. DeSantis noted that Florida didn't expand Medicaid under the ACA, and that the states who did that "are struggling financially ... But we're going to go after the cost." People are paying too much for everything, and to fix that "you need price transparency, you need to hold the pharmaceutical [companies] accountable, you need to hold big insurance and big government accountable, and we're going to get that done," DeSantis said; he didn't offer further specifics.

Ramaswamy pushed for more competition. "We don't have a healthcare system in this country; we have a sick-care system," he said. "We need to start having diverse insurance options in a competitive marketplace, and cover actual health, preventive medicine -- diet, exercise, lifestyle, and otherwise. And here's how we deliver that: end the antitrust exemptions for health insurance companies. That's where the competitive marketplace begins."

The candidates also had vastly differing opinions on the causes of and solutions for the fentanyl crisis. "Drug cartels are invading our country and they are killing our citizens by the tens of thousands every year," said DeSantis. "The elites in [Washington] D.C. don't care that fentanyl is ravaging your community ... [The president] has a responsibility to fight back against these people." He recommended building a wall across the Southern border to prevent the drugs from coming in.

Although securing the border wall might help, "the harder part is dealing with a crisis of purpose and meaning -- the mental health epidemic that's raging across the country like wildfire," said Ramaswamy. "Even after we get [rid of] fentanyl ... we're deluding ourselves; the real false promise here is thinking that we're going to have dealt with the underlying mental health epidemic in this country by just dealing with the demand side of it."

Haley pointed the finger at where the fentanyl was originally coming from: China. "We need to end normal trade relations with China until they stop murdering Americans with fentanyl," she said. "They need our economy; they will immediately stop that."

During the debate, the candidates were combative, often talking over one another and claiming that one of their competitors took an opposing position -- something the competitor often denied. The only candidate not involved at all was former president and current front-runner Donald Trump, who skipped the debate entirely as he had done for all the other Republican debates.

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