A sweeping federal campaign to curb gender-affirming care for minors is testing the limits of Washington’s authority over medicine and placing San Francisco clinics at the center of a national legal battle, leaving transgender adolescents uncertain about whether their treatment will continue.
Federal policy debates about transgender health care are already affecting the San Francisco Community Health Center, even though new federal regulations have merely been proposed.
“You don’t have to ban something outright to restrict access to it,” said Dr. Tatyana Moaton-Santiago, the clinic’s chief strategy and workforce officer. “You just have to make people afraid — afraid to provide it, afraid to seek it, afraid to fund it.”
This episode of “Civic” examines how federal actions targeting gender-affirming care for minors are affecting clinics, families and transgender youth, drawing on patients, providers and legal experts to understand what’s at stake for trans youth nationwide.
In December, U.S. Department of Health and Human Services Secretary Robert F. Kennedy Jr. announced new federal policy proposals that would bar hospitals that receive Medicare and Medicaid funding from providing gender-affirming care to minors.
“We’re done with junk science driven by ideological pursuits, not the well-being of children,” Kennedy said.
Because most hospitals depend on Medicare and Medicaid reimbursements, critics say the proposals could effectively function as a nationwide ban.
Community health centers across the country rely heavily on federal support and regulatory approval to operate, and on participation in Medicaid and Medicare programs that provide a large share of their funding.
Even though no new regulations have been issued, San Francisco Community Health Center leaders say consequences have already arrived. Lance Toma, the organization’s chief executive officer, said the clinic lost federal funding shortly after the administration took office in 2025 because of the clinic’s work serving transgender patients of all ages. Toma said funding from the Centers for Disease Control and Prevention was terminated because of its “trans focus.”
At the same time, the U.S. Department of Justice has taken steps to investigate providers offering gender-affirming care, including seeking medical records from hospitals.
That legal and financial pressure, Moaton-Santiago said, forces clinicians to weigh the needs of their patients against potential dire consequences.
“We’re having providers who are having to make the choice of providing medically necessary care to folks who are seeking gender-affirming care, having to vacillate between those decisions and what are the policy implications, what are the legal implications,” she said.
San Francisco has long positioned itself as a national leader on LGBTQ+ health care. But Moaton-Santiago said the city’s political support does not shield clinics that rely on federal funding from shifts in federal policy.
“We operate in a federally regulated ecosystem,” she said. “We participate in federal programs, and that creates vulnerability, regardless of what city or state policy says.”
At the University of California, San Francisco — one of the nation’s leading providers of gender-affirming care — officials said they are reviewing the federal proposals and assessing their implications for clinical services. In a statement, the university said it would “continue to do all we can to support the interests of our clinicians, patients and families, and the dignity of all members of our community.”
Caught in political crossfire
For some patients, the stakes feel intensely personal.
Eric, a 15-year-old sophomore at Oakland High School, began hormone therapy after working with doctors, therapists and his family. He said he realized during middle school that he wanted to transition, and the care he received helped address the distress he felt during puberty.
But in recent months, Eric has been watching federal policy debates with growing anxiety.
“I do worry that the care could get cut off,” he said. “Testosterone is a controlled substance. If my doctors aren’t allowed to prescribe it to me anymore, then I have to find some way to get this thing that I really need to live my life.”
At a November rally outside the Emeryville headquarters of Sutter Health — a Northern California hospital system that had announced it would halt care for transgender minors before later delaying the decision — Eric framed the issue as one of autonomy.
“People who are arguing for small government are trying to say that government should have a voice in my medical decisions, my personal medical decisions that I spent months consulting with my therapist, my parents and my doctors about,” he said.
Disputed report drives policy
The upheaval began with President Trump’s announcement shortly after his inauguration that “it will henceforth be the official policy of the United States that there are only two genders. Male and female.”
In the months that followed, he signed a series of executive orders targeting transgender rights for people of all ages, prompting federal agencies to issue guidance, launch investigations and propose new regulations.
The Department of Health and Human Services also commissioned a report on gender-affirming care for minors as the scientific basis for its proposed restrictions. It argues that medical treatments — including puberty blockers and hormone therapy — lack sufficient evidence of safety and effectiveness.
Supporters say the report reflects growing international debate about how best to treat adolescents with gender dysphoria.
But many physicians and medical groups sharply dispute its conclusions. Critics say the review departs from the standards used by major medical associations and relies on a narrow interpretation of existing research.
Some researchers have also questioned how the report was assembled, noting that the author group included policy specialists and analysts outside the area of pediatric or psychiatric medicine.
Dr. Jack Turban, a psychiatrist at UCSF, where he directs the Gender Psychiatry Program, said the document reads less like an independent scientific review than a justification for a policy decision already made.
For decades, clinical guidelines have supported treatment for carefully evaluated adolescents. The care often starts with counseling, then social transition, like name and pronoun changes, and, in some cases, medications, such as puberty blockers or hormone therapy. Surgery for minors is rare, and the number of people who receive this care is tiny. Estimates suggest that 1% to 2% of U.S. teens identify as transgender, and only a subset pursue medical treatment.
Courts likely to decide outcome
Most consequential policy changes are still moving through the federal rulemaking process. That includes publishing proposed rules, gathering public comments and issuing a final regulation that responds to those comments.
Dale Melchert, a staff attorney for the Transgender Law Center, an Oakland nonprofit law firm, said the process imposes legal constraints on federal agencies.
“Agencies can’t just act arbitrarily,” Melchert said. “If they’re going to take a drastically different position from the prior regulation, they have to explain how or why.”
Even then, the federal proposal to bar hospitals participating in Medicare and Medicaid from providing gender-affirming care to minors may face significant legal challenges, he said.
Melchert pointed to a section of the Social Security Act that says that the federal entity providing health care funding — the Centers for Medicare & Medicaid Services — is not authorized to exercise supervision or control over the practice of medicine.
“It is unprecedented,” he said.
If the agency attempts to enforce the proposed restrictions, courts will likely decide whether the policy exceeds federal authority, he said.