According to a recent CMS letter, clinics across the country are being warned against providing gender-affirming care to individuals under the age of 21. “Federal financial participation (FFP) is strictly limited for procedures, treatments, or operations for the purpose of rendering an individual permanently incapable of reproducing and, under 42 C.F.R. 441.253(a), is specifically prohibited for such procedures performed on a person under age 21,” the letter reads, citing a 1978 regulation restricting federal funding for sterilization.

It appears increasingly likely that the Trump administration is preparing to target transgender adult healthcare nationwide. In his campaign video, Trump stated he intends to investigate gender-affirming care for transgender people of any age. At the same time, reports indicate the Department of Health and Human Services is preparing to release a junk science review targeting both transgender youth and adults, with one internal letter referencing plans to study the “chemical and surgical mutilation of children and adults.”

It would not take much for transgender adult care to be severely disrupted. The forthcoming HHS report could be used to justify a national executive order threatening hospital funding for any institution that treats transgender adults.