Texas Emerges as Focus of New Trump Administration Actions to Limit Gender-Affirming Care 

Since early 2025, the Trump Administration has sought to limit youth access to gender-affirming care, taking a comprehensive approach to impose and enforce limitations. The administration has implemented or initiated dozens of actions with this aim, some of which have been challenged in court. In response to these actions, at least 40 health care institutions have walked back the provision of gender-affirming care over the last year and a half. This attrition has occurred in waves and in direct response to policy making – first following an executive order laying out the administration’s approach to limiting this care in January 2025, and then several times since in response to subpoenas (see below), proposed rulemaking, and a (now vacated) “declaration” from the Secretary of Health and Human Services, among other efforts. Over this period, when providers shut down services, they have generally said they were doing for reasons such “external pressures beyond our control,” “new federal orders targeting such procedures,” and “mounting pressure from the federal government”, not because they had concerns about safety, medical indication, or effectiveness. At times state Attorneys General have pushed providers to reopen or maintain services, stating that failing to do so would put them in potential violation of state non-discrimination laws and some have expressed frustration that pulling back on this care has at times preempted formal policy making. Pressure from the federal government to end care, oppositional pressure from states to provide care, and institutional barriers to providing best practice care, have left clinics and clinicians in a challenging position.

Notably, the most recent actions out of the administration have been concentrated in Texas, even though the state has banned youth access to gender-affirming medical care since 2023. The administration may have  selected Texas as a site to enforce and pursue investigations against providers in an effort to forum shop and force changes within a hospital in a state where the Attorney General has aligned policy priorities. This includes three main actions in just the last couple of weeks, widely seen as intensifying federal efforts to limit this care. The three actions are as follows:

• On April 30, 2026, the DOJ sought assistance from a federal district court in Texas  in enforcing a subpoena of Rhode Island Hospital (RIH). This request for enforcement stemmed from a July 2025 action where the department issued over 20 civil subpoenas (at least 7 of which have been quashed in court) to providers delivering gender-affirming care to young people, including to RIH. While the hospital does not operate in Texas, DOJ states its investigation of Federal Food, Drug, and Cosmetic Act (FDCA) claims is taking place in the Northern District of Texas in front of Judge Reed O’Connor  without providing a more detailed explanation for the relevance of the venue. The DOJ appears to be especially focused on off-label prescribing of hormonal/puberty blocking prescription medication, a common practice in medicine across medication classes and diagnoses. The FDA regulates drug approval, labeling and manufacturer promotion. However, the FDA does not regulate physicians’ prescribing decisions. This marked the first time the department asked a court to compel compliance with these administrative subpoenas. Within hours of the request for enforcement, and before hearing from RIH, the Texas court ordered RIH to comply within 14 days. RIH appealed to the 5^th Circuit Court of Appeals (covering Texas, Louisiana, and Mississippi) and sought a stay which was denied, though the appeal continues.
  
  In parallel, on May 4, 2026, the Rhode Island Child Advocate, the state official charged with protecting the legal rights of children in state care, asked a  federal district court in Rhode Island  to quash the same subpoena and on May 9^th the hospital asked to join as an intervenor (specifically noting it had not had an opportunity to respond to DOJ’s petition in Texas and that the clock to comply with the order was running), which the court granted. RIH filed its own motion to quash on May 11^th. On May 13, 2026, the court quashed the subpoena and enjoined DOJ from “seeking, receiving, using, retaining, or disseminating any patient-identifying information or protected health information produced by RIH in response to Administrative Subpoena.” The court also questioned the case’s nexus to Texas. DOJ stated it would comply and appeal to the 1st Circuit Court of Appeals (covering Maine, Massachusetts, Rhode Island, and Puerto Rico), which it filed on May 15th.
  
  On May 18^th the federal district court in Texas demanded that RIH produce the requested documents in just over 24 hours in camera (to be held by the court and not available to DOJ). In response, though they were not a party in the Texas matter, Rhode Island Child Advocate sought an emergency injunction with the 1^st Circuit on May 19^th , requesting the court order the hospital not to produce documentation (to the Texas district court). The 1^st Circuit denied the emergency request that night. At the same time, RIH told the Texas court it planned to comply with the document request and would anonymize and de-identify patient information (though on an extend timeline than that requested by the court). Watching what happens next will require monitoring both district (Texas and Rhode Island) and both appellate (5^th and 1^st) courts moving forward and teasing out parallel litigation.   
• On May 6, 2026, the U.S. Attorney’s office in the Northern District of Texas issued grand jury subpoenas to NYU Langone Hospital, and per NYU, other health care institutions. A grand jury summons suggests a criminal investigation, as does the direction to turn requested documents over to the FDA’s Office of Criminal Investigation. This is widely viewed as an escalation over the previous subpoena efforts that were administrative in nature. These subpoenas were issued by the Federal District Court in the Northern District of Texas  less than a week after DOJ efforts to enforce the out of state RIH administrative subpoena in Texas, in the same federal district court (discussed above).
  
  What is known is based on information released by NYU Langone, first by way of a public statement, and then in making the full subpoena public (and eventually adding it to an updated version of their statement. New York’s Shield Law requires any entity in the state that receives a request for legally protected health information to attempt to notify the individuals to whom that request pertains at least 30 days before complying with it, which may have influenced the hospital’s decision to go public.  The subpoena to NYU included a sweeping demand for document production for the 2020-2026 time period. The documents requested included, for example, personnel files of those associated with provision of or billing for gender-affirming care, billing records and documentation policies, communications and materials with pharmaceutical companies regarding gender-affirming care, the identities of and detailed medical information on patients seen for gender-affirming care, communications related to off-label use of hormones, communications with World Professional Association for Transgender Health (WPATH), among other types of information. The subpoena requests that the produced materials be sent to the FDA Office of Criminal Investigations in the Kansas field office which might suggest an investigation related to the FDCA. 
• On May 15, 2026, the DOJ announced a “resolution to end pediatric ‘gender-affirming care’ and create [a] detransition clinic” with Texas Children’s Hospital [TCH]. DOJ stated the settlement is part of its “ongoing national investigation into violations of federal law in connection with the provision of sex-rejecting procedures on minors” (their term for gender-affirming care). The release stated TCH “entered into agreements with the Department and the Texas Attorney General that include commitments” not to provide young people with gender-affirming medical care (which is already banned in Texas) and “pay over $10 million in damages and civil penalties” related to “false billing” allegations under the FDCA, the False Claims Act, and federal fraud and conspiracy laws. Additionally, TCH agreed to establish a clinic dedicated to providing detransition-related services, an unusual move that the state and DOJ say are “first-of-its-kind”.In relatively rare cases when someone seeks medical care in detransitioning, they would not need a specialized clinic to do so.Separately, the Texas AG, Ken Paxton, issued his own press release with similar content to the one issued by DOJ except that it additionally notes that as part of the settlement, multiple providers were terminated and had their privileges revoked.
  
  The DOJ wrote that “the claims resolved by the United States in the settlements are allegations only and there has been no determination of liability. Both entities have denied all allegations.” In a press statement that has since been removed from their website, TCH, wrote that throughout the process with the DOJ and Texas AG they have been “navigating an unconscionable campaign of mistruths and mischaracterizations related to gender affirming care.” The institution writes they have been compliant with all laws and is “settling to protect our resources from endless and costly litigation.” 

The administrative and grand jury subpoenas as well as the settlement DOJ entered into with TCH, especially relating to provider terminations and revocation of privileges, will likely add to the chilling effect already characterizing the provision of gender-affirming care. Additionally, the language used throughout the DOJ documents discussed here could foster misinformation related to gender-affirming medical care (such as referring to it as a “destructive and discredited practice”), which remains recommended for young people who need it.

While Texas has banned core gender-affirming medical services for young people since 2023, the Trump administration DOJ has chosen a federal district court in Texas to file its enforcement efforts, and with the help of the Texas Attorney General negotiated a settlement with a Texas hospital, potentially seeing it as a warning to other hospital systems. The Rhode Island federal district court judge who quashed the administrative subpoena offers one theory as to why the lone star state has been in the spotlight, in a generally sternly worded order, accusing DOJ of selecting Texas “in favor of a distant forum that DOJ deems friendly to its political positions.”