Federal Legal Actions and the Shifting Landscape of Gender-Affirming Care in Texas

The landscape for gender-affirming medical care in the United States has undergone significant transformation over the last eighteen months. As the Trump administration continues to implement a comprehensive strategy to limit youth access to such care, Texas has emerged as a primary focal point for federal enforcement efforts. These actions, characterized by an increase in subpoenas and high-profile legal settlements, have created a challenging environment for health care institutions, clinicians and the families they serve.

A Coordinated Approach to Limiting Care

Since early 2025, federal policy has sought to restrict gender-affirming services through a series of executive orders, proposed rulemaking, and administrative declarations. These measures have prompted at least 40 health care institutions to discontinue gender-affirming services. In many instances, providers have cited mounting federal pressure and the need to navigate an increasingly complex legal and regulatory environment as primary reasons for closing these programs, rather than concerns regarding clinical safety or medical efficacy.

While Texas has maintained a state-level ban on gender-affirming medical care for minors since 2023, federal authorities have increasingly selected the state as a venue for litigation. Legal observers and judicial orders have noted that this strategy may represent an effort to pursue enforcement in jurisdictions viewed as favorable to the administration’s policy objectives.

Recent Federal Enforcement Efforts

In recent weeks, the Department of Justice (DOJ) has intensified its actions, focusing on hospitals and providers through both administrative and criminal investigative channels:

• Subpoena Enforcement: The DOJ sought to enforce an administrative subpoena against Rhode Island Hospital in a federal district court in Texas. This move, which was met with legal challenges in both Texas and Rhode Island, highlights the administration’s focus on off-label prescribing practices for hormonal medications.
• Grand Jury Investigations: 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 other institutions. The involvement of the FDA’s Office of Criminal Investigation signals a shift toward potential criminal inquiries regarding billing and prescribing practices.
• Hospital Settlements: On May 15, 2026, the DOJ announced a settlement with Texas Children’s Hospital. The agreement includes provisions for the hospital to cease providing gender-affirming care, pay over $10 million in damages and civil penalties, and establish a clinic dedicated to detransition-related services.

The Impact on Clinical Practice

The current environment has left many clinicians in a difficult position. The use of language in federal documents—such as characterizing gender-affirming care as a “destructive and discredited practice”—stands in contrast to the guidance provided by major medical organizations, which continue to recommend such care for young people when clinically indicated.

The settlement with Texas Children’s Hospital, which included the revocation of provider privileges and the termination of staff, serves as a significant warning to other health systems. Many institutions now face the choice of maintaining services in the face of litigation or withdrawing to protect their resources from ongoing legal costs. This “chilling effect” has made it increasingly difficult for patients to access best-practice care, creating a fragmented and uncertain system of support.

Key Takeaways

• Strategic Venue Selection: The federal government is actively utilizing courts in Texas to enforce subpoenas and settle cases, even when the institutions involved are located in other states.
• Escalation of Tactics: The shift from administrative subpoenas to grand jury investigations involving the FDA’s Office of Criminal Investigation marks a significant escalation in federal oversight.
• Institutional Attrition: Dozens of hospitals have ended gender-affirming services, citing external pressures and the need to mitigate legal risk.

Looking Forward

As litigation continues to unfold across multiple federal districts and appellate courts, the long-term status of gender-affirming care remains in flux. Patients and providers are left to navigate a landscape where federal policy and state-level legal environments often conflict. For those requiring care, the current climate necessitates careful monitoring of both state and federal court decisions, as these rulings will continue to shape the availability of medical services for the foreseeable future.