DETROIT — The Michigan parents of transgender minors who rely on gender-affirming health care, such as hormones and puberty blockers, said they are living with fear as the Trump administration targets what the president calls a "dangerous trend" and what defenders call "life-saving" care.

At least nine Michigan facilities now offer gender-affirming care for those younger than age 18, according to Planned Parenthood of Michigan. Three of the nine are in the Grand Rapids area, two are in both Detroit and Ann Arbor and there is one each in Marquette and Ypsilanti.

Gender-affirming care refers to social, psychological, behavioral or medical interventions that support and affirm someone's gender identity, according to the World Health Organization. It can include hormone treatment, puberty blockers and surgery that aid in transitioning to another gender.

Michigan Medicine, one of the state's largest hospital systems, confirmed it provides "comprehensive care" to transgender, non-binary, and gender diverse children and adolescents at the C.S. Mott Children's Hospital. But the University of Michigan health system wouldn't comment on how many patients it serves or the specific types of care it offers, though details on Planned Parenthood of Michigan's website said it offers puberty blockers and hormone therapy.

"University of Michigan Health teams are assessing the potential impact of executive orders and agency actions on all of our health care services and the communities we serve," spokeswoman Mary Masson wrote in an email. "Our priority remains delivering high-quality, accessible care to our patients while ensuring compliance with the law."

In January, President Donald Trump signed an executive order that would end federal research and education grant funding for institutions that provide gender-affirming care to minors, if enforced. A federal judge blocked enforcement of the order in March, while a lawsuit filed by several states against the Trump administration plays out.

“It is the policy of the United States that it will not fund, sponsor, promote, assist, or support the so-called ‘transition’ of a child from one sex to another, and it will rigorously enforce all laws that prohibit or limit these destructive and life-altering procedures,” the order says.

Trump's executive order referred to gender-affirming care as engaging in the “maiming,” “sterilizing” and the “mutilation” of minors. The order encourages Congress to adopt a law letting those who receive gender-affirming care and come to regret it, or their parents, to sue the providers.

Shortly after the order was signed, one of Michigan's largest hospital systems, Corewell Health, announced it would no longer begin new hormone therapy regimens for minors seeking gender-affirming care.

Karessa Weir Wheeler, of Lansing, has a 22-year-old transgender daughter, Ellie, and a 16-year-old transgender son, Newt. Newt sees an endocrinologist who is part of a Corewell Health group, she said.

"We were established patients, so we felt a little bit safe, but when we had Newt's next appointment, it brought along a lot of fear," Wheeler said.

Corewell quickly reversed its decision after Equality Michigan urged Corewell Health’s Board of Directors and executive leadership to reevaluate their decision in a letter co-signed by 45 other organizations.

"It was just really disheartening to see health care institutions quickly withdraw care because of an executive order," said Roz Keith, founder of Stand with Trans, one of the letter's cosigners.

Michigan Attorney General Dana Nessel also wrote an open letter to Michigan health care providers and patients, reminding them that federal funding has no influence on Michiganians' right to health care without discrimination, or health care providers' obligation to comply with Michigan's antidiscrimination laws.

That came ahead of a group of Michigan Republican legislators introducing a package seeking to ban gender-affirming care statewide for children under 18, arguing that safeguards need to be put in place until teens are older and can make such life-changing decisions.

"I want any kid going through a difficult time to get the help they need," said state Sen. Thomas Albert, R-Lowell, during a May 7 press conference. "That care should be evidence-based and always in the child’s best interest, both now and in the future."

Rejecting gender ideology

About 1.6 million people ages 13 and older — 0.6% of the population — identify as transgender in the United States, according to the Williams Institute at UCLA School of Law. This includes 1.4% of youth ages 13-17, or about 300,000 youth, and 0.5% of adults, or about 1.3 million adults.

Studies have shown that gender-affirming care for transgender people under the age of 18, such as puberty blockers, mitigates negative mental health outcomes.

A study led by two authors at Seattle Children's Gender Clinic found having access to hormones and puberty blockers for youth ages 13 to 20 was associated with 60% lower odds of moderate to severe depression and a 73% lower odds of self-harm or suicidal thoughts compared with youths who did not receive these medications over a 12-month period.

But the Trump administration has targeted trans health care during the president's first months in office. In February, the administration was forced by a court order to restore a webpage put up by the Department of Health and Human Services about gender-affirming care, but said it rejected the concept of “gender ideology” and said there are only two sexes, male and female.

“Any information on this page promoting gender ideology is extremely inaccurate, and disconnected from the immutable biological reality that there are two sexes, male and female," the HHS website said. "The Trump Administration rejects gender ideology and condemns the harms it causes to children, by promoting their chemical and surgical mutilation, and to women, by depriving them of their dignity, safety, well-being, and opportunities.”

Earlier this month, the Trump administration issued a 409-page report that questions standards for the treatment of transgender youth issued by the World Professional Association for Transgender Health. It advocates for a greater reliance on behavioral therapy rather than broad gender-affirming medical care for youths with gender dysphoria. Critics have called the report inaccurate.

There is no evidence to suggest that identifying as transgender is an inherent risk factor for mental illness in adolescents, and is not a mental disorder, according to the American Academy of Pediatrics.

But Michigan GOP lawmakers pushing the proposed statewide ban on gender-affirming care for minors said there's no long-term evidence that these services are safe.

Albert, a co-sponsor of a three-bill package, likened the proposal to age restrictions on driving, smoking and drinking.

"These safeguards exist because we understand that kids need time to grow, mature and fully understand the consequences of major decisions," he said.

The bills also would expand patients’ ability to seek damages for medical malpractice and would require health insurance providers to cover the costs for patients who choose to detransition.

Albert said the package was designed with "compassion, care and common sense."

At least one study published in the Journal of the American Medical Association shows that it is rare for adolescents who receive gender-affirming care to regret it several years later.

Advocates said the care is "life-saving," as was the case for Keith, the founder of Stand with Trans, whose son came out as trans in 2013. She'd never heard of gender-affirming care and had no idea what it meant, but her son, who was in eighth grade at the time, did.

"He had done research for two years, so he knew exactly what he needed, what he wanted to do, what his next steps were for his transition, but we had to catch up," Keith said. "I knew that he was struggling, and as a parent, I knew ... I would do whatever was needed to take care of my child, but I just didn't know what that was."

Wheeler agreed that gender-affirming care is not optional.

"This is both physical and mental care for them," Wheeler said. "It keeps them feeling safe and supported and feeling good about their body, feeling confident about themselves, that they are exactly who they know themselves to be."

Still, resources for trans adolescents and their families were scarce when Keith's son came out in 2013. It took almost a year to get him the support that he needed, and the family traveled to Boston to see a specialist.

Hoping to help other families in the same situation, Keith founded Stand with Trans, a Farmington-based nonprofit that helps trans kids and their families access resources such as support groups and therapy, in 2015.

"These adolescents and young teens had, you know, they felt they were the only ones, and so it was really important for them to find community and to see that they weren't alone," Keith said. "And parents needed a place to safely talk."

Wheeler's family currently works with Stand with Trans, and she said support from the community, along with medical providers and even state lawmakers, is helpful for her as a parent.

"It's so scary when you think about people just wanting your child to not exist," Wheeler said. "Just that dread of seeing your child leave the nest and go out in the world that doesn't want them, but having other parents go who have gone through it, and just communities that they themselves have found..., they definitely get their support from their communities, too."

Expanded care

Over the last decade, care available for transgender youth has expanded significantly in Metro Detroit, Keith said. The nine providers of gender-affirming services for people under the age of 18 are all over the state, including a few in northern Michigan. Several declined to be interviewed, including Corewell Health, which also offers gender-affirming care to those under 18 through Helen DeVos Children's Hospital's Gender Care Clinic.

Corner Care Center in Ypsilanti and the Ruth Ellis Center in Detroit also declined to comment.

Keith said 10 years ago, the conversation around trans kids "was always about the bathroom."

"Unfortunately, that conversation has dissolved into harmful rhetoric about taking away rights and that trans people don't exist, and that nonbinary identities don't exist, and that you are what your biological sex is," she said.

While many good things have happened within the transgender community, they're still fighting an uphill battle, Keith said.

"It's like ... dodgeball," Keith said. "Every day, there's something new, and we're trying to stay on top of it."

Within its first months in office, the Trump administration has made several efforts to erase the mention of transgender people on U.S. government websites and passports and remove them from the military.

Wheeler said it's been demoralizing for her whole family, and they have talked through different scenarios, in case access to gender-affirming care becomes more limited.

"Some of the options that the endocrinologist laid out to us made a lot of sense," Wheeler said. "If we can't continue the hormone therapy, kind of our best option until Newt turns 18 would be to continue the puberty blockers."

The family is thankful that Newt still has access to care, but has backup plans in place, Wheeler said.

"It is a little bit scary every month when we go to fill those prescriptions, you know, whether it's gonna actually happen or not," Wheeler said.

Fears about losing access

Erin Knott, executive director of Equality Michigan, said parents overwhelmingly don't want politicians dictating their children's medical decisions.

"The health and well-being of transgender youth should never be a political talking point. Parents — not the government — are best positioned to make decisions about their children’s healthcare," Knott wrote in an email. "They deserve the freedom to access the care their child needs, just like any other family."

Denying access to gender-affirming care has real, harmful consequences, she said.

"It puts transgender youth at significantly increased risk for anxiety, depression, and suicide," Knott wrote in an email. "Every major medical association agrees: transgender young people, like all young people, do best when they are supported and can access medically necessary care guided by well-established standards."

If young people can access care, it erodes their self-esteem and their mental health can take a downturn, Keith said.

"People feel like they're these hard-won rights, and all the progress we've made, are going to disappear, that we are taking steps backwards," Keith said. "It's anxiety-inducing."

While Wheeler feels confident that Michigan residents will always be able to access the care they need, if entire health systems couldn't or didn't want to continue providing gender-affirming care for her children, she would move.

"I would find the care somehow," she said. "We would make it continue to happen."

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