Why Children's Hospital LA finds itself in a quandary over gender-affirming care

Children’s Hospital Los Angeles — one of the country’s oldest and largest providers of gender-affirming care for children and young adults — now finds itself at the center of the national debate over transgender care for young patients.

The hospital faced criticism and an investigation from California’s attorney general after it paused taking in new patients under 19 for gender-affirming hormone therapy in response to President Donald Trump’s executive order that aims to restrict transition-related care for youth.

But Friday afternoon, the hospital confirmed to LAist that it was lifting the pause, saying it had been briefly needed "to assess the potential impact of recent federal policy changes."

California Attorney General Rob Bonta applauded CHLA’s decision and vowed to stand by the hospital’s work.

"While the Trump administration attempts to bully and intimidate through its threats to withhold critical federal funding, California remains firm in its commitment to uphold the dignity and rights of all," Bonta said in a statement. He added that the state will continue to legally fight "the President’s executive order targeting transgender youth."

How we got here

In its Jan. 28 order, the Trump administration wrote that the federal government "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 executive order called gender-affirming treatments "chemical and surgical mutilation."

The Trump administration has been attempting to enforce the order by restricting, or threatening to restrict, federal grants linked to transgender healthcare, including to L.A.-area health providers.

Many healthcare institutions now find themselves in a quandary, even in states like California with anti-discrimination protections. Outside California, providers in Virginia, Colorado and New York made similar moves to restrict care, despite state protections against gender identity discrimination.

Children’s Hospital L.A. found itself in a similar bind: The hospital’s Center for Transyouth Health and Development is the largest clinic treating transgender youth in the country, as well as a leader in clinical research for trans youth.

Though it now risks crossing the new administration, its pause in care for new patients also risked running up against California’s "shield laws" designed to protect this type of medical care, not to mention creating ill will within a community they’d dedicated themselves to serving.

L.A. City Councilmember Hugo Soto-Martinez, whose 13th District includes CHLA, had blasted the earlier decision in a statement; protesters had assembled outside the hospital; and doctors from other local providers had publicly criticized the pause.

Was the pause in care legal?

Two lawsuits against the Trump administration will determine the answer to this question. In the meantime, it depends whether you ask the state or the federal executive branch.

Under California’s anti-discrimination law, healthcare providers can’t discriminate against transgender patients.

In a letter to CHLA, Bonta said: “Electing to refuse services to a class of individuals based on their protected status, such as withholding services from transgender individuals based on their gender identity or their diagnosis of gender dysphoria, while offering such services to cisgender individuals, is discrimination.”

Bonta also said any fears over a loss of funding were unwarranted, and he committed to protecting CHLA and its patients. Several federal judicial rulings have also blocked parts of Trump’s executive order that aimed to freeze funding.

The hospital indicated Bonta's support was crucial to its decision to reverse course, saying “in light of commitments from ... Bonta to seek additional protections for CHLA and its patients, CHLA is lifting its pause on the initiation of new hormonal therapies for patients seeking gender-affirming care, effective immediately.”

What happens next?

This is a legal battle playing out on several fronts.

Oregon, Washington and Minnesota have sued the Trump administration over the Jan. 28 executive order, and the ACLU has filed a separate lawsuit on behalf of private individuals. California has not yet joined these suits, but Bonta filed an amicus brief in support of the latter case on Feb. 21.

Adding to the uncertainty is the belief that laws affecting access to care for transgender people could change.

The U.S. Supreme Court is set to weigh in this year on a case determining whether state bans on care for transgender minors are allowed.

Elana Redfield, federal policy director of the UCLA School of Law’s Williams Institute, said the case in Tennessee likely won’t directly affect access to transgender care in California, but it could give Congress momentum to pass federal legislation that restricts access to gender-affirming hormones and surgeries.

“This is about federal funding, and pretty much across the country, most providers of gender-affirming care do receive federal funding of some kind,” Redfield said. “So I think it's going to remain a very concerning issue until it gets resolved.”

Another open question is whether CHLA will once again begin to offer gender-affirming surgeries for patients under 19, which are still on pause at the hospital. (The hospital said the decision to pause surgeries for people under 19 was in place before Trump’s executive order.)

Advocates for the LGBTQ community have criticized the pause in surgeries as well, which CHLA said are still available to the hospital’s patients once they turn 19.

Ariela Cuellar, spokesperson for the California LGBTQ Health and Human Services Network, criticized CHLA’s decision-making even after the pause on gender-affirming hormone therapy was lifted, saying that any pause in care amounts to a denial in care.

“It goes against so much other research and findings from [the American Academy of Pediatrics] that have stated that this care is life-saving,” Cuellar said. “ We need to hold these hospitals accountable in these decisions moving forward, keeping those politics aside from caring for the patients.”

A closer look at the hospital's finances

According to the most recent data available for CHLA, two-thirds of the hospital’s total inpatient and outpatient revenue came from Medicare and Medi-Cal, totaling $723 million.

The threat of losing some of this funding could put the nonprofit hospital in a tricky position, but not a unique one.

About 60% of gross revenue for hospitals in California comes from Medi-Cal and Medicare, according to state data.

CHLA, meanwhile, had about $1.7 billion in net assets in 2023, according to the hospital’s most recent tax filings.

How are other health providers handling this?

Other area hospitals have continued to provide care while they evaluate what Trump’s order will mean for their patients.

Children’s Hospital of Orange County said it is reviewing Trump's directive and is “committed to providing evidence-based, safe, compassionate care to children in accordance with all applicable laws and regulations.”

St. John’s Community Health, which has more than a dozen locations across Los Angeles, says it will not bow to the Trump administration’s order — and says it is making plans to make up the anticipated funding losses.

Healthcare providers “should never bend to the whims of the Trump administration and fall in line — we must continue to challenge and resist all attempts to harm marginalized communities, no matter the political risk,” St. John’s President Jim Mangia said in a statement.

What the medical community says

The American Academy of Pediatrics has supported gender-affirming care for minors since 2018 and opposes “any laws or regulations that discriminate against transgender and gender-diverse individuals, or that interfere in the doctor-patient relationship.”

The American Medical Association, the Endocrine Society and the American College of Obstetricians and Gynecologists, among others, have also taken similar positions supporting gender-affirming care for adolescents.