ANN ARBOR -- After two of Michigan's premier hospital systems decided to end gender-affirming care for minors, transgender and nonbinary youth have been left scrambling to continue their treatment.

In the last few months, the University of Michigan and Corewell Health instructed their doctors to end the care under legal and regulatory threats from the federal government. Both health care systems previously served gender-diverse children and adolescents in accessing hormonal therapies.

The hospitals' decisions have left past and future patients in an anxious state. Those who had already begun treatment find their supply of medication dwindling, while doctors at other facilities have struggled to keep pace with the intake of new patients amid increased scrutiny in a divisive political moment.

While Michigan's patient populations are difficult to estimate, officials with the LGBTQ+ advocacy group Stand with Trans estimate about 1,000 young people in the state have been affected by the decisions.

There are some 22,100 minors ages 13 to 17 who identify as transgender living in Michigan, according to UCLA's Williams Institute, with 724,000 in the US.

Despite being identical twins, Phoebe and Cypress Milligan have had different gender journeys after they were both assigned male at birth.

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Phoebe began transitioning to female at 13, eventually starting hormone replacement therapy under the guidance of a pediatric endocrinologist at U-M.

"I have had no issues whatsoever," Phoebe, 17, said of the medication she takes. "They have unilaterally made my life far better."

Cypress, on the other hand, only started gender-affirming care after coming out as genderfluid a few months ago, working with their pediatrician as they prepare to further transition.

"It's great just knowing that there will be change that comes," Cypress said, adding that the treatment so far has given them confidence, hope and "love for myself and who I will get to be in the future."

Cypress had planned on starting estrogen at Michigan Medicine's Child and Adolescent Gender Clinic at C.S. Mott Children's Hospital before it suspended treatment for young patients.

Phoebe and Cypress hope their pediatrician can extend refills on medication while they search for new doctors.

Those specializing in the care of LGBTQ+ youth say Michigan-based providers are struggling to keep up with the demand for consultations and continued gender-affirming treatment.

"Patients and families are traveling hours. They're traveling states. They're traveling days. Some people I know are going to Canada for care," said Daily Andrews, director of clinical services at Stand with Trans.

Wait times were already lengthy before the recent policy.

"People think you just walk in and get hormones, and that's just not the reality. There's a lot of testing," Andrews said. "There usually is at least three visits over the course of six months to a year before prescribing even happens."

Most patients who lost care are opting for smaller private practices if the facilities can manage the capacity, Andrews said, though "providers are scared."

Doctors contacted by Bridge Michigan who still provide gender affirming care to minors say their workload was already heavy before the hospitals' decisions.

"I'm like the captain of a single Titanic lifeboat ship, and have been unable to save everyone crying out from the water for years and years already," Dr. William Powers, a family physician in Farmington Hills, told Bridge Michigan in an email.

"I'm watching the major institutions light their lifeboats on fire deliberately while emailing me, asking if I can take on even more refugees as their patrons leap into the freezing water with no respite in sight."

Powers said he now carries a firearm because he's received death threats "from both sides." He said any minors that he agrees to treat "must go through an exceptionally high degree of scrutiny to make absolutely certain that it is the correct treatment for the correct patient."

"As a result I don't have many, because I'm extremely cautious and judicious with this therapy for them."

Fin Lauffer began her medical transition in the fall of 2020 at 11 years old after being assigned male at birth.

As COVID-19 forced her and other fifth graders to attend classes online, Lauffer was able to reflect and research.

"I think it was just more time to think," the 16-year-old recalled, saying she had previously made changes to her external appearance in the years before the pandemic -- she grew out her hair and changed the clothes she wore.

"There was one definitive event, but there was also, like, several other things leading up to it."

Kami Michels, her mother, recalls the day her daughter came out as transgender.

"She handed me a sheet of paper that said, 'Mom, I don't want to be a boy. I want to be nonbinary. I was scared to tell you, even though I knew you'd support me,'" Michels said.

The two moved quickly.

After consulting with a social worker at U-M's gender clinic, Lauffer received a small arm implant, which her mother calls a "puberty pauser," that slowly released a gonadotropin-releasing hormone agonist to suppress puberty.

Reuters found that between 2017 and 2021, the country had at least 4,780 cases of adolescents who started puberty blockers after receiving a diagnosis of gender dysphoria, which is defined as a person's psychological distress owed to the misalignment between their sex assigned at birth and gender identity.

The Endocrine Society, a leading international association of doctors and scientists who deal with the hormone system and metabolism, recommends treating gender-dysphoric adolescents in the early stages of puberty with the type of synthetic hormone Lauffer received to delay further puberty development.

By the beginning of this year, Lauffer's implant had been removed and her gender-affirming care regimen moved to a series of oral medications -- estrogen, a sex hormone associated with female development, and spironolactone, which limits the effects of the male sex hormone testosterone. Lauffer's doctor also regularly tested her blood to ensure the medications were working as intended while keeping her body healthy.

Estrogen and spironolactone are a common combination in feminizing hormone therapy. Doctors use a different regimen of medications for their transgender patients who were assigned female at birth.

Following U-M's decision to end treatment, Michels made some critical preparations for her daughter, getting a years-worth of refills for prescriptions during an off-boarding appointment with Lauffer's pediatric endocrinologist.

"They were hustling and doing what they could for their patients," Michels said, adding that her daughter has since completed her intake with a new provider.

People have organized an "underground" network to share resources to address the "dangerous pause" caused by a lack of services, according to Clark Ausloos, a licensed counselor and assistant professor at Oakland University specializing in LGBTQ+ care.

"We have seen a lot of coalition within the counseling profession," he said. "It's a little bit more privatized in the sense that information can be shared, but in a way that can still kind of protect some of those organizations that provide care."

Young patients who have found a path to continued treatment sometimes find themselves in more generalized practices, Ausloos said, which can be less equipped to address the specific needs of the LGBTQ+ population than larger institutions.

"These were organizations that were really specialized in working with trans or gender diverse youth and endocrinology," Ausloos said. "I'm hearing, just tangentially from clients, there's some barriers there -- confusion, new learning of language."

Patrice Wade-Olson, a nurse practitioner at Detroit's Corktown Health, a clinic that provides care to LGBTQ+ people, said with decreased access, some patients may take steps to secure medication through "unverified sources," which can have risks.

"How do we know that that is a verified medication ... if you didn't need a prescription and you could just buy it, " Wade-Olson said. "You just want to have caution."

Scientific evidence has led major physician groups like the American Psychological Association to support gender-affirming treatments in a clinical setting for children, adolescents and adults. But withholding these treatments can be detrimental.

While puberty blockers are reversible, stopping them resumes sexual development, which some gender-dysphoric youth may rather avoid.

"When evidence-based care of gender dysphoria is interrupted or restricted, suicide, depression, anxiety, disordered eating, and poor quality of life follow," Dr. Meredithe McNamara, an assistant professor at the Yale School of Medicine, said in remarks prepared for a congressional hearing in 2023.

Even when young patients receive care for gender dysphoria, it's rare.

About 0.1% of the privately insured adolescent population in America receives gender-affirming treatment or surgery, according to recent studies.

As president-elect, Donald Trump pledged to "stop the transgender lunacy" on his first day in office, following through with a Jan. 20 executive order to strip federal recognition of transgender people. Other orders have extended anti-trans policies to the military, sports and schools.

One order rescinded guidance from the World Professional Association for Transgender Health, which has established international guidelines for providing care to transgender and gender diverse individuals, describing it as "junk science." The White House also characterized the use of puberty blockers as "chemical and surgical mutilation."

The US Department of Health and Human Services subsequent position on pediatric gender dysphoria describes the condition as "not pathological" and not requiring treatment, a conclusion refuted by the country's leading medical researchers.

"This report misrepresents the current medical consensus and fails to reflect the realities of pediatric care," Dr. Susan J. Kressly, president of the American Academy of Pediatrics, said in a statement after HHS published its treatment guidance.

"Patients, their families, and their physicians -- not politicians or government officials -- should be the ones to make decisions together about what care is best for them based on evidence-based, age-appropriate care."

The administration's investigation into the University of Michigan, which received a federal subpoena for providing gender-affirming care for minors, has been part of a broader national pattern that's had a "chilling effect on health care providers," according to Christy Mallory, interim executive director at the Williams Institute.

"At the same time, there's pushback against these efforts," Mallory noted, referencing a multistate lawsuit joined by Michigan Attorney General Dana Nessel against Trump and other officials to challenge their efforts in restricting access to gender-affirming care for those under 19.

Following the complaint, Nessel authored an open letter to the state's health care providers, writing that "withholding the availability of services from transgender individuals based on their gender identity" while continuing to offer the same services for cisgender individuals "may constitute discrimination under Michigan law."

"We're a target in a campaign," Cypress Milligan told Bridge. "The only reason that they stopped for us is because we are a minority group."

In Michigan, where state civil rights protections extend to transgender people, U-M and Corewell's decisions to stop providing gender-affirming care to trans minors appears to be "clearly discriminatory," according to ACLU of Michigan staff attorney Jay Kaplan.

"They are still providing hormone therapy protocols for cisgender patients, which does raise civil rights issues," said Kaplan, who leads ACLU of Michigan's LGBTQ+ Project. "We've spoken to families. We've encouraged them to file complaints with the Michigan Department of Civil Rights and request that it be investigated."

While the legal matter remains unresolved, the consequences of Trump's actions, in addition to recent and forthcoming Supreme Court decisions on trans rights, have already had an impact.

Emme Zanotti, a senior director at the LGBTQ+ advocacy group Equality Michigan, said the federal government's policy has essentially created a "domestic refugee situation," where trans people are making significant lifestyle choices due to political persecution they feel.

According to the Movement Advancement Project, 55% of transgender people surveyed have "taken steps to be less visible as an LGBTQ+ person in their community." Nearly 1 in 10 transgender people report moving states since November 2024.

"A lot of these families came to Michigan. We have families who moved here from Oklahoma and Texas and Kansas, where they lost their civil liberties," Zanotti said. "Now they're feeling squeezed again."

Amy Milligan, mother of twins Phoebe and Cypress, is raising her children in Ann Arbor with her wife. Milligan told Bridge she had previously seen the University of Michigan as a "beacon in the community," an institution that delivered high quality care to a patient population that "turned to them for their expertise."

But the university's recent actions have cast doubt on that vision, with Milligan now believing that "the community won't protect us." She spoke out against the school's cessation of gender-affirming care during a recent U-M Board of Regent's meeting.

"We've always made our life decisions knowing that there were certain places that weren't safe for us to live," Milligan told Bridge. "This country is fast becoming a place where it isn't safe anymore."