The government’s largest health insurance program for federal employees has officially ended coverage of gender-affirming care for anyone under 19 years old in compliance with Donald Trump’s executive order mandating it. 

The U.S. Office of Personnel and Management’s Healthcare and Insurance program – which covers “8 million Federal employees, retirees, former employees, family members, and former spouses,” according to the handbook – sent a directive to health insurance companies that work with the federal government stating they must comply with the order, along with another one Trump signed declaring there are only two sexes, male and female.

“All Carriers for Plan Year 2026 ‘will exclude coverage for pediatric transgender surgeries or hormone treatments’ for the purpose of gender transition,” the directive states, according to Huffington Post. “OPM recognizes that there are some bona fide medical conditions, such as precocious puberty, or therapy subsequent to a traumatic injury, where hormone treatments for individuals under the age of 19 may be lawfully covered by Carriers.”

Precocious puberty is when a child goes through puberty too young. These kids often take puberty blockers to keep them aligned with their peers. As such, the directive makes it clear that cisgender kids can use puberty blockers, but transgender kids can’t. 

Trump’s executive order on gender-affirming care bans people under 19  from accessing puberty blockers, hormone therapy, and surgical procedures — or, as the order calls them, “chemical or surgical mutilation” — as gender-affirming care for transgender individuals. The order threatens prosecution against sanctuary states that protect this care. The American Civil Liberties Union (ACLU) has already pledged to sue to block its enforcement.

“Across the country today, medical professionals are maiming and sterilizing a growing number of impressionable children under the radical and false claim that adults can change a child’s sex through a series of irreversible medical interventions,” the order states, omitting the fact that gender-affirming care has been safely provided to cisgender and trans children for decades and is suggested as a best medical practice by most major American medical and psychological associations.