Senate Jt Sen Asm Sub1 Sub3 — 2026-04-06

And we are going to move into our joint hearing with Senate Budget Subcommittee No. 3 on Health and Human Services. So we welcome Senator Menjavar and committee members from the Senate Budget Subcommittee No. 3. And this is issue number one on your agenda, which is access to gender affirming care in California. Thank you. Thank you. Good afternoon. This is a very warm and small committee room. It's on.

Good afternoon, honorable members. It's a pleasure, and thank you for the invitation. I'm Nellie Palma. I'm the Senior Assistant Attorney General for the Health Care Rights and Access Section. This is the section that leads on the Attorney General's affirmative health care matters. This includes civil rights and health equity, consumer protection, reproductive justice, tobacco enforcement, and fair competition. In the civil rights and health equity arena, this includes ensuring access to health care for LGBTQ plus community. This includes, of course, gender affirming care. I would like to pass to Deputy Attorney General Crystal Adams, who is our lead on several of our matters involving gender affirming care. and she can walk through the efforts of the Attorney General to address these issues.

We'll go through the panelists and then we'll do the questions. We'll turn over to DMHC.

Good afternoon, Chair and the committees. My name is Tyler Sadwith. I'm the State Medicaid Director at the Department of Healthcare Services. I'd like to just provide information about this topic in Medi-Cal. Gender-affirming care is a covered Medi-Cal benefit when medically necessary. Gender-affirming care refers to services provided to address the incongruence between a Medi-Cal member's gender or sex assigned at birth and their gender identity. Services must be rendered by providers specially trained and experienced in providing culturally competent gender-affirming care services. The department supports and ensures access to medically necessary, evidence-based gender-affirming care for Medi-Cal members in alignment with state law and its mission to promote the health and well-being of all Californians. Recent federal actions disregard established peer-reviewed evidence-based research showing gender-affirming care is effective, medically necessary, and improves health outcomes for Medi-Cal members. As another panelist shared, CMS recently issued three proposed rules and one declaration by the United States Health and Human Services Secretary Kennedy. One proposed rule with amendments to federal hospital conditions of participation would ban hospitals participating in Medicare and Medicaid from providing puberty blockers hormones or surgery for treatment of gender dysphoria in minors The second proposed rule would prohibit Medicaid and CHIP funding for puberty blockers hormones surgeries to treat gender dysphoria in persons under 18 in Medicaid or 19 in CHIP although mental health services would continue to be covered. The third proposed rule would classify gender dysphoria not resulting from physical impairment as excluded from the federal definition of disability. So those are proposed rules. The Secretary's Declaration, which was issued not as a proposed policy but as final policy, declares puberty blockers, hormones, and surgeries to be unsafe and ineffective as treatment for gender dysphoria in minors. The declaration sets up the basis for excluding providers who deliver gender-affirming care from all federal health care programs, putting all of their reimbursement at risk, not just reimbursement for gender-affirming care. This declaration is currently being challenged by a multi-state coalition, including California, with a summary judgment granted in favor of the plaintiff. In February, the California Health and Human Services Agency, in partnership with the department and other state departments, submitted public comment letters articulating strong opposition to the proposed rules, noting it would restrict access to medically necessary gender-affirming care and would harm Medi-Cal members. The agency expressed concerns with the proposed rule and the potentially devastating effects it would have on the lives of some Medi-Cal members and their families. California law protecting access to gender-affirming care in Medi-Cal remains fully in effect. Further, for foster youth in California, access to gender-affirming care and mental health services is expressly protected under state law. Proposed federal rules are not final and do not carry the force of law at this time. Accordingly, California's Medi-Cal and CHIP policy continues to guarantee coverage of all medically necessary gender-affirming care backed by state law and existing departmental guidance. The department is committed to ensuring timely access to gender-affirming care, including pharmacy services, medical care, mental health care, surgeries, and related ancillary services. We have a history of providing guidance to Medi-Cal managed care plans to affirm and establish these requirements. Plans and providers may not deny or limit care based on a member's gender identity. Coverage decisions must rely solely on medical necessity consistent with clinical guidelines established by multiple medical societies, including WPATH, the Endocrine Society, the American Academy of Pediatrics, and the American Psychological Association. The Medi-Cal provider manual requires all gender-affirming services be rendered by providers specially trained and experienced in providing culturally competent, gender-affirming care. The department has issued all plan letters in the last few years to reinforce this policy, including in 2024, regarding transgender, gender-diverse, and intersex cultural competency training, in 2018 regarding access to transgender services, and in 2016 regarding transgender access requirements. The department and the California Health and Human Services Agency are preparing strategies to maintain access to these services if the federal proposals are enacted. Thank you.

to close their program, the Attorney General sent out a letter reminding providers of their obligation under state law. But said providers continue doing what they were doing, what happens next after the letter was sent? So I believe you're referring to Children's Hospital Los Angeles. So we are continuing to closely monitor the provision of care across the state. And as I said, we are taking action against Rady Children's Hospital for deciding to try to end their entire program. So we are working diligently to make sure that hospitals are following their obligations. But Sutter, Kaiser, and Children's Hospital of LA have all stopped programming.

I'll defer to my colleagues for that. Yeah. Again, we are continuing to monitor the situation. We're not at liberty to discuss any strategy that may be up for consideration, and certainly not on something as delicate as this matter.

Sure.

So Rady Children's Hospital is under Attorney General conditions. The Attorney General approved the merger of Children's Hospital of Orange County and Rady Children's Hospital San Diego in 2024 and imposed conditions that required Rady, the surviving entity, to continue to provide the same level of care that existed when the merger was approved, and that's for a period of 10 years. And specifically called out was gender-affirming care as well as other services. So in that situation, it was necessary to ensure that this vital hospital continued to provide that care. When the AG approved those conditions, it took into consideration that what was left was a hospital that basically controlled children's health care in that area of the state, San Diego, Orange County.

So the Attorney General found it necessary to take affirmative action to ensure that those services could continue for patients in that area.

So in this way, we've targeted the, for lack of a better word, the source of the problem, which is the federal administration. That does not mean that we may not proceed against additional hospitals, but right now our efforts are really to address the source of the concern. that which is trying to remove the ability of any of our hospitals to provide this care at the threat of losing all of their federal funding.

Yeah, no, I mean, I think the bottom line is our authorities over the health plans. We don't have the authority to require providers to provide gender-affirming care services. I think that's ultimately the question you're trying to get at. It's why we continue to advocate for individual enrolings coming to our health centers. So far, we have been successful in working with health plans to arrange for care, whether that's in-network or out-of-network. So, you know, at this point, we've been successful, but we need people to come to us. As I think you'll probably hear, the number of providers and facilities willing to provide these services are dwindling. But so far, we've been successful in the cases that have come to us.

Yeah, so the time and distance standards, the timely access standards, we have geographic and ratio standards. The plans are meeting that for those provider types broadly.

We don't have specific requirements specific for gender-affirming care services because there's not a specific specialty type for gender-affirming care specifically.

No, what is your title? Ryan, sorry. Ryan, Tyler, sorry. Chief Deputy Director.

Ryan is my first name. Tyler is my middle name, and I go by Tyler.

The senator was not wrong.

Thank you, Senator. So I think at this time we're sort of keeping a close watch on how CMS will land on finalizing the proposed rules that they put out. And I think depending on what those proposed rules mean in terms of being issued and promulgated as final rules, that will help the state better understand what changes, if any, are needed.

I can say from the Department of Justice's perspective, we are fully committed to working with the agencies on any potential legislative strategies. So we definitely defer to their expertise and look forward to coordinating with them.

Right. Those are very important. Obviously, we're here to protect the patients. we're also here to protect our providers who are providing the care to this community. So I think that that would go a long way as well to sort of bridge the gap on any sort of holes that exist in our shield laws.

Yes.

Do we anticipate anytime soon? We don't know.

Yeah. You know, there are various rumors that might float around, but at the end of the day, we don't have any insight into exactly when they'll draft.

So because there is no written ruling yet, there is no ability to appeal. So the court did make an initial ruling from the bench, but that was not the full final written order. So that's what we're waiting for. Once the district court makes that ruling, then.

Okay.

I mean, I don't know. I'm not 100% sure, but I do think that this is a very controversial issue, you know, as we've seen. So I think it's certainly possible, and we are ready to fight to protect this care any way we can.

So, Member Bonto?

Yeah, no. And let me just say for like, let's just say psychiatry. There is not like a special designation for a psychiatrist that provides gender affirming care or other specialties. So we're looking broadly at the category of a provider type, and we have standards there. But looking at it specifically for those that provide gender-affirming care is not something that there's a special license or something that we look at specifically.

Yeah, I mean, I think we'd have to look at the license. So there needs to be like a licensing structure around a specific type of provider that would provide gender affirming care. I'll just say, I mean, I think we'd want to think very carefully about that. there is already a tremendous amount of fear from providers who are providing gender-affirming care to indicate that they are a provider that is providing those services in provider directories. So again, want to be thoughtful about anything that we don't want to make it worse than it is now, but I think we'd have to look at is there a special certification or licensing process for a provider specific to gender-affirming care? The challenge though without having that specific licensure is that we don't have any ability right now to track and therefore understand whether or not we are actually providing that care to patients who are in need of that medically indicated care. And just to be clear, we don't collect utilization data, for example, either. So we don't track the number of individuals that are accessing these services either. But yes, I just, there's this challenge of there's not the specific specialty for gender affirming care, So we're looking broadly at the types of providers that provide these services. That means that we have a significant gap, and I understand the sensitivity, but I also just want to acknowledge and recognize that it creates another challenge for us where we are actually not able to determine whether or not we are providing, that we are meeting the network adequacy commitments that we are obligated to do so.

Maybe I'll just start. Just to reiterate, we don't have authority over the providers,

Over the health plans, sure. No, so I just want to be clear from DMHC's perspective, I would say not,

So we do have certain continuity of care policies as Medi-Cal members transition from one delivery system to another or sometimes from one plan to another. So if someone comes from the fee-for-service delivery system and they have a trusted relationship with the provider and then they're sort of assigned to the Medi-Cal managed care plan, we have continuity of care policies where, you know, for up to about a year, that plan has to at least offer an opportunity for that provider to be able to do that. to provide services to that member. The provider is not obligated to do it, but we obligate the plan to offer payment to that provider. So we have continuity of care policies in effect today as members covered by Medi-Cal transition between delivery systems within the program. Sometimes as members churn in and out of Medi-Cal, obviously we can't cover services for people who are not enrolled in the program. So members may inevitably face some cognitive care issues if they move to another source of health care coverage or lose Medi-Cal as a source of coverage.

Because it's a gray area, I recognize that, but we're clear on what California's law is. And we're clear that we intend to defend that law at all costs. So what might we be able to do that's much more proactive as opposed to just allowing institutions to make their own independent decisions in terms of guidance?

in effect, prohibit any provider that offers these services to the impacted population, which are our minors here, from being able to receive any federal Medicaid or Medicare funding. And so there's a choice. Do you enforce a California law that, you know, says they must provide that services? If we lean on enforcement, we would, in effect, be forcing them to forsake Medicare and Medicaid dollars. I mean, that is what's at stake if these rules are finalized. So one solution would be setting up a state-only program or some state-only programming or grant to allow these services to continue to be reimbursed in lieu of the Medicare and or the Medicaid revenue that is being used today. I think what's especially challenging as proposed by the rules is that it would be hard for a provider to say, okay, I'll treat all other medical care and bill it to Medi-Cal as applicable, but for gender-affirming care, it's state-funded because as proposed, the rules would bar them from participating in Medi-Cal completely. So in effect, it would be creating a state-only program for a provider that operates exclusively in that state-only program and doesn't participate in Medi-Cal at all. So that's one potential pathway that this takes if those rules in the declaration are finalized.

None other than to say, as my colleague mentioned, we have every intention of challenging any such rule that would attempt to strip federal health care fundings from providers for providing this medically necessary care.

Great. Thank you so much. Appreciate the time by everybody. Believe it or not, to my colleague on my right, I too care about people and want to protect them. Um, uh, you know, and, and when it comes to this topic, uh, it is one that I am very concerned about, um, for different reasons, uh, should come as no surprise to anybody up here. Um, but also, uh, the, I, the realization that a lot of Western society has abandoned, transgender-affirming care for children. California continues to go full steam ahead on it. And I don't, you know, there have been studies after studies and we could cite them. And I'm sure every single study that I give would be somehow discredited by some facts or, you know, I mean, we could have this debate forever. But there is a lot of scientific evidence that gender affirming care for children, particularly surgeries, is problematic, and that is why a lot of countries are abandoning it. And in fact, the American Medical Association, which isn't exactly, you know, some liberal or some conservative think tank, does not have the same view as other institutions cited here. And so I think, you know, with that in mind, my biggest concern is our children and decisions that could be made to impact their entire life. And with that I have a series of questions and some of them have I think been answered but I just want to make sure I have it clear And I ask the Department of Justice since these are legal questions And just so I'm totally clear, California health plans are required to cover gender-affirming care, correct?

That's interesting.

Okay. And, you know, recently, I have a 12-year-old, and he's undergoing a, you know, medical issues, you know, in anybody's business. but I was surprised to log into his account as I always do. I mean, you know, this is a, he's a great young man. Also, I have to remind him every day to brush his teeth. Yet after his doctor's appointment, I couldn't see the clinician notes on why, on what's going on. I mean, this is an individual who actually depends on me to guide him through this medical issue. Why is that?

So there are medical privacy laws that kick in at a certain age, and that's probably what you are seeing there.

I understand. California-specific law. There are obviously federal HIPAA laws, which California goes a step further and makes it 12 years old.

So there are privacy laws that cover any patient that is seeking that care. Again, I think my colleague is more well-versed in terms of a parent's rights in certain circumstances, but there are privacy laws that protect medical records.

So I think it's helpful to consider what gender-affirming care is.

of the land. I disagree with that, but that's the law of the land. I mean, I believe my child is much better equipped with parental support around those issues. And, you know, a child, a 12-year-old might think they don't have parental support when they really do. But just to be clear, I'm not only talking about surgeries. I mean, mental health treatment, puberty blockers, you know, without the consent of parents, I totally object to. Again, I know that's not the law of the land, but it does really like concern me though, that, um, that, and I've, I've been saying this a lot this year, but I am, I am, I, when I say grown man, I mean, that's subjective. I'm a pretty short guy, but, um, but I'm a grown man and there are treatments that I can't receive right now, uh, because of plans or guidelines. And I don't see any support from the state of California or the Department of Justice on any of those items and laser focused on suing hospitals that aren't giving puberty blockers to children, but not adults. You won't want to give adults hormone replacement therapy. Won't defend that as a person's withering away, but no problem. A kid, we will defend that. We will sue the hell out of that children's hospital.

Yeah, correct. I understand it's the law and you're enforcing it. And this building often makes those laws and I object to all of them. but just to be clear on that, I think the issue that I have is that these laws are created for those families that don't have those supportive environments that where we look at with a blanket, you even said they were broad. That is actually my fundamental issue is that all the loving and nurturing parents in the state of California have lost the right to their children in order to protect as you said the very small number of children. And that is a big problem. How am I supposed to help guide my children, four of them, through all of this if I can't access this? And believe it or not, kids lie to their parents. Good kids lie to their parents. I lied to my parents. I still lie to my parents. You know? Hey, Joe, how's it going? It's going great. You know? So it's going to happen. You know, I love my parents to death. Hopefully my kids love me. Yesterday my son was mad at me. But so, you know, California continues to pass laws to move this ball forward in terms of privacy for children. One of them recently was AB 1955, when my understanding is the state of California was sued and lost on six of three decision by the Supreme Court. What's the status of that? Because in the schools where the peers and teachers know is sort of where this is starting. And so it's really important to me to understand what the state of California is going to do after losing that litigation on AB 1955. Because there are school districts in my district that that bill is continued to be used against. I just want to refocus. This is a health committee. I know you're talking about a bill in education. Yes. No, actually, because when these secrets are happening at schools and the teachers know, their peers know, and then later on they're going to talk to their mental health.

It's important for me to know what's happening in my kid's life, and this is totally relevant. What's happening now in regards to that? I'm going to bring us back because, once again, you probably got the agenda and the briefing on health, gender-affirming care in health providers, hospitals, clinics. These panelists were not brought here to talk about what's going on in schools. I just want to bring it back. I'll rephrase. If my child goes and sees a therapist at school, AB 1955 required that they don't inform the parents. Recently, the Supreme Court ruled 6-3 that that therapist could not talk to the children, as well as the parents, as well as everybody. Does the state of California continue to implement those health care protections at the schools and keep those secrets from parents?

All right. Okay. Last question. And thank you, Madam Chair, for bearing with me. But a statement was made by the Department of Justice, respectfully, that the Trump administration is intimidating hospitals. To me, it seems like the state of California and the Department of Justice is intimidating hospitals. After all, it is the state of California that's suing the hospitals. So now the hospitals and these health plans are in a situation which are trying to decipher the difference between federal and state laws, which seem to conflict. So why has the state of California opted to, and apparently looking at other situations, why has it opted to litigate against those providing federal? treatment in California rather than finding another avenue to litigate?

Okay, I think it's a fair point if you say there has been no change in federal law. It appears the guidance will be coming soon. I hope that the state of California does not intimidate our providers, our hospitals, our health plans if they're trying to figure out, you know, between the federal law and the state law. And that's an issue we have. I mean, take the battle up with the Trump administration if you choose. You'll win some, you'll lose some. But I think going after our California providers is a mistake and should really be revisited. Thank you. Thank you. Director, I just had a couple follow-ups just to clarify because the health chair brought something up that I think it just went over my head. Just to clarify, since we don't characterize or certify, we can't track if there's equitable access to gender-affirming care. So we look at provider types. We don't collect data on individual enrollees that are under the plans that we regulate. So I don't know services accessed by one population versus another. Because you mentioned so far that everyone's been able to meet. Those that have contacted our help center, so far, and again, I want to be very clear, it is a fairly low number. We want more people to call us. We do a lot of outreach to try to get more to call us because so far, for those that have contacted us individually, we've been able to work with the plans to find a provider that can provide services. And that's the helpline you mentioned? Our help center. Yes. And then the TGI website also shares information. Correct. Yes, there's a lot of information that links to both DHCS, Department of Justice, healthcare rights, a lot of good resources. So dmhc.ca.gov. Okay. Department of Finance, I don't know if you can help me. I asked this question last time. We allocated $15 million to help with gender-affirming care. Has that been utilized yet? Running out of chairs. Joseph Donaldson Department of Finance So as noted we did include that million I believe Cover California is still implementing those dollars I believe they be providing program updates and some of our forthcoming committee hearings So I would defer to Covered California on kind of the implementation of those dollars Okay. I don't know if you have any questions on that. We can move on to the next panel. Okay. Thank you so much for participating in our first panel. Our second panel is gonna focus on how providers and families navigate access to gender affirming care. Whoever is the doctor, we'll start with you, doctor. I'm the doctor. I just play one on TV. No, just kidding. Thanks for having me today. My name is Dr. Johanna Olson-Kennedy. I want to talk a little bit about the history of gender-affirming care, but also the present state of gender care in the United States. The medical care for transgender patients began nearly 100 years ago. Magnus Hirschfeld began documenting and treating trans patients in the late 1920s at his institute in Berlin until it was burned down by the Nazis in 1945. The first recorded genital surgery occurred in Germany in 1931. This surgery happened shortly after the synthesis of estrogen in 1930. Testosterone was synthesized in 1935, and Dr. Michael Dillon became one of the first trans men to access masculinizing hormone therapy in the late 1930s and 40s. Dr. Harry Benjamin began treating transgender people in the United States in the 1960s and 70s and was the catalyst for the development of the World Professional Association of Transgender Health Standards of Care. Dr. Benjamin received hundreds of letters from people interested in obtaining medical care, including youth, as young as 14. In the 1970s, care became increasingly accessible through academic institutions across the United States, And as it did, opposition to the care was also on the rise. Utilizing the same tactics as we are seeing today, predominantly citing lack of evidence, academic clinics began shutting down, and by 1979, they were all shuttered. Medical care for transgender patients was all but unavailable except in private practices and community clinics. Medical care for transgender patients did not move back into academic centers until the HIV epidemic. I am the former medical director of the Center for Trans Youth Health and Development at Children's Hospital Los Angeles. We began treating transgender adolescents and young adults in 1991, and the clinic was likely the earliest of its kind in the United States. I trained as a fellow in adolescent medicine. I am board certified in both pediatrics and adolescent medicine at Children's Hospital L.A. from 2000 to 2003, 2003 and shortly thereafter began providing medical care for transgender youth and young adults in 2006 the use of gnrh analogs what we call puberty blockers in the lay community was introduced into the world of medicine By a team of providers in the Netherlands It was so clear that experiencing the irreversible aspects of puberty was one of the most distressing experiences for transgender individuals to undergo particularly transgender women who cannot go back and ungrow their Adam's apple, their vocal cords, their tall stature, their facial hair, et cetera. The introduction of puberty blockers to this area of medicine has perhaps been the single most important development since the synthesis of hormones. These kinds of medications have been used in the United States since 1980, in the pediatric population for central precocious puberty, and in the adult population for a variety of medical conditions. GnRH analogs have a long and enviable safety profile. Estrogen and testosterone have been used for decades, close to a century, in the treatment of transgender adults and adolescents. I want to move on to the treatment of gender dysphoria. the persistent distress caused for some people who are trans because of their gender incongruence. Relief from gender dysphoria is the primary reason transgender people seek gender-related medical care. I discussed in the history about the use of medications most commonly utilized, GnRH analogs, estrogen, and testosterone. It is really important to note that all human beings have all of these hormones in their body naturally. The goal of medical treatment is to change the ratio of these hormones in order to induce the development of secondary sex characteristics that are truly aligned with one's gender identity. In other words, testosterone for the development of a more masculine voice, facial hair and body shape, and estrogen for the development of breasts, softer skin, and a rounder figure that typically accompany female puberty. Prior to accessing medical care, many, if not most, youth and families have a long process before ever seeking medical attention. The process almost always begins with the young person discovering and investigating the feelings they are having related to the discomfort around their assumed gender. In other words, maybe a feeling such as, why am I uncomfortable being called she or daughter? Or why did I feel so happy when I was referred to as he? What generally follows these feelings is a very long and private exploration of trying to understand what, how, and why these feelings are occurring, and if there are other people experiencing similar thoughts, and what can be done, if anything, about this discordance. As adolescents learn more about what it means to be a transgender person, they also learn that if they want access to professionals, they must disclose this information to a parent or guardian. This process of disclosure is excruciating for many. It is my observation that adolescents often feel scared, guilty, or ashamed of learning about their gender and they don't want to upset their parents or create chaos in their family. Sometimes holding this truth about self leads to social isolation, anxiety, depression, self-harm, and thoughts about suicide. Prior to disclosure many adolescents are already engaged in therapy to address those issues that are not known to other people to be related to gender dysphoria. Adolescents, in order to receive care, must come out to their parents. And then the cycle of discovery begins anew for those parents. They too begin to try to understand what, why, and when their child started on this journey, what it means, and probably most preoccupying whether it's true, and how to proceed cautiously. Around the time of the assault on transgender youth that began in earnest in 2017, there were more than 70 programs across the country providing multidisciplinary care. Multidisciplinary care teams include medical providers psychiatrists psychologists social workers peer navigators case managers and more Multidisciplinary care has been the recommended model for both adolescents and adults since the inception of the WPATH standards of care in the late 1960s I can't attest to what every single program does, but I know that many, if not most, of the centers providing this care practice in this way. Every patient is different. Every patient has different medical needs. They have different lengths of time. They're coming in at different places in their process. It is very individualized care. Every parent or guardian has different needs as well. Good practitioners in medical care for anyone, but in this case transgender patients, spend a lot of time listening. We learn about the process of understanding one's gender and coming out, what that's been like for the young person and their parents or guardians. We assess what changes a patient has made to feel more comfortable. We ask about mental and medical health of both the parent and the family members as well as the patients. If patients have a therapist outside of the clinic, we ask to communicate with them. If additional therapy is warranted, we refer patients accordingly. Recommendations about medical interventions are made together with the patient, their care team, and their parents. No medical interventions can legally occur for minors without the consent of a parent or legal guardian. None. Not blockers, not hormones, and certainly not surgery. As of this year, 27 states across the country have banned access to care for transgender minors. Many of those bans are in litigation. Many families have traveled to California to get the health care their adolescents need. The Center for Trans Youth Health and Development at Children's Hospital Los Angeles was a beacon program, the longest established and largest program serving transgender youth probably in the world. We were leaders in the provision of care with decades of experience between all of our providers. We were innovators in research, contributing dozens of manuscripts about the impact of medical care for transgender youth. Our patients, families, and providers felt safe there. Our care was thoughtful, compassionate, and informed by science. At the time of the shuttering, we had just under 3,000 youth receiving services. When we learned the program was being terminated, the shock and disbelief was unimaginable. As the medical director, I had not been involved in the decision-making, nor were any of our clinicians. Patients were informed four days after our team was informed through a text message followed by a certified letter. The ripple effect was profound. Within three weeks, our team were scrambling to see as many patients as possible, with the visits massively prolonged to hold the devastation being felt by patients and parents. A place where transgender young people and their families felt safe, seen, and well cared for was abandoning them because of the threat of losing federal funding for the rest of the hospital. The moral injury experienced by our patients, families, and team members will likely not be repaired for years. Since our program was closed, our patients and families have had to seek other programs for their medical care. Programs are scarce, and those that accept Medi-Cal even more so. As happened in the 1970s, transgender care is being forced to adapt to the closure of programs because of myths and disinformation. In the absence of any major administrative shift, the care will have to move into community organizations and private practices. Unwilling to abandon my patients, I left CHLH to form an independent practice. Creating infrastructure for a new health care corporation is incredibly difficult, time-consuming, and expensive. If you want ideas about how to help people doing this, make it easier for us to get contracted with insurance companies because my same patients that I was contracted with at CHLA, I'm not able to get contracted with in my new practice. New practices need to get contracts in place with insurance plans unless they intend to charge cash. But transgender patients deserve to have their health care costs covered by insurance, whether that be private or public plans. The shift I made had to be fast because health care is ongoing. Patients can't stop needing care to wait for offices to be established. I was fortunate enough to have people that believed in me and were willing to provide foundational support. I want to be clear, the cost of running a comprehensive medical practice that is multidisciplinary and includes behavioral health does not pay for itself, as reimbursement rates for both medical and mental health care is inadequate. Nonetheless, transgender young people need health care, and I am here to provide such care. I know there are others who are hoping to establish practices for their patients to receive this care as well, but the task is daunting, and it's scary, and people don't want to do it because they're afraid for their safety. I am now seeing families that moved from states where youth care was banned. They moved down to San Diego, and now they can't get care at Rady's. And now they're coming up to me. They're driving miles, many miles, to see me because the program's closing. Even before clinics were closing, getting appropriate health care for transgender youth was very difficult. But traveling to a different state or city is incredibly painful and costly, and many, many, many people cannot do it. Parents are in a constant state of fear and anxiety. Every single time I see a family, I've been asked if my new clinic is going to close if the conditions of participation are dropped in the way that we've heard earlier today. If we applied this level of chaos and cruelty to any other medical condition, the level of brutality would be stark and indefensible. Transgender young people do not stop needing medical care because their programs are shut down. I listened to the gubernatorial candidates speak at the LGBT Center, and many of them floated this idea of backfilling the hospitals. Thing is, that's a very expensive way to do that. It's much less expensive to talk about setting aside money to help people provide this necessary care. I really appreciate the opportunity to share my experiences and thoughts on this platform, and I am available for any questions. Dr. I'm going to squeeze in a question because I have to step out real quick. Sure. Can you share what a minor can get under the whole umbrella of gender-affirming care without parental consent? Therapy. Can they go in and get puberty blockers? No, they cannot. Can a 13-year-old go and say, I want top surgery? No. Without telling my parents? No. Okay, so it's just talk therapy. Correct. Can that therapist prescribe antidepressants after that conversation? No, a therapist can't prescribe anyway. A psychiatrist would have to, but no. Because you mentioned the child would have to come out to the parent to be able to get approval from their parent to move forward with anything under gender-affirming care. That's correct. Okay. Thank you so much. We're going to continue this panel. So we've got J.M. Jaffe, Raisha Henscom, Will Loaf, and Jane Doe Parent. And you're welcome to start your testimony. and it's about five to six minutes per person. I'm left here to be the bad guy to put the time limits on it. But we just, we want everybody to be able to say their part. And then I know there will be more questions from the dais. I believe we have clinics coming up after this. And then we'll move on to public comment from the general public. So we have a lot to do. But this panel is just to recap how providers and families navigate access to gender-affirming care. So please go ahead and start when you ready Hello everyone My name is J Jaffe I use they and them pronouns and I the executive director of Lyon Martin Community Health Services in San Francisco We're on Mission Street. I've been there 16 years, and I'm excited to just share a little bit more about Lyon Martin and what we've been facing. So Lyon Martin is a primary care clinic in San Francisco, and we primarily serve queer, transgender, non-binary, and cisgender women. We were established over 45 years ago and we are actually the first and currently the only trans-led federally qualified health center in the country. We are truly by us for us, meaning that 100% of our medical providers are queer, 80% of our staff are transgender themselves, and two-thirds of our patients are transgender. We care for over 3,000 patients across California, originating from over 250 different zip codes, and 90% of our patients live under the 200% federal poverty level. We do accept commercial, Medicaid, Medicare, and we see uninsured undocumented clients, regardless of ability to pay. So earlier in my career at L.A. Martin, I actually started as a trans health manager, and I advocated for both my own medically necessary gender-affirming surgery through my employer-sponsored coverage at Kaiser in 2012, and through the IMR process got it approved. And I then subsequently helped over 2,000 individuals get gender-affirming surgery through their insurance, through the appeals and the IMR process from 2010 to today. So through appeal after appeal, independent medical review after review, across multiple insurance companies, advocating for each surgery that came across our desk, we helped change the landscape of access for gender-affirming care in California. which then rippled across the entire country, right? We saw New York follow suit. We saw all these other states follow suit and kind of mimic that process. Health plan policies were then updated to reflect these evolving standards of care once we held them to account through the appeals process. The Insurance Gender Nondiscrimination Act passed in 2005. We didn't get the first Medi-Cal surgery covered until 2010. We didn't get the first vaginoplasty until 2012. we didn't get the first FFS until 2015. This has been an ongoing process. And so I know that we are in a new situation where we are battling this again, but I say this to really bring us back to the history of how we got this landscape to be how it is today. And it's through the appeals and the IMR process and holding these insurance companies to account. Specifically talking about Lyon Martin and the federally qualified health center space, as these federal attacks have escalated on transgender health care, we're seeing real impacts on our operation, our staffing, our strategic planning. We've had to withdraw from or avoid applying to federally sourced contracts, including state contracts that are federally sourced and city contracts that are federally sourced, right? And Laya Martin, we are in a little bit of a unique position being a lookalike health center, so we don't have that 330 funding for them to dangle over us, But we do have our reimbursement through PPS, and so our status itself is very important. But it does differentiate us a little bit from other FQHCs that do have that federal grant being basically toyed with, right? So I do want to make that distinction. But at the same time because of our protected status we are actively increasing access to minors for our care because we saw the hospital systems start shutting down We did not see the state or the city come to our savior And so we just, you know, because we have the expertise, decided to open our doors to minors. And that has resulted in a lot of unexpected expenses, as you can imagine. And unfortunately, you know, because we're also seeing cuts on the city level because of all the trickle down cuts that are happening, this cost shifting from the federal government to the state, to the state, to the city, to the city, to the CBOs, to the CBOs, to the patients, is really what we're seeing happening, right? So our community-based organizations are footing the bill. Our patients are footing the bill when this is supposed to be covered care in California. Just as an example, you know, we just won an award through CDPH for $450,000 a year for us, and then we lost $400,000 from the city. So it's kind of a wash, right? And so we really ask that the state and the cities all be working together to really bolster this work. As an FQHC, we are mandated by both mission and law to serve all patients regardless of ability to pay. And today, transgender health care is integrated in some form across most community health centers in California. Care for transgender youth, however, has been largely concentrated in hospital-based specialty clinics. And as these hospital-based clinics are closing, the care is being shifted over to community health centers. Thousands of young people and their families have lost access to care almost overnight, and we're going to see another 10,000 kids without gender-affirming care providers looking for new providers at clinics where we only serve 3,000 people per year, right? So we're talking about almost needing to double our size to really even remotely provide care to this patient population. So as this network erodes, we really are just coming here to ask that you all really understand that we cannot fill this gap without money. We need funding in order to scale up, to get new clinics, right? Like we have a capital campaign happening to expand our space and move to a space that's twice our size, have twice the capacity. But the funding for that is nowhere to be found. And we are applying to every state grant we can find. And we're not seeing state agencies prioritize transgender health. So we're putting forward this ask for $26 million to really save transgender health care in California, to save the transgender people who rely on California for this care and to not leave us in the dust. Thank you so much for listening. Thank you to committee chairs, Assemblymember Addis and Senator Mandjavar. Thank you so much for this opportunity and all those assembled here today. I'm grateful for this opportunity to share our story. My name is Raisha Hanscom, and I use she, her pronouns. I am so proud to be mom to Will. and a sibling. I'm a member of the Rainbow Families Action Group, and we've come together to grieve and share resources about how to support each other and our kids in response to escalating attacks on trans youth and our families. RFA has been contacting representatives, protesting, rallying, and connecting all over the state, dreaming of and demanding an environment where our kids could just be kids and receive the care they need. Thank you. All the while living in a constant state of worry, knowing that access to gender-affirming care could end at any time because of these federal attacks Our story began almost six years ago when my son Will was 11 He bravely came out to our family as trans And two years later Will experienced a debilitating decline in mental health in the form of anorexia because his gender dysphoria became unbearable. You're doing amazing. You're doing amazing. You're doing amazing. Oh, thank you. Thank you. I'm grateful to our providers at Kaiser who supported his recovery and delivered care tailored to my son's needs. And now, at almost 17, they continue to support Will by delivering evidence-based, thoughtful, and safe gender-affirming care. His story, like many trans youth nearing high school graduation, includes gender-affirming surgery as an important part in preparation for college or before launching on their paths to adulthood. When Kaiser put a pause on gender-affirming surgeries in July, we were crushed. We did not hear the news from our trusted providers, but through the media. Communication at Kaiser became more sporadic, and we tried to speak to our endocrinologist about surgery referrals, but the process of surgery consultation remained unknown. We were encouraged to look out of network. My family, and many families receiving gender-affirming care, experienced anxiety, confusion, and disbelief that hospitals would defer care that's so important. While only a few institutions like Children's Hospital Los Angeles closed their gender-affirming care programs entirely, all families are fearful that care could end at any moment. Many institutions, including Stanford in June, Kaiser in July, and now UCSF, or just a few weeks ago, have stopped providing gender-affirming surgical care or made it extremely difficult to access surgical care. Due to the immense federal political pressures and pre-compliance from hospitals, even in California, where this care is supposedly protected, we are constantly wondering if our medications will continue to be available and whether the care of experienced and ethical physicians will be among the care levels denied to us next. Our team at Kaiser couldn't give us concrete timeline for six months about surgery referrals. They encouraged us to go out of network, and so in January, after researching, calling, and inquiring, I found a surgeon and scheduled a consult even if it meant I would have to pay out of network fees. I learned that this particular surgeon was engaged by Kaiser already, and as a Kaiser patient, I had to follow the rules of their contracted relationship, and we canceled our appointment. From this office, I learned that new Kaiser referrals might begin by the end of February. This time came and went, and we got back in line with Kaiser patients, hoping that the cost of surgery would still be covered by Kaiser before the rules changed again, and that Will would indeed have the surgery before leaving home for college. And now here we are in April, after nine months of inquiry, back and forth with a surgeon, and lots of emotional turmoil. Just five days ago, we were granted an initial surgical consult scheduled with Kaiser in hopes of a referral to the surgeon I had originally contacted. I'm hopeful, but until the day of surgery, I won't feel confident that this ride is over. I want to be clear. Our providers are caring, and information seems to be changing all the time. but families I've spoken with are experiencing this emotional roller coaster and deferral of services, not just at Kaiser, but across the entire healthcare system and in all aspects of care is scary. This includes trans youth and adolescents on hormone blockers or trans youth receiving hormone replacement therapy and surgery. These are scheduled procedures recommended by trusted providers that for some have been canceled or deferred with no explanation, and families must scramble to find alternative care. As far as I understand, based on communications with a network of hundreds of families with trans and non-binary kids, and what we hear from hospitals and healthcare providers, the number of surgeons currently providing surgical care to youth under 19 and who accept insurance numbers two. statewide. Two surgeons to serve all of California's trans teens and families. Even if only a small number of trans youth decide to pursue surgery under 18, we know that access to this care is severely limited and delayed at this point. I'm a member of a group of loving parents with teenagers in their last years of high school trying to experience high school. And we want to be present to support our children in recovery after a gender-affirming surgery and before they leave our homes. I know of families who have taken action on their worst case scenarios and have moved outside of the U.S. or seeking gender-affirming care and surgery in Mexico or Canada or further abroad. These are financial and psychological burdens for all and our lives are being severely impacted as this care is at extreme risk because of federal attacks. The continuity of care for trans youth, as we have heard, is imperative because gender dysphoria is a huge daily concern and watching these hospitals and health systems fail one by one does not feel safe. Will and I are among the privileged to have insurance, even in a system that feels unstable. There are so many without coverage who desperately need this care. I ask you, as lawmakers in one of the few U.S. states where government is actively conducted by the people and working for the people, and I've witnessed that today, there's so much happening here in support of trans youth. Will you please fulfill your obligation to protect our kids' right to health care? Please support this $26 million one-time general fund investment to protect and stabilize access to care for transgender kids and their families, and make sure that families like ours continue to have this essential care for our kids in this highly uncertain and unstable environment. It's absolutely critical for all trans kids, for kids screaming to be their best selves. For my son, who's here today, he's an exceptional human. Thank you. Will, your turn.

Thank you so much. I think we have one more parent. Yes. One more parent.

I feel a little heavy right now and the point of privilege here. I sometimes say, as a fellow veteran, we put on a uniform to defend a country that sometimes won't defend us. So I feel that. And I'd also like to say that I think it's phenomenal that your children have you, too, as parents. There are many of us that don't have affirming parents. So I just want to thank you for you being amazing parents. I would love to kick off some questions I have. I forgot your name. Shoot. What's your name? I forgot your name. I apologize. J.M. J.M. E.D.

And you mentioned you were nodding your head when the doctor talked about the insurance barriers. Can either of you expand a little bit more on insurance coverage, not rolling over or not covering for you?

Because said hospitals told the LGBTQ caucus and briefed us and said, we are connecting patients to providers. They have one surgeon that they have contracted with that I'm aware of. I don't think that they have contracted with other gender-affirming care, like primary care providers or mental health providers. And any of the four from your experience, peers, your patients, has anyone called DMHC's helpline to get connected to help navigate any of that?

Okay. I think there's so much going on and we're just trying to get our needs covered. I don't think it's in everyone's state of awareness. A lot of people don't know that they can do it without a denial, right? So you can do it with just a delay in care, but you have to document every interaction that you've had and be like, this is a delay. This is when we started the process. This is where we are now. But people don't always know that they have a right to go straight there without having a denial in hand. So people are often waiting for something to be formally requested and denied, then go through the insurance complaint process or grievance process and then go to the IMR. But most people don't even know that IMR exists. So we need to do a better job of bringing awareness to the options that the director mentioned earlier. Yeah. And I think even there's opportunity for, you know, being more transparent around the denial data. I think there's also opportunity to be more, to enforce more. You know, these fines are not big enough for the insurance company to care, right? Like we'll have, we'll show DMHC data of, you know, these are the denials we're seeing with this particular insurance company. It doesn't seem like they always know that information. and then we'll sometimes hear like, oh, we did a $50,000 fine for this one insurance company after like a decade of denials and for Anthem La Crosse is like nothing You know it nothing for them There also an issue with the insurance companies requiring buy bill services This is especially important for blockers. So there is a health plan, a Medi-Cal health plan in Los Angeles, who used to be an incredible supporter of our work and trans care and just recently denied and said we'll cover a blocker, but it's buy-in bill. Well, we heard about the cost for a blocker implant is upwards of a $200,000 cost, and who can buy that? I mean, the families can't. These small practices can't, and even when I was at Children's and Blue Shield did this, we couldn't afford to do that. Thank you. My last question to you. So the story that you mentioned, is Kaiser going to be paying that out-of-network service?

Okay. Why is it false? Because I did not withhold data because of the political environment.

you're referring to. I know what you're referring to. This is my life. Yeah. This is my life. My life has been threatened. People have said horrible, atrocious things to me, even outside this building as I was walking in So I know exactly what you referring to The problem is that It a problem right Because we can have a conversation on this without people threatening how they feel on an issue correct

Absolutely, and I'm totally willing to answer your question about blockers. Here's the thing. If blockers are supposed to pause puberty, you have to give them when puberty starts. Or early in puberty. It's in the name. It's literally in the name. This is a reversible intervention that gives people exactly time to do what you're talking about, which is engage in conversations with professionals about what is it going to look like for me to be a trans person? How am I going to navigate these things that are really hard? That's the purpose of puberty blockers. The fact that people are coming for puberty blockers makes no sense.

Yes, there is. But I also want to add that it's extraordinarily rare that somebody even accesses service in time for blocking their puberty. It's really, really rare. We're talking about a very, very small number of people, which is why the time and energy and effort and all of this going into it is beyond understanding to me. There are actual real problems that we should be talking about, but not letting people have access to this really important intervention that is a reversible intervention is a big problem. It's cruelty. It's just cruel.

I think we should be having these conversations.

And when one of us walks out this door, we're going to get a piece of mind from somebody else for sure. Both of us will. So we should need to be able to have these conversations. And in fact, I will say this right now, this building, there are consequences for having opinions like mine. You dare have opinion like mine on a piece of legislation that is like this, and there are consequences of those actions.

There are daily impacts for trans people. Every day we live with the constant threat of our survival being taken.

So with all due respect.

Yeah, with all due respect.

No, they shouldn't be.

nobody should be threatened for their livelihoods.

Right?

because I disagree with anybody who would hurt or harm anybody.

And just like when you walk out of this building,

people that appreciate your perspective on things.

Well, last thing I want to say is, you know, I think it's good to know your perspective on parental involvement.

and the idea that this isn't germane to the budget is definitely incorrect because the state is making a decision on whether to fund these types of services.

Yes. It's never been the case that people could access care, medical care, without parental consent. I'm glad

That's a false thing that's out in the atmosphere, but it's not true. We're going into a love fest. Thank you.

I can't speak to how many other families are experiencing it. I can say I have called insurance. I've spent 10, 15 hours on the phone with insurance, additional 10, 15 hours on the phone with Rady's. I have emailed my senators, the Armed Forces Budget Committee. I've gotten no responses other than we want to help you guys, and we show up every day to make sure that our veterans are taken care of. But show me. So I don't know what those numbers are, and I am not going to pay that bill. I will tell you that.

And this is a federal insurance issue, right? Like, this is a TRICARE issue. Our timeline lines up where it shouldn't have been an issue, and that was a full endeavor. Like, we knew it was coming. So we worked really hard to have the procedure done before it happened to no avail.

I think what would be really great is if someone could advocate for if if you have contracted with a provide. I know that the way the contracts work, it's or I've been told is that contracts occur between a facility and a plan. But if they're in this, this is such a unusual circumstance that it would be really helpful if the insurance. When this first happened, there was a representative from Blue Cross that contacted me and said, hey, our beneficiaries really want to stay in care with you. Can we work on a contract with you? So it would be nice if there could be a much quicker conduit to getting contracted with insurance plans I don know how that would work but I think it would be really helpful Like you know this person has this experience and has been doing this for 20 years and was doing this at Children Hospital but no longer can

We recognize that as a gap. I think one of the responses that was offered was that there is some sensitivity where some providers might not want to be listed. but it seems like, A, there was a bit of a requirement in some statute previously. In your estimation, given the fact that there are only two people who are able to provide surgery right now in the state of California, Do you believe that there are providers who would actually want to be included in explicitly providing gender-affirming care? I mean, I can't speak for other providers, but I have had a lot of conversations with people who very, very quickly removed all traces of their name from their websites. They removed any content related to gender care just out of their own fear of their personal safety. And I mean, that happened at Children's. The day after I left, they scrubbed their entire website of any trace that I'd ever been there. And so I don know that people have an appetite for that I think some people do and some people don I think if somebody is a solo practitioner and they providing this care probably don want to be on such a registry Maybe a bigger organization might do that. I think it would be very, but there's not a lot of people doing the work. It's going to be a short list. That's for sure.

And maybe it's not like a registry, but maybe it's just the insurance plans, knowing what their network is. So when someone calls, they know what to say, you know, and it's not necessarily like a public thing, but at least we know the network, right? And we know how to connect people to the right. Because otherwise, how can we make sure that there's anywhere near the level of adequate care in the coverage so that we have coverage on paper in theory, but not the ability to provide care?

Is there a sense, particularly that for those who are kind of Southern California based, that we're seeing more people go out of the country for care?

I would say as parents, you find your community, we find out who the doctors are that will help us by talking to other moms. And the groups that I'm a part of, the support groups, are getting smaller and smaller because people are leaving. Like literally have secured their visas, gotten new jobs, and left the country. So some people are leaving the country just for care. Other people are permanently relocating.

it is super sad, especially as a veteran. I shouldn't have to leave the country that I fought for, but I will. If it means, if I can't get care for my kid here, I will get care for him somewhere else. And that's a, that is a common thread with parents. And there are also folks who are preparing their kids for college who are looking out of the country for safety and continuity.

That is a statement of legal fact was offered by this practicing doctor. Yes.

Or legal guardian. Let me just add that in. Whoever has legal medical decision-making for that young person has to provide consent.

Do you want us to stay?

Laura Sheckler?

Okay. Thank you. I'll be really brief. I know this has been a long hearing and really appreciate you taking the time to prioritize this and to all of our amazing panelists today. My name is Laura Shuckler. I'm here with CPCA Advocates, which is the advocacy affiliate of the California Primary Care Association. And I'm here on behalf of a coalition of statewide organizations who have been working on a budget ask to resolve or at least address some of these federal pressures and the impacts on providers here in California over the past six to eight months have been working on this. And we'll just say that this budget request is supported by nearly 90 community-based organizations statewide So we are requesting a million one general fund request that would preserve a provider network of youth gender care providers and access to this medically necessary care across California. So the budget request is broken up into two different buckets. The first part of it is a $1 million administrative cost that would go to the Department of Health Care services to be able to create a state-only funded pathway for Medi-Cal to cover any services that are restricted from federal financial participation. We see that for the youth gender-affirming care services that we've talked about today. We have done this with the department before. Obviously, we have other state-only funded services, but have done this for even FQs in the past for different state-only services. So we know it's possible. And then the remaining $25 million would be used as a provider stabilization fund. So this would be for the provider network that is willing to continue providing these services and scale up those services, you know, if and when we see additional hospitals withdraw from this care. As we've already heard, thousands of patients have already lost care to date, so this is already needed, but we do continue to hear from hospitals that they plan to withdraw from care when we see the finalization of these CMS rules, even if they are challenged through the courts, including here in California. So that funding would be used for a variety of things, could be used for increasing staffing, for infrastructure costs, medical malpractice insurance, legal costs. We did hear from Lyon Martin about their particular structure, but for other federally qualified health centers, if they did need to separate this from their financial funding streams, they would need to go through a legal process of setting up something called an other line of business where they completely separate financial, operational, all of the services from their federal funding streams to be able to offer state-only funded services. Or other health centers would be thinking about setting up a completely separate entity or partnering with other organizations who could potentially offer these services. So all of that would require a significant amount of resources. And then the last piece of this budget item which really speaks to one of our parents Jane Doe today would be to cover uncompensated care costs for the families who have lost coverage through their federal insurance plans so through TRICARE if they're veterans and also for federal employees who have had their coverage for gender-affirming care discontinued and we'll pause there

You mentioned under things like legal. Oh, well. If I'm understanding the question correctly, how we're envisioning this would be that DHCS, their medical program is still required to cover medically necessary gender affirming care services. So even if we pulled it into state-only Medi-Cal, there would still be a reimbursement pathway for that. But what we actually would need for the providers who are potentially smaller providers or see a fewer number of youth patients right now, is that they would actually have to potentially expand their clinic space, hire more providers do things like FQHCs would lose their federally covered medical malpractice insurance So they would have to purchase that separately So it really would be those infrastructure costs that would help them set up and scale up to provide services for these patients, and then coverage, hopefully here in California, would continue under the Medi-Cal program or through commercial coverage.

I'm wondering what guard roads are going to be in place to track if infrastructure is growing. How are people going to get there? Is it going to grow and equate to X amount of people now going to those facilities?

Yeah, and I have to say I'm not as familiar with where those covered California dollars have gone and how they've been implemented on that side. But I think we do have lots of other programs that we could really look to. For example, some of the uncompensated care funds in the abortion space, for example, or some of the TGI health and wellness funds, which haven't been focused necessarily on youth in the past. I think this would need to be a slightly different structure, but I think we have lots of examples to look towards here in California. to think about structuring a program like this, and then obviously there would be different metrics and outcomes that we could track.

I know you mentioned that as families lose coverage, that these possible dollars are going to help with that, and the effort of maximizing those dollars, because I'm sure we won't have enough to cover everything. I wonder if there is a possible way to first look with the families to ensure that, I think I use the family, the mom earlier example, where if the family lost a coverage, you know, try to fight first for those dollars. And if not, then we would have some dollars to help those families.

But then they, in the current situation, they're not being compensated for those dollars. I'm just trying to maximize the dollars to help as many families as possible. So I'm just putting that into how do we do that, you know, to ensure we do help more families.

For as many as possible.

And I think that that would be a conversation in terms of how this program is structured through both, you know, thinking through how we'd write any trailer bill language and then ongoing conversations with Health and Human Services, with DHCS, with potentially CDPH, et cetera, which we have been in conversation with all of those departments on an ongoing basis.

My name is Eric. I'm the Health Services Outreach Manager at the Sacramento LGBT Community Center, and I'm here because I see the impact of gender-affirming care every day. People we serve, especially those with low incomes, are losing access as providers pull back and clinics close under federal pressure. What was once stable, reliable care in California is being disrupted in real time. access to medically necessary life care is critical This million investment in a billion budget is a small targeted step to stabilize providers prevent system collapse and ensure All right Thank you

Hi, my name's Kevin. I'm from Sonoma County. I just wanted to thank you all for holding this hearing and say that if the federal government wants to take away parental health care rights in order to go against the evidence-based recommendations of the American Association of Pediatrics and the American Medical Association, I believe the state has a duty to step in and help protect these incredibly vulnerable children. Thank you. Thank you.

letting the federal government cut Medicare for gender-affirming care will impact hundreds of thousands of people across the state. Gender-affirming care has made me able to be here today. I would not be here without it. It has made my life way much better, and I really hope that you all will keep enabling access to it. Thank you so much for your public comment. I appreciate it. Hello, my name is Dina Lon from the San Francisco Community Clinic Consortium. We represent 11 nonprofit community health centers in San Francisco. Our health centers just want to continue to do what they've been doing, which is providing very high-quality primary care and behavioral health care and dental care to their patients. And we support this budget ask because we believe it will contribute to that. Thank you. Thank you. Good afternoon or evening. Christine Smith. Can you lower the mic? Sure. Good afternoon or evening. Christine Smith with Health Access California, urging you to support the $26 million one-time general fund investment to establish state-backed continuity and provider stabilization framework for gender-affirming care in this upcoming fiscal year. Everyone deserves the freedom to access the health care they need and to be treated with dignity and respect. Thank you. Thank you. Erin Friday, mother of a daughter who used to believe that she was trans. She was never trans. All the doctors told me that she would commit suicide if I did not transition her. So when Joanna Olson-Kennedy talked about consent, she's lying. What she does is she forces parents by telling them that if they do not transition their child, if they do not poison them with cross-sex hormones and puberty blockers, that their child will kill themselves. She also sicks CPS on the parents who refuse to capitulate. I was one of those parents. I had Child Protective Services come to my house when I refused to call my daughter a son. Well, now she's 19. She's got her full body intact. My name is Layla Jane. I'm someone who underwent the... very procedures you guys advocate for. Look at me. Don't look away. I had puberty blockers, testosterone, and surgery approved at 12 years old. Did I become a boy? No, I'm a female, just one with scars and nerve pain, along with other complications even years out. My mom was pushed into agreeing with this by threats of suicide by my doctors. Stop monetizing the bodies of mentally unwell and autistic children that would otherwise grow of this like myself. Protect children, not the wallets of physicians. Thank you. Thank you. Hi, my name is Beth Bourne. I'm the mother of a child who was groomed and programmed to believe that she could be a trans boy in California public schools. Kaiser Permanente offered my daughter at the first visit to go to the gender clinic where she could get a double mastectomy and puberty blockers and testosterone. I am a loving mother. I told my daughter that she will always be female and she got to grow up to be a healthy, whole woman. The truth is kindness. It's impossible for somebody to be transgender. I mean, think about it. If you're a boy, you grow up to be a man. If you're a girl, you grow up to be a woman. Thank you. It's child abuse to lie to your child. Cynthia Craven's Women Are Real. The panel that was invited to speak, Where are the doctors, scientists who've conducted systemic reviews on research on the efficacy of sex-denying procedures? Where are the parents who've lost their daughters or sons to gender identity ideology? Where are the detransitioners now suffering because of medicalization? Where are they? I have a friend, Richard. He was a detransitioner. He had schizophrenia as a youth, and they convinced him that he should identify as a woman. Medicalization followed. His penis was internalized into something that resembled a bit. Sorry? Thank you. Oh, all right. Everyone only gets 30 seconds. Hello. My name is Sarah Kim, representing TV Next for the thousands of followers of Asian community. I'm here to ask you and tell you that there is a real cost for our children. We need to care for our children psychologically and mentally and physically. The sex-rejecting procedures actually is not really helping our children because we have a lot of children who need mental help first, psychological help first. It is irreversible and also irresponsible for the adults to look through these children. So please protect our children. Thank you. Good evening. My name is Janine Pera. The elephant in the room. Why are there no detransitioners on the panel? Puberty blockers are not medically necessary. I did not hear a reason why you made that statement multiple times. They cause permanent damage, life-altering damage. Puberty is a natural process. Yes, uncomfortable, but all of us go through it, and it should be natural. Stop medicalizing our children. Thank you. Thank you. My name is Cheyenne Kenny. I come here representing Gen Z. I'm against convincing children that there is something wrong with them. They don't have the capacity to make life-altering medical decisions, and also detransitioners matter as well. So no more mutilating children. Thank you. Thank you. My name is Elizabeth Kenney. I from Oakland California Stop butchering step Stop beaitreggh research Stop beHAM Someday I from Oakland Arts Stop butchering kids. Stop butchering kids. Stop butchering kids. Stop butchering children. Stop butchering children. Stop butchering children. It's got to stop. Stop butchering children. They don't deserve it. Thank you. Good afternoon. My name is Suzanne Itzentan. I'm a family physician and the chief health officer of One Community Health, which is a federally qualified health center in Midtown Sacramento. And not only does gender-affirming care decrease the risk of mental health disorders and suicide, safe spaces for these individuals are critical for them obtaining preventive and chronic care services, too. And I see more and more of my patients feeling increasingly unsafe in medical environments. And so it's really important that we preserve payment for this life-saving care and also protect the individuals receiving the care as well as the clinicians and the organizations providing it. Thank you so much. Hi, Chair and members. Sorry. George Cruz on behalf of the California Behavioral Health Association. Our members across California deliver gender-affirming care through health centers at the OPERATE and provide behavioral health services that support trans and LGBTQ plus individuals at every single stage of care. and we want to express our appreciation for the joint hearing, bringing attention to the critical issues relating to gender-affirming care and ways that the state can better support trans individuals. Access to gender-affirming care and services are deeply intertwined with behavioral health outcomes for LGBTQ plus communities, and research consistently demonstrates that access to gender-affirming care is associated with reduced rates of depression and suicidality. Thank you so much. I know you're speaking really fast. Thanks. Good afternoon, committee. My name is Kylan Fowler, and I'm a representative of San Francisco Community Health Center. We have served transgender and diverse patients in the Tenderloin for decades. Federal action have already closed major organizations. We absorb those disparity patients without funding. We have our own federal grants terminated. The $26 million invested is not a luxury. It is a minimum requirement to keep California gender-affirming care system from collapses, and we urge your full support. Thank you. Thank you. Good evening. I'm here as the loving parent of a young trans child. We recently moved back to the U.S. from abroad, and we were really unsure of whether our move was the best thing for our child, but I remember thinking, we'll be in the Bay Area. It will be okay. I really need you to make it be okay. We need you all to step up for families like ours. We need you to uphold the inclusive laws that brought us back to California, resist federal overreach and fund access to this safe, effective, and life-saving care so it will still be there when it's our child's turn to need it. Thank you. Thank you. Madam Chair, Horacio Gonzalez, on behalf of DAP Health, also known as the Desert AIDS Project, we serve about 88,000 patients with primary care services, 1,000 of whom are receiving gender-affirming care. Unfortunately, because of what's happening at the federal level, that number continues to rise as we move to step in and absorb patients that are being disrupted by providers that are not only curtailing their services, but in some cases outright eliminating them. The $26 million investment will go a long way to ensure that providers like DAP can continue to step up and ensure that these vital care services will continue to be provided. Thank you. Thank you Good evening Chairs and Members Angela Pontus on behalf of Planned Parenthood Affiliates of California representing the seven Planned Parenthood Affiliates that are gender care providers in support of the million request for gender care infrastructure Thank you. Thank you, Madam Chair and Members. Megan Subers on behalf of the Los Angeles LGBT Center. I want to first express gratitude to this committee and for the panelists for coming today to talk to you. We are in very, very strong support of this $26 million investment that will provide life-saving care that we are required to provide in California to this community. Thank you. Thank you. Good afternoon, Chair and members. Omar Al-Tamimi with the California Pan-Ethnic Health Network. Just want to thank you for having this incredibly important conversation. Keeping it short and sweet, just want to really thank you and support the initiative and really support your – support the legislature. voice our support for the legislators' work in the past and the work that they're doing now to continue to protect youngsters and folks who are dealing and going through such a, I think, difficult and human moment in their life. And so just really want to voice our support for you all for having this conversation and then also want to voice our support for the LGBT Health and Human Services Networks. Thank you. In support of that. Thank you. Thanks. Hi, my name is Margo, and I'm here with Rainbow Families Action. Thank you for this hearing. California has always been a leader in LGBTQ care and now care for transgender, gender diverse, and intersex people. This care is medically necessary, evidence-based, and recognized by every major U.S. medical and mental health association. But for my family, it is essential to the survival of my trans youth. Please support this vital funding to protect TGI healthcare in California. Thanks. Good afternoon, my name is Chris. I am also a veteran. I have a trans son. I'm also in support of this in the same way that Will and Raisha and the other veterans said today. I think it's really important and this is something that I fought for when I was out there. Thank you. Thank you. Good evening. Thank you all for your time. I'm here with Rainbow Families Action, and I'm the parent of a beloved transgender teenager. And I'm here to ask you to protect access to gender-affirming health care for all Californians. This bill would help to protect equity so that whether or not families can pay to try to access health care outside, this bill would help to be able to create systems so that they can continue to access it through Medi-Cal or through other supportive community clinics. Please support this bill to ensure that all of our children have the care that they need to live full and healthy lives. Thank you. My name is Gabrielle. I'm here from the East Bay and with Rainbow Family Action. I'm a grateful parent to two amazing daughters. Thank you to the committee and panel for the time and consideration on this important issue. I support the $26 million one-time general fund investment to protect and stabilize access to care for transgender people and their families. I see the beauty in our family and friends who are living wonderful lives thanks to gender-affirming care. California should protect and support all families, people, and individuals who seek care that allows them to be their healthiest and happiest. Thank you. Thank you. Hi, Kathy, she, her. I am the founder and executive director of Trans Family Support Services. I'm here representing thousands of transgender youth and their family across California that we serve, who right now are scared and devastated. They losing trusted health care providers not because the care isn necessary but because the federal threats and pressure that are forcing providers to step back These are families who are trusting California to be a safe place a place where their children could access medical care without fear. California has the power to protect these families. Thank you. Hello, good afternoon. My name is Aston Gorgio Williams, and I'm here speaking on half of the California LGBTQ Health and Human Services Network. I am here in strong support of the $26 million budget request to protect access to transgender health care. Additionally, I would like to state for the record that TransLatina Coalition is also in strong support of this proposal. Thank you. Hi. My name is Madi. My pronouns are they and them. I'm here with Trans Family Support Services. Over the past year, trans youth health care has been under direct federal attack. Discriminatory laws and regulations have created fear and forced capitulation from health care providers and clinics alike, undermining the protections offered by our state and harming an already vulnerable community. This budget proposal will help rectify the harm caused and ensure California's commitment to equality for all. I urge your support. Thanks. Hello. My name is Dr. Malachi Cote, and I'm a licensed psychologist and the executive director of the Gender Health Center here in Sacramento, California. The demand for our services, we provide gender-affirming care. The demand for our services has only increased with providers stepping away from providing this care, canceling services with patients. It's left our community members scrambling to find medically necessary care. To ensure health equity for all people, we need to safeguard these crucial health care options. Thank you. Thank you. Hello. Here's my kid. Hi, my name is Corey, and I live in El Cerrito. I'm the parent of a beloved trans child and I urge you to support this investment in the health of young people in California. My own kid is about to graduate from college and they are thriving because they got the care they needed while they were still young enough to receive the full benefit. They went through their second puberty at a developmentally appropriate time, i.e. not as an adult, and have emerged as a young adult who is ready to go, healthy, responsible, and capable. I want this for all families of trans kids. Please vote to allocate this funding. Thank you. Hello, I'm Jessica from PFLAG chapters of San Jose Peninsula, Clayton Concord, Limarinda, and Tri-Valley. Nationwide PFLAG focuses on making a better world for our LGBTQ loved ones, and for many of our families, gender-affirming care has made the difference between our children thriving or barely surviving. As you have already heard here, access to care in our state is already frayed. It needs to be reinforced so that parents will not have to tell their children that the care they depend on is completely gone. Please approve this $26 million budget request so that California's protections remain meaningful. Please do not back down. Thank you. Thank you. Hello, my name is Mary Moyle. I'm with the Sacramento PFLAG chapter. I am also here to speak for the Danville, Fremont, and Oakland chapter as well. Many of us, PFLAG is a parent-driven group. Many of us are the parents of children who have had gender-affirming care, and we can attest firsthand to how much that has benefited their physical and mental health. Thank you so much. Thank you. Hello. Thank you. I'm a parent and a teacher, and I'm here to say that I support the $26 million budget request. And thank you for holding this hearing and for your time. Have a great afternoon. Thank you. Hello and good afternoon, everyone. Sam Castle. I'm a social worker intern at the Gender Health Center. I transitioned at the age of 36 and will be 44 years old this year. I can personally attest that gender affirming care saves lives. It saved mine. Provider stepped in to walk this journey with me when my family would not. Asking for $26 million out of a $300 billion budget is a small request for something fundamental to human rights. I wholeheartedly support the budget that protects and stabilizes access to transgender care, ensuring everyone can receive the health care they need. Thank you. Good luck with you, Ms. Davi. Good afternoon, members. My name is Camila Camelion. My pronouns are she, her, Eya, and I'm a policy director at California and Latinas Reproductive Justice. And for identification purposes, the treasurer at the California Coalition for Reproductive Freedom, in strong support of the $26 million ask, just want to share that the infrastructure for trans health care is collapsing in real time. And we appreciate your vote in support of this. Thank you. Thank you. Good afternoon. Craig Pulsar on behalf of Equality California. First off, just wanted to express our sincere thanks to the chairs, members of the committee for convening this hearing. I think you can see families and patients across California really looking to the legislature for leadership and just thank you for being the champions that we need in this moment. Also just wanted to express our strong support for the $26 million investment to stabilize the health care delivery system for trans youth and their families. and without this funding there is a very real risk in the near future that more patients could lose access. Thank you. Hi, my name is Riley. I'm a law student and also a trans athlete. The current federal administration has shown nothing but disdain for the lives of everyday people living in this nation. Gender affirming care saves lives. I'd like to thank a majority of you for all looking at the science, for listening to trans people, for listening to trans youth and to their parents. Please approve this funding. Thank you so much. Thank you. Good evening. Linda Way with Western Center on Law and Poverty. Appreciate you hosting this hearing, as well as the witness and parent who's provided their direct experience, as well as the turnout. We support the $26 million funding, whether that be part or separate from Medi It sounds like if the rules become final it have to be separate but regardless we support the million Thank you. Thank you. Good afternoon, members. Tristan Brown of CFT, a union of educators and classified professionals, here to voice our support for backfilling the transgendered care that you've seen in the Capitol. We have signs everywhere that says, all students are welcome here. We believe no matter who you are, you're a student in our schools, you have a safe and supportive environment. We're happy to support the effort. Thank you for doing this. Thanks, Tristan. Hi, my name's Haru Seki. I help run a group called Indivisible Sacramento, and I'm just here as a community member in strong support of protecting us, because nobody's going to help us but us. And I think the best thing that we can do in California is realize that we have to help ourselves. I really appreciate your time. Thank you so much. Hi, my name's Aaron Maccaro, and I'm also just here as a community member. I grew up in Sacramento. I own a home here. I've lived here most of my life. I'm also a transgender resident of the city. Parents of trans kids as well as transgender adults, I think, are really looking to the state legislature for leadership and protection, frankly, from the federal government on this issue. Gender-affirming care is life-saving, and gender-affirming care is something that, for some of us is going to be a factor in our health care, just like someone that's receiving treatment for diabetes. Thank you. So in support. Good evening. I'm Erin Evans on behalf of the County of Santa Clara in support of access to critical, lifesaving, gender-affirming care. The county operates both a gender health care center as well as gender-affirming care clinic. We also litigate and advocate to preserve access to this critical care. Thank you. Thank you. Good evening, Nora Angelas with Children Now. Gender-affirming care is life-saving and medically necessary for many children and youth supporting their mental health and overall well-being. Recent federal actions have jeopardized this care. We support the $26 million investment that will help ensure continuity of care through a state-only Medi-Cal pathway as well as stabilize the network. Thank you. Thank you. Good afternoon. My name is Renee Bayardo. I'm here as a parent today on behalf of myself and my son. Thank you Thank you Hi y My name is Milo Baiman I a director and attorney at East Bay Community Law Center in Berkeley I also trans and without this type of care I would not be where I am today So thank you for considering this bill. Thanks. Hello. My name is Evelyn. I'm a trans woman from San Francisco and an organizer with Indivisible. I've lived and thrived for 15 years, my whole adult life because of gender-affirming care. I am a productive Californian for the last 10 years because of a gender reforming care. Thriving trans people earn more and pay more taxes, so this funding is a good investment. Transgender surgeries reverse damage from unwanted puberty, and puberty blockers prevent the need for those surgeries. They are a good investment. And puberty blockers prevent the changes for which there is no surgery. Trans adults like me and many of my friends envy trans children for the once-in-a-lifetime opportunity. Hello, my name is Syntharia Manikannan. I'm a current UC Berkeley law student and an intern with the East Bay Community Law Center. I'm here in support of access to gender affirming care in California and this $26 million bill as a policy that is not only necessary for health equity, but also crucial to the physical health and well-being of all individuals. They're going to need you to litigate all these cases soon. I'll be there. I'll be there. Hi, my name is Emily Chow. I'm also a law student at UC Berkeley and a student intern at the East Bay Community Law Center. I strongly, strongly support access to gender-affirming health care and this $26 million budget request. And I want to thank you to all the panelists and the members here today. Thank you. Copy and paste what I told her. My name is Shaina Kirk. I'm here representing Rainbow Families Action. I'm also the loving parent of a beautiful transgender daughter and a therapist offering gender affirming care myself. I want to thank all the members and chairs who are putting in tireless work and efforts to listen and show their care for the most vulnerable members of our community. I strongly urge your support for the budget asked today that would help support the devastating cuts that are coming and allow health care providers to continue providing essential health care services to transgender and gender expansive patients who depend on this care. to live full healthy lives safely. Hello, thank you, honorable members for your service on this committee and thank you to our panelists and especially Will I Madeline Merwin I am here as a resident physician who is an obstetrician coming to have urge your support of this budget expansion so that I can continue to give the life care that the American College of Obstetricians and Gynecologists and the American Medical Association support as life-saving and medically necessary evidence-based care. Thank you. Hi, David Bullock, SFV Alliance. My colleague Aaron Friday talked about the pressure that comes from doctors. It also comes from schools. It comes from activists that encourage kids that are transitioning and the parents do not accept it to remove themselves from it. And it also came from you three. Not you, sir, because you weren't here, but you remember Assemblymember Carrillo's AB665 that allows a child to remove themselves from their parents with a professional person. and also AB957 by Wilson. Can I continue? My time's up. Now it's done. Thank you. Anyways, yeah, you three have pressured parents into transitioning to order. And it's not fair. Amy Costa of Fullman Strategies on behalf of Alameda County in full support. Thank you so much.

We will miss you dearly. We will miss you dearly, Madam Senator. Thank you, I wanna thank all the folks that have come and thank our members again for their decorum and everyone who was so generous with their time, mostly with their courage, so generous with their courage on this one. We are gonna move back to our subcommittee, number one on health,