Within this climate, many workers, like Quinn, are mobilizing in private. Others are taking action in the open as union members, participating in protests against hospitals that roll back services or staging creative actions to show support for their patients. While no one is free from fear of repercussions, those organizing as union members seemed more comfortable going on the record, and those who are retired especially so.

But every healthcare worker I talked to said they are desperate to do what they can to stem a mounting attack on an already vulnerable population and keep providing care that they fervently believe saves lives. “I have seen what not providing gender-affirming care looks like, and objectively speaking, it results in worsening mental health issues, can result in increased mortality, and can worsen patient outcomes,” Andrea Soto López, a pediatrician for a Los Angeles–area hospital, told me over the phone.

To protect her privacy and prevent retaliation, Soto López did not want to talk about the specifics at her hospital or disclose its name, but she did say that her union, Committee of Interns and Residents (CIR), is “currently organizing, figuring out next steps, making sure we move forward in a strong manner.” She is regional vice president for Southern California, a position on the national executive board of CIR, which is an SEIU local that represents more than 37,000 resident physicians and fellows across the United States.

“We are currently working locally in California as well as on the national executive board to be able to organize around this very important issue that affects our trans and gender-diverse youth,” Soto López explained. “We have taken a stance on this for years now. In our 2023 national CIR convention, delegates passed a resolution pledging CIR to defend gender-affirming care as evidence-based care in our local hospitals.”

Recently this commitment was put into practice, with some success. The union worked with Democratic Socialists of America–Los Angeles to organize a February 6 protest against Children’s Hospital Los Angeles (CHLA) for pausing vital forms of gender-affirming care. (The hospital told me via e-mail on February 14 that it was “maintaining the existing pause on gender-affirming surgeries on minors,” and “pausing the initiation of hormonal therapies for all gender affirming care patients under the age of 19.”) In recent weeks, similar protests have taken place at hospitals across the country, from New York to Washington, DC, to Chicago, and Sophia Nova, a former member of DSA’s national leadership, told me over the phone that at many of these actions, workers and unions from a variety of sectors have turned out, in part due to organic movement connections.

CHLA also received pushback from California Attorney General Rob Bonta, who wrote a letter to the institution warning that “withholding services from transgender individuals based on their gender identity or their diagnosis of gender dysphoria, while offering such services to cisgender individuals, is discrimination,” and violates California state law. The hospital also faced follow-up weekly protests and a petition from Los Angeles–area physicians decrying the restrictions.

When I asked Soto López what CIR was demanding, she told me, “The call is: Don’t stop providing evidence-based medicine to your patients. Continue providing the standard of care to your patients you should be providing. The call is also that these are services that are protected by California law. This is the standard of care. If you would not withhold chemo from a cancer patient, you should not withhold gender-affirming care from a trans or gender-diverse patient.” (The American Academy of Pediatrics says that gender-affirming care is in the best interest of transgender and gender-diverse children and adolescents.)

Such demands appear to have had an impact. As reported by the Los Angeles Times and confirmed in a statement sent to me by e-mail, CHLA is “lifting its pause on the initiation of new hormonal therapies for patients seeking gender-affirming care, effective immediately.” (The hospital isn’t resuming surgeries.) The hospital is attributing this decision to its review of “recent U.S. District Court temporary restraining orders,” as well as “commitments from California Attorney General Bonta to seek additional protections for CHLA and its patients.”

But Soto López told me, “I definitely think the power of collective action played a significant role here.” She said, “Physicians, the patient population affected, the labor sector, and community organizations came together to call CHLA to adhere to the standard of care when it comes to trans or gender diverse patient populations.”

This call, too, has emanated from transgender people, including young people whose basic healthcare is under attack. Thirteen-year-old Noella, who publicly identifies as transgender, was the MC of a February 15 rally in Chicago to protest Lurie Children’s Hospital pause of gender-affirming surgeries for patients under 19. (Reporting indicates that Lurie is continuing to provide hormone therapy, puberty blockers, and behavioral health services, though I talked to one parent who said necessary steps to advance their daughter’s hormone treatment had been disrupted. Lurie did not return several requests for comment.) “It’s important for children to get care, and it’s up to the adults who work at these buildings to provide it for us,” she told me, as snow fell on the crowd.

Illinois does not have a state-level ban on gender-affirming care for minors. Yet, in response to the Trump administration, some—though certainly not all—Illinois medical institutions are pausing or restricting key forms of gender-affirming care, even as the Illinois attorney general’s office warns that the state’s “Human Rights Act requires healthcare providers to provide healthcare to all residents and prohibits unlawful discrimination on the basis of sex, which specifically includes gender identity.” And in some cases, hospitals are being vague or untransparent, as well as flip-flopping in response to public outcry.

No matter what protections exist on the books or legal challenges are levied against the Trump administration, if hospitals maximally comply with Trump’s edicts, or if patients are confused by poor communication, it means appointments are getting canceled and delayed, and healthcare being denied to people who need it.

Rebecca is a primary-care physician who works with transgender adults and children in a state where gender-affirming healthcare for minors is banned. She told me that medical institutions “have this ridiculous idea that obeying and maximally complying will lead to anything else but further restrictions, further compliance.”

“I am honestly appalled and disgusted by multibillion-dollar organizations rolling over and saying, ‘Don’t take our federal funding,’ instead of doing the absolute minimum and standing up for providers and patients and saying, ‘We won’t be swayed by a moral panic,’” added Rebecca, who is going by a pseudonym to protect herself from retaliation, and requested I not share where she works or lives.

Some healthcare workers want to make sure their institutions don’t get a chance to comply. Sydney Simpson is a registered nurse in interventional radiology at Kaiser Permanente San Francisco Medical Center, and a member of the California Nurses Association, a labor union. Last Thursday, Simpson gathered with about 20 other nurses in the lobby of the hospital, which is home to the Gender Pathways Clinic, holding signs that read, “Transgender rights are human rights,” “Nurses care for all patients,” and, “This is a sanctuary hospital.”

The demonstration followed a similar action outside Kaiser’s South San Francisco Medical Center the day before. At both locations, nurses also passed out information about immigrant rights. “The idea was that we would designate both of these facilities publicly as sanctuary hospitals,” Simpson explained over the phone. “Our government called California a sanctuary state, and San Francisco is a sanctuary city.” Simpson and their colleagues want sanctuary to extend to the hospital level.

“As a trans person myself, I am looking to my community for reassurance,” added Simpson, who works as a quality liaison for Kaiser’s San Francisco and South San Francisco hospitals, a union position. “I was thinking about what I would like to see from my nurses. I’m not just a nurse at these facilities, I also access these services. It’s a way to let our patients know where we stand.”

Nurses had not received any indication that Kaiser had pulled back services, but Simpson underscored that, if services were cut, “these things would not happen publicly. If I wanted to find out that’s happening, I would be heavily reliant on the parents of trans kids to tell me that. So this is very much getting ahead of the situation, letting people know to contact us as union nurses if their kids’ services are getting cut.”

The nurses want Kaiser to publicly lay out its plan for protecting patients from ICE and preserving gender-affirming care, and also to pledge to protect nurses who stand up for their patients. And they are part of a larger union, National Nurses United (NNU), the largest union of RNs in the United States, which has publicly condemned the Trump administration’s “attacks on trans people and patients.”

“Gender-affirming care is life-saving care for any patient,” Nancy Hagans, a registered nurse, the president of the New York State Nurses Association, and one of the copresidents for NNU, told me over the phone. “Everyone deserves to be taken care of properly, the way they need. If you have a heart condition, you go to a cardiologist and take care of your heart. When someone decides to go to gender-affirming care, it’s not only helping them physically, it’s helping them mentally.”

Simpson, who said they “escaped Alabama for San Francisco,” knows how important it is to protect those sanctuaries that do exist. They hope this sanctuary organizing can spread throughout the Kaiser Permanente system, which fans throughout the country. “Politicians are deciding how to treat us, like humans or not, but regardless of what they decide, we will always be here, and nurses will always have our backs.”

Ken Haller, a retired pediatrician in primary care, and an emeritus professor of pediatrics at the Saint Louis University School of Medicine, understands this too. He lives in Missouri where a state law prohibits gender-affirming surgeries for people under the age of 18, and bars hormones and puberty blockers for young people who didn’t start treatment before August 2023. Doctors who provide such care to children and teenagers can face penalties, including the loss of their license.

In Missouri, what that means for patients who need gender-affirming care, he said, “is they have either had to find care out-of-state or move out-of-state. A lot of our kids have gone to Lurie, which means a five-hour trip both ways. It’s really difficult.”

Lurie’s pauses to some of its gender-affirming care are “very alarming,” said Haller. “These kids are just really desperate, and I can’t imagine what’s going to happen if these places of medical sanity have to cut back on their services. It’ll be tragic for a lot of kids. The fact that this care was there at least gave people hope that if I move to another state I can get the care I need. But if this becomes a nationwide thing, this will be disastrous for a lot of kids, and I’m afraid a lot of kids might not survive it.”

Meanwhile, Haller has been fighting within his state, by opposing a bill that would make Missouri’s restrictions on access to transgender healthcare permanent. He testified against the bill on February 3 at the Missouri State Capitol in Jefferson City, and afterward, took to social media to reflect on his experience. “I’ve learned, once again, how important it is to do something, anything, even when we know that the immediate outcome is not going to be what we want,” he wrote, in a social media post that was shared widely. “Because we may find something else there, something even more important: friends, purpose, community.”

Rebecca is linked with groups of physicians trying to come up with ways to support trans rights in states that have banned gender-affirming care for minors. Sometimes, supporting patients means helping them get the resources they need to cross state lines. Providers also strategize about how to best protect patients’ personal medical information, or how to connect their patients to community resources. The Beyond Do No Harm Network, for example, supports healthcare workers to uphold their commitments to trans and migrant patients.

“Everyone is looking for certainty about, ‘This will be the thing that will keep our patients safe 100 percent.’ The truth is, that doesn’t exist anymore,” she said. “Amid this onslaught of federal violence, there’s nothing that’s 100 percent safe.”

But, she said, “people can do lots of different things and communicate with their patients clearly and figure out the best plan and how they can do everything they can.” And there are many scrappy groups on the ground, many of them led by transgender people, trying to help youth and adults get the healthcare and support they need. Connecting with such organizations has been critical to keeping herself from being “completely depleted,” she said, as has connecting with other healthcare workers who are trying to advocate for their patients.

Meanwhile, more unions are coming forward to condemn Trump’s actions. The executive council of 1199SEIU, the largest healthcare union in the United States, released a statement on February 24 saying it “unequivocally stands against” Trump’s executive orders targeting transgender people. The union promised to “fight to protect funding for federally qualified health centers, which serve as a critical source of care for transgender individuals and other marginalized populations.”

But even as there is strength in community, this is a challenging time for those trying to keep their patients well. Quinn, the therapist, said their clinic “provides a lot of LGBTQ care.” In recent weeks, the clinic has absorbed patients from nearby medical institutions that cut their services in response to Trump’s actions and declarations, though that has eased somewhat after Trump’s executive order was temporarily blocked on February 13.

Management is “on the same page” as workers about maintaining gender-affirming care at the clinic, Quinn said, and in that sense, “I feel lucky.” But merely continuing care is a low bar. Quinn’s patient base, by virtue of being personally targeted by Trump’s attack, faces a hostile environment for healing.

“We do a lot of trauma work,” Quinn said. “A lot of our work is helping people find safety and trust that the world is a safe place, so a lot of that has taken a huge setback. And the amount of stress, pain, insult, and moral injury that our trans clients are experiencing is overwhelming.”

“In particular, it’s this feeling of not being seen, of social deletion, of ‘We’ve done all this work to prove the medical necessity of this care, and it’s really scientifically based stuff that we are doing here,’ and to have that be ignored, it’s puzzling, maddening, and it’s affecting our providers and, of course, our patients as well.”