An 18-year-old transgender college student tried to refill her estrogen prescription at Northwestern Medicine in Chicago. She was told she needed to wait until her 19th birthday.

In Texas, a 37-year-old U.S. Army veteran regularly went to a Department of Veterans Affairs hospital for gender-affirming care, including therapy, wigs and prosthetics. Staff suddenly cut the services.

And in Colorado, a 37-year-old scientist for the federal government planned to undergo transition surgery. She discovered her insurance would no longer cover it.

A decade ago, these denials wouldn’t have been allowed. The federal government widely supported access to transition care.

That changed last year when the Trump administration began issuing sweeping directives across the government banning or limiting treatments for people with gender dysphoria, which is the distress felt from a mismatch between birth sex and gender identity.

Those who back restrictions on transition care — including conservatives such as President Donald Trump — say they are focused on protecting trans youth who can’t consent to or understand the long-term effects of treatments like puberty blockers, hormone therapy and surgeries.

But the administration’s actions and the resulting impacts have been far broader, blocking thousands of adults — including veterans, longtime government employees and older teens — from getting healthcare they need.

Since Trump re-entered office, he has signed an executive order prohibiting hospitals that receive federal funding from providing transition services to “children,” but the directive includes a broad definition of child: anyone under 19. The Department of Veterans Affairs has ended transgender care at the agency’s hospitals for anyone who wasn’t already receiving hormone therapy. The Department of Health and Human Services has enacted a rule that prohibits gender-affirming care from being covered as an essential health benefit under the Affordable Care Act — reversing an Obama administration expansion of trans care access. Federal officials have scrapped coverage of transition treatment for federal and Postal Service employees unless they are “mid-treatment.” Next year, the administration will end their coverage entirely.

What trans people are asking for isn’t extraordinary, advocates say. Nearly everyone, at some point in their lives, receives medical care related to their gender expression: taking estrogen or testosterone during menopause or treating erectile dysfunction. Many private insurance plans also cover gender-affirming care.

Tell us about your access to transition care as a transgender adult — Fill out form

To understand the effects of the Trump administration policies, NBC News conducted more than 30 interviews with trans adults, treatment providers across the country, conservative activists and lawmakers as well as advocates and lawyers from the nation’s largest trans rights groups.

Trans adults from Florida to Washington state said they’ve lost access to treatment or had procedures canceled because hospitals and clinics opted to roll back transition care amid the crackdowns. They’ve started saving money and setting up online fundraisers to pay out of pocket for gender-affirming surgeries. And they’ve faced long wait times and lengthy drives to see doctors who still offer care.

Academic research has shown that access to such treatment improves the mental health of trans patients, including reducing suicidal thoughts.

Those who have already faced barriers to care said they’ve experienced depression and anxiety affecting their ability to feel comfortable in public or perform well at work. Half said they have been stockpiling hormones in fear of further restrictions.

Come June, Kacey Garner, a 25-year-old Postal Service clerk in Mackinac Island, Michigan, will no longer be eligible to remain on her parents’ health insurance. She spent months worrying about switching to work benefits, since her transition care wouldn’t be covered.

She stressed about the need to pay $170 out of pocket every three months for hormone therapy. She didn’t know whether she’d be able to afford facial feminization surgery, which can cost as much as $50,000.

Without it, she spends hours on her makeup to alleviate constant worry about not “passing” as a woman.

“I have not felt relaxed in a very long time,” she said. “Actually, I don’t even know if I’ve ever been relaxed.”

She ultimately left the Postal Service job this month after her hours were cut, and she is now looking for work with more health insurance benefits.

Advocates say the federal restrictions stem from a yearslong effort backed by the country’s largest conservative groups, including the American Principles Project and the Alliance Defending Freedom, to paint being trans as an emerging political ideology rather than an inherent human trait. The push has resulted in policies at the federal level and in 17 states that reject trans people’s gender identities by making sex assigned at birth legally unchangeable.

The conservative Heritage Foundation has been a major driver behind the federal changes, which it outlined in its Project 2025 policy road map. Jay Richards, the organization’s vice president of social and domestic policy, said the foundation also authored model bills used in state policies redefining sex.

He said the organization doesn’t have “a settled position” on adult transition care but supports banning public funding for the treatment, regardless of age.

“We think restrictions, for instance, on the use of federal funds — Medicare, Medicaid, and things like that — that’s perfectly within the jurisdiction, in terms of constitutional questions, of the federal government,” Richards said. Any further restrictions, he said, should be left to states.

During a podcast interview in February, foundation President Kevin Roberts went further. He claimed transition and violent extremism are linked, suggesting that gender-affirming surgeries be outlawed.

Beyond federal restrictions, more than a dozen conservative states have targeted transition care for adults — and at least one has proposed outlawing it altogether. States like Florida and Texas have led the charge, implementing policies restricting care that the Trump administration is now matching on the federal level.

The tactics that federal and state governments are using have been adapted from the “abortion playbook,” said Elizabeth Gill, senior counsel at the American Civil Liberties Union.

“This looks very similar to what anti-abortion activists did over a range of years, which is passing all kinds of laws that make accessing the care more difficult,” she said.

Gill said the restrictions on trans care aren’t merely about whether procedures or medications are safe.

“The Trump administration has been clear in its intent from basically day one of this administration — that a priority of the administration is to push trans people, both youth and adults, out of public life,” Gill said.

The White House did not respond to requests for comment or answer written questions.

In public appearances and online, Trump often rails against what he calls “transgender mutilation” of children, often repeating a vague pledge to stop “transgender for everybody.”

‘Redefinding the word child’

Days after his inauguration, Trump took aim at transition care.

His executive order barred federal funding from hospitals that provide the treatment to “children.” But — in a short yet significant definition — it included 18-year-olds as kids, prohibiting many legal adults from starting or continuing treatment. Eighteen-year-olds enjoy many other rights and freedoms, including the ability to drive, vote, enlist in the military and purchase a rifle.

Aleksandra Vaca was caught in the fallout. Last year, she moved to the Chicago area for college, making an appointment to refill her estrogen prescription at Northwestern Medicine.

Vaca had realized she was trans four years earlier, while living in Austin, Texas, just as the state declared transition care for minors to be child abuse. That meant Vaca couldn’t start hormone therapy at the time — a delay that she said triggered severe depression and led her to contemplate suicide.

Most days, she struggled to get out of bed. Once she turned 18, she started treatment. Getting up became easy. The brain fog she’d experienced for years vanished.

“Everything was different,” she said.

She’d hoped to get a fresh start in Illinois. But hours before her appointment, Northwestern called and informed her that doctors wouldn’t prescribe her estrogen until her 19th birthday, citing Trump’s order. The denial, she said, felt especially ridiculous: Her birthday was later that week.

She immediately thought about her time in Texas. “It just brought it all back,” she said.

Northwestern Medicine declined to comment on Vaca’s case, citing privacy laws, but said the hospital “does adhere to the executive order.”

Denials and delays take heavy tolls on trans people, often because they have already waited years to access care, said Ash Orr, press relations manager at Advocates for Trans Equality, a prominent trans rights organization.

“That emotional toll isn’t just about healthcare access — it’s about having your stability and your livelihood constantly undermined,” Orr said.

Other policies defining children as 18 and under are rare. Two states, Alabama and Nebraska, set legal adulthood at 19. The Children’s Health Insurance Program, a joint federal-state initiative providing low-cost health insurance to kids, covers 18-year-olds.

Simone Chriss, an attorney at the Southern Legal Counsel, a nonprofit civil rights organization based in Florida, said Trump’s order sets a “terrifying” precedent.

“If we’re able to ban this care for people who are 18 years old by simply redefinding the word ‘child,’” she said, “then we can redefine it to mean under 25, or whenever they think brains are fully developed, and it’s dipping a toe into banning care for adults.”

Cutting coverage

Transition care at the VA had always been comprehensive for S.W., a 37-year-old Army veteran in Texas who served four years and deployed to Iraq. She received hormone therapy, individual mental health services, group therapy, prosthetics, wigs, laser hair removal and referral letters for surgeries.

Then last spring, nearly everything changed.

The Trump administration announced that the VA would phase out care for gender dysphoria, eliminating all transition care services except for hormone therapy to veterans already receiving the treatment through the agency. Now-banned trans military members who were receiving treatment during their service are also eligible to continue it.

“I mean no disrespect to anyone, but VA should not be focused on helping Veterans attempt to change their sex,” the agency’s Secretary Doug Collins said in a statement last spring. “All eligible Veterans — including trans-identified Veterans — will always be welcome at VA and will always receive the benefits and services they’ve earned under the law. But if Veterans want to attempt to change their sex, they can do so on their own dime.”

Trans veterans described confusion about what is and isn’t covered.

S.W., who asked to go by her initials because she fears harassment by anti-trans groups, said she needed an exam, including a physical and blood work, before a gender-affirming surgery last year. But she said her VA primary care doctor wouldn’t perform the checkup because it was related to transition care. Instead, she went to urgent care. She paid a $50 copay, and her insurance through her IT job covered roughly $150. She said the visit at the VA would have been free.

“I do not feel like I’m getting full access to the benefits I earned as a veteran,” said S.W., who set up and maintained antenna sites for radios and a Stryker brigade combat team during her service. “I never know when I’ll find out that there is something the VA can’t do because it’s related to me being trans.”

VA officials did not answer questions about the policy changes. In an emailed statement, Quinn Slaven, a spokesperson, said that the VA “has received almost no criticism in response to this policy — proof that the vast majority of Veterans and Americans support it.”

The VA isn’t the only federal agency that’s cut trans health coverage.

The Trump administration in January excluded transition treatments under the Federal Employee Health Benefits and Postal Service Health Benefits programs, which combined cover some 11 million federal employees, retirees and their families. There are exceptions for workers already receiving treatment, but next year, all transition care coverage will end. The government cited efficiency and protecting federal dollars as reasons for the changes.

Studies have found that transition-related care has a negligible impact on overall healthcare costs for employers.

B., a geologist in Colorado who’s spent roughly a decade working for the federal government, is considering canceling her employee health insurance and buying a marketplace plan with the hope of getting transition surgery covered. But benefits for her alone, she said, would cost what she currently pays to also cover her partner and their child.

“The more I continue to learn to accept myself,” said B., who asked to go by her first initial because she did not have permission to speak to the media, “the less tenable this becomes.”

When federal restrictions mix with state policies

Before the Trump administration started dismantling transition care for adults, states had begun the process. Every year, some consider more stringent moves.

Add federal restrictions on top of the state ones, and providers must navigate a constantly changing legal maze. They need to track new laws, agency rules, executive orders and declarations as well as legal challenges and rulings — to know whether they’re in compliance.

Twelve states bar Medicaid from covering transition-related treatment, regardless of age, and 14 ban state employee health plans from covering such care, according to the Movement Advancement Project, an LGBTQ think tank. Two allow insurers to refuse to cover gender-affirming care.

The federal and state restrictions have led some institutions to stop offering treatment. The University of Florida, for example, halted transition services through its health center this month, citing the evolving landscape.

Daniel Hogan, 21, a rising senior at the university studying natural resource conservation, said he was excited to go to UF, because he believed he’d receive stable care for the first time.

“I thought it would be a solid thing,” Hogan said. “And to have that dangled right in front of me and then it taken away is just very, very upsetting.”

Florida is among the most restrictive states. It is alone in requiring that only physicians prescribe hormone therapy and that they do so in person — even though nurse practitioners can prescribe many of the same medications via telehealth for other purposes.

Clinics run by nurse practitioners had to stop providing hormone therapy unless they could hire a licensed physician, causing some to shutter, according to providers in surrounding states and advocates.

Izzy Lowell, a Georgia-based doctor who runs QueerMed, a national telehealth clinic, told NBC News that in order for her to treat Florida patients, they must leave the state.

That can mean driving 12 hours from Miami to cross state lines. Her patients sit in a parking lot for their appointment, and afterward, she sends their prescription to a nearby pharmacy. Then, they’ll drive 12 hours home.

“I get new registrations every day from people in Florida,” Lowell said.

Increasingly stringent restrictions have been proposed and enacted in other states, too.

Tennessee Gov. Bill Lee, a Republican, signed a bill earlier this month that requires providers who receive state funding to report “statistics regarding all transition procedures” to the state health department — including the patient’s age, sex, county of residence, medications, dosages and diagnoses.

This year, Oklahoma state Sen. Shane Jett introduced the first bill to completely ban transition treatments, regardless of age.

The bill would block transgender adults from procedures like breast augmentation and treatments such as hormone therapy — but would allow cisgender people to receive them. Asked about the discrepancy, Jett said transition care preys on a person’s “psychological context” and manipulates people into a lifelong treatment path. Nontransition care, he said, is intended to “get normal function back into the body.”

Similarly, while the federal government has restricted transition treatments, it has pushed to expand access to hormone therapy — including potentially removing testosterone’s classification as a controlled substance — for cisgender men and women.

Leslie Dvorak, the owner and medical director at Pride Health Clinic in Omaha, Nebraska, said that every person, regardless of identity, receives care that could be considered gender-affirming, such as hair removal, breast augmentation and hormone therapy. Dvorak, who spent 21 years in the U.S. Air Force, started providing transition care eight years ago while working at a federally funded health center.

Now in her private clinic, she said she is navigating not only Nebraska’s restrictions on transition care for minors and its ban on Medicaid coverage, but also laws in 10 other states where she’s licensed to practice via telehealth. This year, Nebraska floated a bill that would have allowed patients to sue transition care providers for up to 12 years after treatments — creating a statute of limitations a decade longer than for any other medical malpractice claim in the state.

Dvorak said she plans to keep practicing, especially since many of her 2,500 patients came to her after other providers stopped offering transition care. She’s not afraid.

“Sue me,” she said. “Good luck.”