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President Donald Trump and Health and Human Services Secretary Robert F. Kennedy Jr. attend an event introducing a new Make America Healthy Again Commission report in the East Room of the White House on May 22, 2025 in Washington, DC.
The Department of Health and Human Services issued an ultimatum to 46 states.
The Trump administration has escalated its campaign against trans-inclusive sex education, ordering nearly every U.S. state and territory to remove references to “gender ideology” from federally funded programs or risk losing millions of dollars.
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The move, announced Tuesday by the Department of Health and Human Services’ Administration for Children and Families, builds on last week’s revocation of California’s grant and signals a nationwide rollback of longstanding public health initiatives.
At stake is the Personal Responsibility Education Program or PREP, not to be confused with the HIV prevention medication PrEP, created in 2010 with bipartisan support to provide medically accurate instruction on contraception, abstinence, and healthy relationships for at-risk youth, including those in foster care, juvenile detention, homeless shelters, and rural communities with high teen birth rates.
Related: Why experts say Trump’s revocation of California grant funds over trans inclusion endangers all at-risk kids
The August 26 letters sent to 46 state PREP officials explicitly assign blame to inclusive content. They state that certain materials, including lessons defining gender identity as distinct from sex or offering pronoun guidance, “do not adhere to the PREP statute,” which “includes no mention of gender ideology” and focuses solely on facilitating abstinence and contraceptive education.
Roughly $81 million in funding could be withheld, suspended, or terminated if states do not comply by October 8 at midnight.
According to internal funding records obtained by The Advocate, the largest allocations include more than $6 million for New York, $4.6 million for Pennsylvania, $4.5 million for Georgia, $4.2 million for Illinois, and $4.2 million for Ohio. Other states stand to lose significant sums as well, including $3.9 million in North Carolina, $3.3 million in Michigan, and $3 million each for Arizona and New Jersey.
“Federal funds will not be used to poison the minds of the next generation or advance dangerous ideological agendas,” Acting Assistant Secretary Andrew Gradison said in the administration’s announcement. “The Trump Administration will ensure that PREP reflects the intent of Congress, not the priorities of the left.”
As The Advocate reported last week, on Thursday, the Trump administration terminated California’s $12 million PREP grant after state officials refused to remove lessons acknowledging gender identity and pronouns. California leaders argued that their curriculum had already been federally approved, was medically accurate, and complied with state law requiring inclusive sex education.
Gov. Gavin Newsom’s office condemned the revocation as political interference. “If it’s a day ending in y, President Trump is attacking kids’ safety, health, and access to education as part of his culture war,” a spokesperson for the Democratic governor told The Advocate.
In interviews with The Advocate conducted ahead of Tuesday’s expanded announcement, two former senior federal officials warned that the California decision endangered evidence-based prevention efforts.
Rebecca Jones Gaston, who led ACF under the Biden administration, described PREP as “a whole person approach to sexual health” that gives young people tools to make healthy choices and avoid abusive situations. “Young people absolutely need that support,” she said. “It’s a loss for all kids.”
She added that the decision represented politics overtaking science. “Anytime politics is getting into health and the well-being of our kids, that’s problematic. It feels very much like weaponry against anything that is outside of what the administration itself deems approvable.”
Adrian Shanker, former deputy assistant secretary for health policy at HHS, called the political influence on health programs for vulnerable people “unfathomable.” “The American people have reason to believe that when Congress allocates funding to federal programs, the funding will be provided equitably and without political interference,” he said. “The opposite of that is what the Trump administration has done by cutting off sexual health and teen pregnancy prevention funding over political disagreements on trans inclusion.”
Related: Health experts warn Trump’s new policies for HHS teen pregnancy program could reverse decades of progress
Shanker warned the fallout could be severe. “These actions are likely to lead to increased teen pregnancy rates, increased STI rates among youth, and potentially new sero conversions to HIV, because of their ridiculous focus on their anti-trans attacks,” he said.
In a follow-up interview with The Advocate on Wednesday, Shanker said the administration’s latest directive makes clear that the threat goes beyond a standoff with California’s governor.
“With California, it was arguably a Trump–Newsom back-and-forth personality contest,” Shanker said. “Now it is very clear that the Trump administration has no problem harming a program designed to prevent teen pregnancy, STIs, and HIV transmission for vulnerable youth, just out of their interest to harm trans kids.”
He described the 46-state directive as part of a broader campaign to erase trans inclusion from public health programs entirely. “Their ultimate goal is simply to prevent any state from providing any program that supports trans people,” he said. “They will throw the entire program out if it is trans-inclusive. It’s harmful not only to trans kids, but to the entire systems that rely on these evidence-based programs to provide sex ed for at-risk youth.”
Shanker emphasized the populations most at risk if PREP funding is cut. “The program specifically serves youth in the foster care system, the juvenile justice system, homeless shelters, rural youth, populations that may otherwise fall through the cracks and not receive this information. That’s why it’s so harmful to threaten the entire defunding of this program over an ideological disagreement.”
The PREP directive is not the administration’s only intervention. In July, HHS also moved to reshape the Teen Pregnancy Prevention Program, another federally funded initiative, by bringing it into line with Trump’s executive orders restricting diversity, equity, and LGBTQ+ content. That rollback went further than PREP, banning lessons on non-penetrative sex such as masturbation, sexual pleasure, and contraception demonstrations like the widely used condom-on-a-banana exercise, which the administration has redefined as “not based on science.”
In a July interview with The Advocate, Dr. Cynthia Graham, a senior scientist at the Kinsey Institute at Indiana University, said that changes to these programs defied decades of research. “Covering these things in a comprehensive way is effective and lowers the likelihood of teen pregnancy,” she explained. “We know that including things like pleasure in programs enhances interventions. Restricting this only increases the likelihood that young people go online, where information may be inaccurate.”
Graham pointed to resources like the Kinsey Institute’s free “Crash Course” sex education series, narrated by sexologist Shan Boodram, which covers gender and sexual orientation. “These kinds of accurate, accessible materials are vital in a climate where young people risk being left without reliable information,” she said.
While U.S. teen pregnancy rates have declined, Graham noted that sexually transmitted infections are rising among adolescents, underscoring the risks of restricting access to information. “There’s no evidence that comprehensive sex education causes harm,” she said. “The evidence is that it saves lives.”
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