Hospitals providing gender transition procedures to minors face increased scrutiny from federal health agencies, warned letters published Wednesday. Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. and Centers for Medicare & Medicaid Services (CMS) Administrator Mehmet Oz wrote separately to health care providers, with both officials directing hospitals to comply with the findings of a comprehensive review of medical evidence, which HHS released on May 1.

The five-part, 409-page report found a lack of evidence supporting gender transition procedures such as puberty blockers, cross-sex hormones, and surgeries on minors experiencing gender dysphoria. Yet dozens of hospitals continue to supply these procedures to minors.

“Given your ‘obligation to avoid serious harm’ and the findings of the Review,” wrote Kennedy in a letter to “health care providers, risk managers, and state medical boards,” “HHS expects you promptly to make necessary updates to your treatment protocols and training for care for children and adolescents with gender dysphoria to protect them from these harmful interventions.”

The same day, Oz informed hospitals that “the United States Government has serious concerns with medical interventions for gender dysphoria in children.”

Based on the comprehensive HHS review, his letter continued, “CMS believes that these interventions were initiated with an underdeveloped body of evidence, lack reliable evidence of benefits for minors, and are now known to carry serious risks of long-term and irreparable harm.”

Oz gave hospitals 30 days to provide information on “the adequacy of informed consent protocols for children with gender dysphoria, including how children are deemed capable of making these potentially life-changing decisions and when parental consent is required,” what protocol changes they planned to make in light of the HHS review, and “any adverse events related to these procedures, particularly children who later look to detransition.”

The letter also demanded “complete financial data for all pediatric sex trait modifications performed,” including the billing codes used and projected revenue from the procedures.” Last November, Texas Attorney General Ken Paxton (R) sued a doctor who prescribed gender transition drugs to minors in violation of state law, then concealed the practice by falsifying the billing records.

CMS also expressed concern in the letter over the price of gender transition procedures, which include surgeries ranging from $50,000 to $130,000. As the government agency responsible for running Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace, CMS manages the health coverage of more than 160 million Americans. They also play a role in approving which health care providers qualify for these massive insurance programs.

“These are irreversible, high-risk procedures being conducted on vulnerable children, often at taxpayer expense,” Oz warned in a statement. “Hospitals accepting federal funds are expected to meet rigorous quality standards and uphold the highest level of stewardship when it comes to public resources — we will not turn a blind eye to procedures that lack a solid foundation of evidence and may result in lifelong harm.”

The letters from Kennedy and Oz warn health care providers that they could be the next institutions to face the ire of the Trump administration unless they refrain from providing gender transition procedures to minors.