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The Missouri Department of Health and Senior Services from the Administration for Children and Families, a division of the federal Department of Health and Human Services. It demanded that gender identity references be removed from federally funded materials within 60 days.

Federal PREP funds support state programs on adolescent health and sex education, targeting groups with high teen birth rates, such those in foster care or in rural areas.

Missouri faces losing nearly $2.3 million, while 40 states and six territories in all could lose a total of about $81 million.

“This action reflects the Trump Administration’s ongoing commitment to protecting children from attempts to indoctrinate them with delusional ideology,� read an .

The notifications came a week after the feds terminated the remainder of California’s PREP grant, amounting to $12 million. The state’s health department had .

“Federal funds will not be used to poison the minds of the next generation or advance dangerous ideological agendas,� Andrew Gradison, assisant acting secretary of the Administration of Children and Families, said in the release. “The Trump Administration will ensure that PREP reflects the intent of Congress, not the priorities of the left.�

Lisa Cox, spokeswoman for the Missouri health department, said the state is working immediately to comply.

Missouri purchases its curriculum from a third-party contractor, Cox said in an email. “We are ensuring contractors are making the appropriate adjustments to the materials.�

The health department partners with 21 entities across the state to implement the curriculum, according to Cox. They include local public health agencies and schools in rural areas, as well as that help youths transition to adulthood.

The letter sent to the Missouri health department cited examples in its sexual health curriculum that must be removed.

They included explanations on how biological sex is different than gender, which is how people identify themselves. One item the letter cited is the statement, “Transgender people are people who gender identity is different from their biological sex … However someone identifies, they should feel safe, respected and included.�

Guidance on discussing diversity with participants also was flagged because it urged facilitators to include gender identity, along with different family backgrounds and racial and cultural groups: “Young people may express themselves in ways that don’t conform with their biological sex … often through behavior, clothing, hairstyles, voice or body characteristics.�

A lesson on giving participants the option to share their pronouns also ran afoul: “The simple act of requesting pronouns sends the message that transgender and gender nonconforming youth are welcome and respected in the group.�

In the letters to Missouri and other states, federal health officials warned that gender identity is outside the scope of the PREP program.

“The statute includes no mention of gender ideology, which is both irrelevant to teaching abstinence and contraception and unrelated to any of the adult preparation subjects,� such as developing healthy relationships and attitudes, the letter reads.

In refusing to comply with the order, California officials argued that materials on gender are medically accurate and meet PREP goals for improving health.

Gay, bisexual and transgender public policy advocates in Missouri also say that teaching adolescents about gender identity helps prevent risky sexual behavior.

Robert Fischer, communications director for , Missouri’s LGBTQ+ advocacy organization, said a lack of comprehensive sex education leads teens to seek answers and experiences on their own.

“That’s when we start seeing that kids will be left behind,� Fischer said. “That’s where we will see that LGBTQ+ youth and others will have to find answers elsewhere, and that’s where that danger begins.�

access to health education that includes information relevant to gender and sexual minority youths (GSMY) is lacking in the United States.

The research points to nationwide surveys showing that gender and sexual minority youths report significantly higher incidences of dating violence, attempted suicide, bullying and alcohol and drug use. They also had earlier initiation to sex, more sexual partners and were less likely to use condoms.

“To improve sexual health outcomes in GSMY, they need to receive sexual health education that is comprehensive and inclusive to all genders and sexual orientations at an early age,� concluded that analyzed school sex education programs over the previous 10 years.

Fischer said he knew before reaching middle school that he was gay, even though he didn’t have the words for it. That is the same experience of others, he said, regardless of their gender identity.

“The reality is that we have to trust youth to know who they are, because a lot of the times, youth already know,� he said. “And they are more than happy to tell us.�