After a courtroom victory for the Trump administration last week, American teenagers may no longer be able to rely on a federal program that lets them access birth control and STI testing on the cheap.

Last week, a panel of judges on the Ninth Circuit ruled to let the Trump administration rewrite the rules of Title X, a $286 million federal family planning program. Under the new rules, Title X beneficiaries — the program helps about 4 million low-income people — are banned from referring patients for abortions. They must also physically and financially separate services that involve abortions from those that don’t.

“You can imagine that sets up a pretty unhealthy relationship right out of the gate.”

But those changes, which abortion rights advocates condemn as a “gag rule,” aren’t the only ones providers must contend with. Clinicians must also now document their efforts to “encourage” minors, as the rule puts it, to tell their families about their plans to get family planning services.

Those requirements, health care providers say, are not only frustratingly vague but also threaten their ability to help adolescents through Title X.

“If I say, ‘Why aren’t you involving your parents? Why are you doing that? Why are you doing that?’ — you can imagine that sets up a pretty unhealthy relationship right out of the gate,” said Evelyn Kieltyka, a board-certified nurse and senior vice president of program services for Maine Family Planning. The organization provides treatment to about 4,400 minors every year through its $1.8 million Title X grant, which is doled out to 47 clinics throughout the state. “And they’re likely to communicate that to their cohort, and they’re less likely to come in, because they fear their confidentiality will be compromised.”

Right now, adolescents make up nearly a fifth of all Title X patients. Though providers already try to persuade them to talk to their parents, minors don’t have to let their parents know that they’re participating in the program. Payments are also scaled off their own, often nonexistent income, so teenagers don’t need to rely on their parents’ insurance to defray costs. (There are exceptions: Health care providers must still let authorities know if a minor is being sexually abused.)

“If told that their parents will find out about the services they’re receiving, [minors] will just not get the services.”

These provisions are particularly crucial to making sure adolescents get birth control and STI testing; 18% of girls between the ages of 15 and 17 say they wouldn’t get sexual or reproductive health care if their families could find out.

“If told that their parents will find out about the services they’re receiving, [minors] will just not get the services. But it won’t change their underlying behavior,” explained Adam Sonfield, senior policy manager for the Guttmacher Institute. “So they’ll still be having sex. They just won’t be getting the contraception they need or the STI services they need.”

The changed rule requires providers to use “specific recordkeeping” to document their attempts to get minors to involve their parents in their family planning decisions, or to explain why they didn’t bother. Sonfield raised the possibility that officials from the Department of Health and Human Services, which oversees Title X, may be able to look into providers’ records.

“It also opens them up to second-guessing from federal officials, who would then be able to review those records and call providers out,” Sonfield said. They may ask things like, “‘Why aren’t you involving parents more often? Here are 20 cases where we think you should have,’” he said.

Monica McLemore, a nurse at Zuckerberg San Francisco General, is mystified about what, exactly, officials want her to even document. She said she has no way to gauge how much of a strain it could put on already overworked providers.

“It’s unclear whether or not the rule requires us to use specific language of what we did and did not say,” said McLemore, who is also an assistant professor at the University of California, San Francisco School of Nursing and testified against the Title X changes in Congress last week. Providers of course take notes to document their appointments with patients, McLemore said, “But what we write, what we say, what we check off — that has never been legislated.”

Kieltyka first started seeing teenage patients almost four decades ago, but she’s still impressed whenever one walks in for an appointment. They’re always sharp, able to talk about their lives eloquently.

“It’s a big deal to make an appointment or come in or walk into a health care facility on their own,” said Kieltyka, senior vice president of program services for Maine Family Planning. The rule change also worries her because the added scrutiny will cut into the time she has with them — already only 15, 20 minutes “on a good day.”

“So all the sudden, if 10 minutes are taken up by this questioning that’s not relevant to why the patient is there — it’s not addressing his or her needs — then I’ve lost a really golden opportunity to get to really connect with them,” Kieltyka said.

In response to several questions about providers’ concerns, a Department of Health and Human Services spokesperson said in an email, “We are still evaluating the full implications of the decision and the appropriate next steps given several considerations. We have not yet begun monitoring or enforcing the new rule. We will provide further guidance in due course.”

Scores of states and Title X grantees, including Maine Family Planning, are challenging the Ninth Circuit’s decision and the rule changes in court. Many have suggested they’d have no choice but to leave the family planning program if they’re forced to stop referring patients for abortions (including Planned Parenthood, which serves more than 40% of all Title X patients). Others say they’ll need to surrender their grant money because they’re simply unable to afford to set up a “clear financial and physical separation” between their services — a mandate that could force clinics to, say, build an entirely separate facility for abortions. (It's already illegal to use federal dollars for abortions except in the case of rape, incest, or life endangerment.)

No matter the reason why grantees leave Title X, clinics across the country are sure to close if they lose access to its money. Including, potentially, clinics funded by Maine Family Planning.

“We’re still looking at all of our options,” Kieltyka told VICE News on Friday. But, “If we aren’t there to provide that access, this is going to be extremely difficult for [teens] to seek services confidentially and to figure out how it will be paid for.”