Texas Children’s Hospital must create the country’s “first-ever detransition clinic,” Texas Attorney General Ken Paxton said Friday in announcing a settlement agreement that concludes a yearslong investigation into the medical center’s treatment program for transgender youth.

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As part of the deal, the Houston hospital also agreed to terminate five doctors who previously provided transition care to children and to pay $10 million to resolve allegations that the hospital improperly billed the state’s Medicaid program for transition care, according to a news release from Paxton’s office. For the first five years of the clinic’s operation, Texas Children’s must provide detransition care for free.

Officials have not detailed exactly what the detransition clinic will offer. Detransitioning, which involves no longer identifying as transgender or stopping medical transition, is rare. The potential medical interventions are similar to those involved in transitioning — mental health therapy, hormone therapy and surgeries.

In a statement, Paxton said the settlement, which the hospital reached with his office and the U.S. Department of Justice, “reflects an institutional and fundamental cultural shift away from radical ‘gender’ ideology.”

Paxton’s office did not respond to a request for comment or provide a copy of the full settlement agreement.

Texas Children’s Hospital, the largest children’s hospital in the country, said it agreed to the settlement after cooperating throughout the three-year investigation, during which the hospital produced more than 5 million documents and conducted multiple investigations of its own. The hospital maintains that it has followed all laws.

“Today, we made the difficult decision to settle with the Texas Attorney General and the Department of Justice, closing a chapter that has been wrought with falsehoods and distractions,” the hospital said in a statement. “To be clear — we are settling to protect our resources from endless and costly litigation. This settlement will allow us to redirect those precious resources to focus on the life-saving care and groundbreaking discoveries of our exceptional clinicians and scientists.”

In response to questions from NBC News about the type of care the clinic will provide, a spokesperson for the hospital said, “The detransition clinic will formalize the supportive, multidisciplinary services we already deliver to all patients who need our care.”

It’s unclear who will lead or staff the clinic. The hospital declined to provide details about the terminated employees, saying, “Our top priority throughout this settlement discussion was around protecting our physicians.”

Paxton’s investigation came amid a larger effort from his office to stop all transition care for minors in Texas. In early 2022, after the state failed to pass a ban on such care for minors, Paxton wrote a legal opinion declaring transition care for minors to be child abuse. Soon after, the state began investigating parents suspected of having provided such care to their children. The next year, the state became the largest to enact a gender-affirming care ban for minors.

A few months before the ban took effect, Paxton announced his investigation into Texas Children’s, which he said was “actively engaging in illegal behavior” by performing gender transition procedures on children.

“Under my watch, I will investigate and bring the full force of the law against any Texas hospital that abuses children with harmful medical interventions to ‘transition’ kids,” Paxton said.

The settlement marks the first resolution in the Justice Department’s ongoing national investigation into transition care — which it calls “sex-rejecting procedures” — for minors. Last year, the department subpoenaed more than 20 doctors and clinics that treat trans minors for alleged healthcare fraud and false statements, among other allegations. This week, NYU Langone said it received a grand jury subpoena from federal prosecutors requesting information about its treatment of trans youth over the last six years.

“The Justice Department will use every weapon at its disposal to end the destructive and discredited practice of so-called ‘gender-affirming care’ for children,” acting Attorney General Todd Blanche said Friday. “Today’s resolution protects vulnerable children, holds providers accountable, and ensures those harmed receive the care they need.”

Studies have estimated that between 1% and 10% of trans people detransition. Less than 1% say they regret their transition, according to the research. The most common reasons cited for detransition were pressure from a parent, harassment or discrimination, and that transitioning was too hard.

In recent years, a few prominent detransitioners, including Chloe Cole and Prisha Mosley, have advocated for restrictions on transition care for minors, arguing in lawsuits against doctors who treated them that their care was too easy to access and that doctors failed them. The medical providers Cole and Mosley accused denied wrongdoing.

Republican state representatives as well as federal officials have pointed to their stories as evidence that transition care is dangerous.

However, most major medical associations in the U.S., such as the American Medical Association, the American Academy of Pediatrics and the American Psychological Association, support gender-affirming care access for minors.

The care the medical associations recommend depends on the child’s age. The associations don’t recommend any medical intervention for children prior to puberty, but rather recommend allowing children to change their name or clothing. At puberty, some trans children might start puberty blockers, and then, in their teen years, hormone therapy. Surgeries for minors are rare and not recommended by the medical associations.

In Texas, advocates for transgender rights said the settlement with Texas Children’s sets a troubling precedent.

“We know that what starts in Texas expands to the rest of the country,” said Andrea Segovia, senior field and policy director at the Transgender Education Network of Texas, a state trans rights group.

Segovia said that Texas should focus on making healthcare more accessible to those who struggle to afford it, rather than targeting care for the less than 1% of Texans who are trans.

“In Texas, the ability to get general regular healthcare is difficult,” Segovia said. “To prioritize a clinic that is based on political gain as your state continues to struggle with basic general healthcare is a slap to people’s face.”

Dr. Morissa Ladinsky, a clinical professor of pediatrics at Stanford University’s medical school, said that when she read news of the settlement, she was confused about why it required the hospital to fire the doctors who previously provided transition care. They would have been the most equipped physicians to treat people who want to detransition because of their expertise, she said.

The settlement, she said, “simply amplifies a fog of confusion” that providers of gender-affirming care are practicing in, “because it’s a clinic created by legal intimidation on terms set by politicians.”

Ladinsky practiced for 10 years as a pediatrician in Birmingham, Alabama, where she treated trans adolescents until the state’s ban on transition care for minors fully took effect in January 2024.

Out of hundreds of patients, she said, two or three decided they wanted to pursue a different treatment path, but they didn’t regret the care they received.

“Regret is virtually nonexistent,” Ladinsky said, “and that’s because we do what we do in the ways we do it — slowly, carefully, methodically and in the context of family and household.”