As of March 2022, officials in the state of Texas have begun to treat minors’ access to gender affirming care (GAC) as child abuse and to target parents of transgender children for investigation by the Department of Family and Protective Services. Although legal advocates have already sued to block such investigations in Texas, policymakers in other states have proposed to take similar actions. These policies demonstrate some of the risks of collecting data about transgender patients, risks which historically were managed by clinicians who intentionally kept references to GAC out of the medical record. Protecting trans kids and their families requires special treatment of their medical records, especially when those records are kept by pediatric gender clinics that are likely to be targeted by state actors who conflate GAC with child abuse.This presentation will demonstrate that as in other areas of medicine in which ethical and legal obligations frequently conflict (e.g., care for undocumented patients), care for transgender children and adolescents may require that clinicians and institutions develop shadow pathways to ensure the safety of patients from the potential risks of disclosure sought by the state. Processes and technologies that silo adolescent mental and sexual health information from other medical records can be adapted for management of GAC information, but are not in themselves sufficient protections. Pediatric gender clinics and their institutions must further prepare to legally defend such information and to anticipate challenges associated with electronic health record access.