The Trump administration will begin implementing its attack on the Title X family planning program while the protracted legal battle over the domestic “gag rule” continues.

Clinics were informed Monday that the U.S. Department of Health and Human Services (HHS) would immediately enforce its ban on federal family planning dollars going to health-care providers that refer patients for abortion care. The administration will also immediately begin enforcing its requirement that clinics financially separate their Title X-funded services from abortion services. A third part of the Title X “gag rule” requiring clinics to physically separate those services will go into effect next year, the Associated Press reported.

The changes to Title X, the $286 million federal family planning program that primarily serves people with low incomes, will cause Planned Parenthood to lose up to $60 million in federal funds, the Washington Post reported.

Trump’s Title X “gag rule” had been held up in the courts but the U.S. Court of Appeals for the Ninth Circuit ruled last week that the administration’s restriction could take effect everywhere but Maryland.

The Office of Population Affairs for HHS alerted Title X clinics on Monday night that the rule would go into effect but did not provide details about compliance, according to the National Family Planning and Reproductive Health Association (NFPRHA). The association called the gag rule “devastating and unlawful” in a statement.

Four million people in the United States, most of them living below the poverty line, receive care at Title X-funded clinics.

Clare Coleman, president and CEO of NFPRHA, said she anticipates Title X grantees will begin withdrawing from the program this week. “The Title X rule creates nearly impossible barriers for poor and low-income people who need high-quality family planning and sexual health care from expert providers they rely on and trust,” Coleman said in a statement, adding that the NFPRHA remains “intent in our efforts to fully protect the integrity and mission of Title X.”

Maine Family Planning (MFP) announced Tuesday that it would withdraw from the Title X program, foregoing $2 million in federal funding. Maine Family Planning won’t close any of its 18 clinics for now. The organization said the anti-choice rule forces “unethical limitations on medical professionals.”

“Without alternative sources of public funding, MFP must fill the gap using its own limited financial reserves to support the network of family planning clinics it directly operates, as well as the various health care providers it subcontracts with through Title X,” the organization said in a statement. 

Maine Family Planning, which filed one of the lawsuits aiming to block the restrictions, will continue challenging the “gag rule” in court.

Reproductive rights advocates criticized the administration for moving ahead with the anti-choice restrictions before the courts had issued a final ruling on the matter.

“For more than two years, the Trump administration’s needless meddling and mismanagement of Title X has led to uncertainty and confusion. Moving forward with this policy to take away women’s rights before the legal process has played out is reckless and will hurt those whom HHS is supposed to serve,” Michelle Kuppersmith, director of Equity Forward, said in a statement.