Within Reach

On a balmy day last spring, Connor Chase sat on a red couch in the waiting room of a medical clinic in Columbus, Ohio, and watched the traffic on the street. His bleached-blond hair fell into his eyes as he scrolled through his phone to distract himself. Waiting to see Mimi Rivard, a nurse practitioner, was making Chase nervous: it would be the first time he would tell a medical professional that he was transgender.

By the time he arrived at the Equitas Health clinic, Chase was eighteen, and had long since come to dread doctors and hospitals. As a child, he’d had asthma, migraines, two surgeries for a tumor that had caused deafness in one ear, and gangrene from an infected bug bite. Doctors had always assumed he was a girl. After puberty, Chase said, he avoided looking in the mirror because his chest and hips “didn’t feel like my body.” He liked it when strangers saw him as male, but his voice was high-pitched, so he rarely spoke in public. Then, when Chase was fourteen, he watched a video on YouTube in which a twentysomething trans man described taking testosterone to lower his voice and appear more masculine. Suddenly, Chase had an explanation for how he felt — and what he wanted.

This was a comfort, but he was terrified his father, an abusive man who often taunted Chase for being “butch” and overweight, would find out that he was trans. Then Chase’s dad was diagnosed with cancer, and after months on and off life support, he died in September 2016.

Afterward, Chase felt safe enough to start transitioning. He moved in with a friend who shared his love for Korean pop music and superhero movies, and took a minimum-wage job at a supermarket deli counter. He also made plans to enroll at the Ohio State University, in Columbus, and applied for Medicaid. But he’d heard that for some trans people, getting approval for hormones or surgery required many expensive sessions with a therapist, and that sometimes they were denied treatment. “I was afraid that would happen to me,” Chase said.

At the clinic, by eleven o’clock, a medical assistant led Chase into an exam room. A few minutes later, Rivard, a petite woman in her fifties with curly brown hair and a stud in her nose, came in and introduced herself. “What are you here for today?” she asked in a soft voice, her usual tone with new patients.

Chase wiped his damp palms on his jeans. He felt a rush of anxiety and excitement as he told Rivard that he was trans and wanted his friends and family to see him as male.

“What are you hoping for and how do you want me to help you?”

Chase wanted a prescription for testosterone. “I’ve done so much research, watched so many videos, and read so many articles,” he said. “I can’t think of any other solution to the way I feel.”

In the past, someone like Chase — broke, trans, and living in Ohio — had almost no chance of medically transitioning. Even if he had the money for private insurance, he might be rejected on the grounds that being trans was considered a preexisting condition. And if he found a plan that would cover him, it would probably have an exclusion for hormone replacement therapy (HRT) and other transition-related medical care, so he would have to pay out of pocket. He would also have to pay for counseling sessions so that a therapist would recommend he be prescribed hormones. Last but not least, he would have to find a doctor willing to treat him — no small task in the heart of the Midwest.

This changed when the Affordable Care Act passed in 2010, making it illegal for insurers to reject people with preexisting conditions. The law helped many trans people get coverage for the first time. According to the Center for American Progress, the proportion of trans people with incomes below 400 percent of the federal poverty level who did not have insurance has dropped by half. (There are an estimated 1.4 million transgender people in the United States, and they are twice as likely as the general population to live in poverty.) The ACA also allowed states to expand Medicaid to people earning less than 133 percent of the poverty level. In Ohio, more than 700,000 people gained coverage, including Chase.

Now, eight years since the law passed, trans people are at risk of losing much of what they’ve gained. After campaigning to repeal the ACA, Donald Trump — helped by Congress, the Department of Health and Human Services, and the Department of Justice — has spearheaded an attack. The government is also using the absence of any explicit federal nondiscrimination protection for LGBT people to undermine their civil rights and their access to health care. This has been especially significant in Ohio, which has no state-level protections for trans people and, before the ACA, offered Medicaid only to parents, pregnant women, children, and people with disabilities. Ohio also lacks the well-funded LGBT networks that exist on the coasts, so when it comes to health care, patients are particularly vulnerable to the whims of Washington. “After the election, people were trying to accelerate transition, to do everything they could, to get as much taken care of before this administration got too far in and everything started to unravel,” said Melissa Alexander, a cochair of the board of TransOhio, a prominent local advocacy organization.

The state legislature is now working to limit access to Medicaid, leaving patients, clinics, and insurers in limbo. The Columbus trans community is preparing for the worst. One woman who takes medications for depression and anxiety in addition to hormones said that if she lost coverage, she would buy what she needed online. “I’d have to be my own pharmacist,” she said. For Will Varnum, a thirty-four-year-old who began taking testosterone in 2016, fear of losing coverage meant scheduling chest reconstruction surgery as soon as possible. “In case insurance coverage goes away, I want to do it now,” he said.

Many of the services Equitas provides are supported by the ACA. Founded in 1984 as the AIDS Resource Center Ohio (ARC), the organization expanded its focus to the broader LGBT community in 2016. The Columbus clinic is one of fifteen facilities located in eleven cities across the state; it serves around four hundred trans people. Mimi Rivard sees a new trans patient nearly every day. One third are on Medicaid, and some have no insurance at all. Advocates worry that if the law changes, the most vulnerable patients — people who are poor, non-white, sick, unemployed, or living without family or community support — will be hit hardest.

Trans people already have some of the worst health outcomes in the country, thanks in part to more than a century of medical gatekeeping and discrimination. In order to address this issue, providers like Equitas have embraced a progressive approach that challenges dominant beliefs about gender and health care. In 2016, federal policy bolstered these efforts. But today, the government is intent on undermining the access to affordable and affirming care that trans people have finally secured.

Last May, I climbed into a cherry-red Honda Fit that belonged to Ramona Peel. A forty-two-year-old with bright-blue hair, two children, and an obsessive love for the Seattle Seahawks, Peel was charged with connecting Equitas to the local trans community. She shot out her hand and then stopped herself. “Let’s model good behavior,” she said. “I’m Ramona; my pronouns are she, her, hers.” I told her my pronouns were she, her, hers, and we shook.

Ohio is a largely conservative state — Columbus is one of its few solidly progressive cities. Its annual gay pride celebration rivals Chicago’s, and Ohio State nurtures a vibrant queer community. But outside the I-270 loop, the city’s unofficial boundary, attitudes lean traditional, and Peel was heading seventy miles north, to lead a training session for a group of caseworkers at an Equitas facility in Mansfield.

The office was located in a one-story brick building that housed a hair salon and a Methodist church. In the sunny conference room, Peel unpacked her projector and took a selfie as a small group filed in and loaded plates with fruit and cookies. Many had been hired before ARC became Equitas. After the changeover, all the employees were required to undergo LGBT-cultural-competency training.

Peel wanted them to understand why the relationship between trans people and the medical community was so fraught.¹ Not all trans people wish to medically transition, she explained, but those who do depend on doctors for surgery or HRT or both. In most cases in the United States, this requires a diagnosis of gender dysphoria, a mental health condition characterized by distress arising from the conflict between the gender one was assigned at birth and the gender with which they identify.

Even routine visits can reveal how little doctors know about this population, a lack of awareness that advocates say has caused a health crisis. In 2015, when the National Center for Transgender Equality surveyed more than 27,000 trans adults, one third reported a negative experience with a doctor; one quarter avoided going to a doctor altogether because they were afraid of having one. Liam Gallagher, a twenty-five-year-old who used to work as a trans-outreach coordinator at Stonewall Columbus, an LGBT community center, told me that several years ago he had gone to the emergency room with abdominal pain. Because he knew he would have to explain his “entire life story,” he delayed going until he became seriously ill. The doctor insisted that his pain was a side effect of HRT, though there is little in medical literature to support such a claim. After several hours, Gallagher was diagnosed with pancreatitis. “Discrimination damages people’s health and makes them afraid to seek health care,” said Harper Jean Tobin, the director of policy for the National Center for Transgender Equality.

This kind of discrimination and stigma in medicine has been widespread and enduring. For most of the twentieth century, doctors considered sex a fixed state. Expression of gender variance was seen as criminal behavior or a sign of mental illness requiring psychological treatment, which sometimes involved electroshock therapy and institutionalization. From 1848 to 1974, it was illegal in Columbus for a person to appear publicly in “dress not belonging to his or her sex.”

Yet advances in endocrinology were making it possible to control the development of breasts and facial and body hair, and in the Twenties and Thirties, some patients underwent “sex change” procedures. One of the first was Lili Elbe, a Danish woman who had her penis removed and had ovaries transplanted into her abdomen in Germany.

Though Elbe died after a uterus transplant, her story galvanized people seeking similar procedures. Physicians largely turned them away. One exception was Harry Benjamin, a German-born endocrinologist and sexologist who began treating trans patients in the United States in the Forties and played a major role in bringing these advances to America. According to How Sex Changed, a deeply researched account of this medical legacy by the historian Joanne Meyerowitz, hundreds of gender nonconforming people approached Benjamin. “I would rather die than be a man all my life. It is a life of torture,” wrote one. Benjamin began treating his patients with hormones and X-rays to suppress sexual function and stop hair growth.

In the Fifties, psychologists developed the concept of gender — a sense of oneself that was distinct from sex. This allowed relatively progressive doctors and more conservative psychologists to compromise when treating someone who wouldn’t or couldn’t live as the sex assigned to them at birth. If a psychological evaluation demonstrated both long-standing feelings of being the opposite sex and an absence of mental illness, a patient would be eligible for “sex reassignment.”

The surgeries were expensive and hard to obtain. The Johns Hopkins Gender Identity Clinic, which started doing the procedures in 1966, received two thousand requests in its first two years. The vast demand allowed physicians to be aggressive gatekeepers. They were disrespectful and often mistrusting. In a letter to a colleague, one doctor wrote, “These patients are simply awful liars.” Only twenty-four of those requests were approved.

Around the same time, trans and gender nonconforming people were beginning to demand political rights and recognition. They built communities and identities around acceptance and pride. People with fluid lives, sexual practices, and gender expressions started to self-identify as drag queens, hair fairies, hormone queens, butches, FTMs, MTFs, shunning the notion that their identities were a problem to be fixed. After decades of looking to the medical establishment for help, they began to see that doctors were only “one instrument or resource to be deployed,” in the words of Angela Douglas, who founded the radical Transsexual Action Organization in 1970. Those seeking treatment learned the script: they dressed conservatively for appointments, professed a desire to lead quiet, heterosexual lives away from their queer communities, and claimed to be “trapped in the wrong body,” a common and overly simplistic stereotype that persists today.

By 1980, advocates and sympathetic doctors had gained some public approval and legitimacy; “transsexualism” became an official gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders III. The Harry Benjamin International Gender Dysphoria Association had formed to develop standards of care for trans patients, which recommended medical treatment but advised that surgery be available only to patients with two letters of support from psychologists or psychiatrists. This conservative model remains in use: typically, therapists determine who is “ready” or “qualified” for treatment. One thirty-five-year-old told me that his counselor made him fill out a six-hundred-question survey, which asked what kind of magazines he read. Another man had a therapist who insisted that he was a lesbian, not transgender.

Ramona Peel knows that the dialogue about trans issues can make some uneasy. Now as in the past, objections to procedures reflect cultural anxiety about gender nonconformity and diversity rather than concerns over body modification. Moving away from a gatekeeping model also requires abandoning the belief that some gender presentations or identities are more acceptable than others and that there is a right and a wrong way to be trans. This would mean any and all gender presentations are valid, a prospect that is upsetting for some and thrilling for others.

Peel, who has taught political science in Midwestern colleges for fifteen years, was matter-of-fact as she explained that gender identity, gender expression, and sexual orientation all “exist on a spectrum.” She dashed to the back of the room and flicked the lights on and off. “This is binary,” she said, “but gender is a dimmer switch.”

Peel was thirty-one years old when she and her wife had a baby boy. She loved her son, but his birth forced her to confront the emphasis society puts on gender. “The idea that I’d now slip into this preordained masculine role was crushing and terrifying,” she said. Within two years, she had come out to her wife, her parents, and close friends.

She was uninsured, living on an adjunct professor’s salary, and so she started ordering hormones online. (This is common — and dangerous: black-market drugs are unregulated, and people on hormones should have a doctor monitoring their organ function.) Eventually, she found an endocrinologist who was willing to treat her but insisted that she also see a therapist. She reached out to Meral Crane, a counselor in Columbus known for working with the transgender community. Since the Seventies, gender nonconforming patients had been seeing Crane for months and sometimes years as she evaluated their readiness for gender transition. “I have seen so many people, I have a gut feeling of a person’s sincerity and actual reality,” Crane told me. She said she could tell when a client “is really a transgender person.”

Crane sent Peel a five-page questionnaire that included questions about dress and sexual activity; it asked her to list “all possible doubts” about transition. “It’s not a rubber stamp,” Crane told me. But to Peel, it all felt unreasonable. It seemed that she was expected to dress as a woman for her first appointment. She was afraid that if she gave the wrong answers, she would lose the treatment she had. She also worried that going out dressed in women’s clothing before she’d developed feminine characteristics would make her a target for harassment. “I wanted to be on hormones for as long as possible before I came out,” she said.

This context can seem abstract to even well-meaning health care providers, Peel told me, which is why having trans people lead cultural-competency sessions demonstrates that their lives are “not theoretical.” She told the group in Mansfield to think of her as the “trans piñata.” “You can ask me questions you think might be offensive, and I’ll answer, but I might say, ‘It’s okay to ask me, but don’t ask another trans person that.’ ” Even some compliments could be hurtful, like “I wouldn’t have known you were trans — you look just like a real woman.”

“Why is that offending you?” asked a social worker in a denim shirt and hat. Peel paused, inhaled deeply, and tried to clarify that “when you imply a trans woman isn’t a real woman, you imply they’re less-than.” (She told me later that she wished she had compared it to telling someone they “look great for their age.”)

“Why is it important that we interact with our LGBTQ patients in a culturally competent way?” Peel asked the group. There were confused looks around the table. This was not just about doing the right thing, Peel explained — it was a public health mandate. Treating LGBT people inclusively is also profitable. Since the mission change, Equitas has seen 25 percent more patients, and revenue is up by 10 percent. If people don’t feel respected, “they are way more likely to fall out of care,” Peel said.

During Chase’s first appointment, Rivard described the changes he would likely experience on testosterone. His voice would deepen, and his body hair would get coarser. He might develop male-pattern baldness, see a change in his body odor, and sweat more. “Ew, I sweat enough,” Chase said.

Like many primary care providers, Rivard asks new patients a barrage of questions. She wanted to know about Chase’s childhood and his family. He told Rivard that his mother, who had come with him, was getting married to her girlfriend in several weeks, and that some conservative relatives would be at the wedding. He hoped to have a prescription for testosterone before then.

Rivard suggested that Chase look into housing for trans and gender nonconforming students at OSU and explained the next steps. He would have some blood tests, and if he decided he wanted to move forward with medical transition, he would get a prescription for testosterone at his next appointment. Then she turned to Chase’s mother and said, “This is definitely a boy, and he’s your son.” Chase told me later how reassuring it was to hear this from a professional. “Before that day,” he said, “I’d never had someone sit me down and acknowledge the fact that I’m trans.”

Last fall, I met Rivard at the Equitas office. The clinic is located on the ground floor of an unassuming building in Columbus’s trendy Short North neighborhood. When the office was an ARC clinic, the street-facing windows were darkened to protect patients’ privacy. After the mission change, the waiting area was remodeled and furnished with brightly colored couches.

Rivard prescribes hormones through a process called informed consent. Developed as a response to medical abuse and exploitation, informed consent is how most health care decisions — involving everything from routine tests to major surgery — are made. It requires that a provider describe the risks and outcomes of a particular procedure and makes sure the patient is capable of making the decision in the context of transition-related care. The approach was adopted in the early 2000s by community health centers in cities with large trans populations.

While Rivard’s philosophy is the norm in cities such as New York and Los Angeles, she is one of the few providers of trans care in Columbus who practices informed consent. “These are medicines to treat symptoms. If a patient meets the criteria for treatment, why do I have to have a letter?” she asked. “If you meet the criteria for depression, I don’t need a letter from your therapist to start you on Lexapro.”

Once Rivard has diagnosed dysphoria, part of her job involves empowering her patients to decide what trans means to them. She understands that some people who seek surgery or HRT may not intend to live and pass as the gender opposite the one they were assigned at birth; instead, they may identify as nonbinary or genderqueer. If a trans woman tells her that she wants hormones and a breast augmentation but does not want bottom surgery, Rivard says, “Yes, that’s okay, there’s lots of women with penises. That’s your genitalia, not your gender.” She tells patients to think of her as Google Maps. “You tell me where we’re going, and I will do my very best to get you there safely and in a timely fashion.”

Rivard’s work is shaped by the decades she spent as a palliative care nurse. One of her first jobs was in a Connecticut hospital in the 1980s, treating patients who were dying from AIDS. “It was a lot of death and a lot of working with families and patients to come to peace with who they were,” she said. Growing up working-class, she saw herself as an outsider in the white-collar world of medicine, which made her feel close to her stigmatized and isolated patients.

After moving to Columbus in 2012, Rivard got a job at ARC providing primary care to HIV-positive people. She had always seen trans patients, so when ARC announced the shift from HIV/AIDS care to LGBT primary care, she volunteered to be the main provider of trans medicine.

She soon noticed similarities between the two populations. “People come with a lot of pain and difficulty, having been shunned by the medical community,” she told me. Her experience deciding whether a patient had the ability to make end-of-life decisions helped her identify patients who might not be able to consent to hormone therapy. Such cases, however, are rare. By the time most people make an appointment, they have been researching and thinking about transitioning for years.

Though the role required learning the most progressive approach to care, Rivard is clear that she’s far from radical. “I used to say, ‘I’m a regular girl.’ When the word ‘basic’ came out, I was so excited. Now I say, ‘I’m basic,’ ” Rivard told me over rice bowls at a restaurant near the Equitas clinic.

She will not prescribe HRT unless a patient is experiencing gender dysphoria. However, she understands that medicalizing gender can be problematic. It’s one of the reasons her patients feel so comfortable under her care. A diagnosis of gender dysphoria is “a tool I have to help you,” she tells them.

But as long as a diagnosis is required, the notion that a transgender identity is a pathology will persist, and no provider can fully shed the gatekeeper role.

Equitas and its patients owe much to a single provision of the ACA: Section 1557, which prohibits discrimination on the basis of race, color, national origin, age, disability, or sex. After the bill passed, the Office for Civil Rights at the Department of Health and Human Services was tasked with figuring out how the law should actually work. Because there is no federal law prohibiting discrimination against LGBT people, the OCR needed to determine whether 1557 would protect gender nonconforming people.

Jocelyn Samuels led the OCR during several years of the rule-making process. “The entire purpose of the ACA was to expand access to health care and health coverage,” she said. “We took that overarching purpose into account when thinking about the legal arguments” underlying 1557. Her team looked at Title VII of the Civil Rights Act, which outlaws discrimination based on sex in employment, and Title IX of the Education Amendments of 1972, which does the same in federally funded education. In recent years, the Equal Employment Opportunity Commission, the Department of Education, and the Department of Justice had found that such laws protect trans people too. A growing number of courts had decided that transgender people are victims of discrimination when they’re denied services, employment, or opportunities because of their gender identity.

One advocate, Lori Gum, watched the agency’s work closely. Gum, who has a raspy voice and seemingly boundless energy, moved in 1981 from Columbus to New York City, where she lived through the worst years of the AIDS crisis. “People die these horrible little quiet deaths all over the place when they’re not insured,” she said. By the time the ACA passed, she was back in Ohio and working as the program coordinator at Stonewall Columbus, where she ran, among other things, a queer ghost-hunting club. The stigma and discrimination against the trans community reminded her of the AIDS epidemic. The ACA was poised to help. A self-described policy wonk, Gum decided in 2013 to become a certified ACA application counselor to enroll LGBT people in the marketplace. She started urging them to sign up despite all the negative press coverage. “I spent the first year trying to convince people this wasn’t a socialist plot,” she said.

Gum didn’t know whether the ACA’s nondiscrimination rules would include transgender people, but she thought there might be a chance that insurance companies would finally be compelled to cover transition care.

In 2015, the agency invited public comment and received nearly 25,000 responses, many from transgender people describing mistreatment and exclusion in health care. The OCR was “seeing horrific things,” said a former HHS employee who was familiar with the process. A trans man from Minnesota named Jakob Rumble told the OCR about an ER visit during which a doctor asked him whether he “had sex with objects.” (Rumble later filed a lawsuit claiming that his rights under Section 1557 had been violated.) Accounts like Rumble’s made clear not only that transition-related care was being excluded from health insurance but that trans people were being turned away when seeking care for conditions completely unrelated to their gender identity. “They were being poked and prodded, and having their privacy violated,” the former HHS employee said.

In May 2016, the OCR finalized regulations for 1557, which mandated that an insurance company with exclusions for transition-related health services could be subject to civil lawsuits. The rule also protected nonbinary people against discrimination.

This was a huge victory. Though 1557 didn’t explicitly require insurers to cover transition-related services, if an insurer paid for hormones for menopausal women, it would likely need to cover them for trans people too. And if procedures such as mastectomies were covered for other conditions, then denying a trans person the same benefits could be considered discriminatory.

After becoming an application counselor, Lori Gum had called insurance companies to find out which would cover transition-related care. Some of the representatives “didn’t even know what trans was,” she told me. “I would sometimes give them diagnosis codes so they could look up the fine print in the policies.” The 1557 regulations “brought this issue to the forefront,” said Wes Campbell, an insurance broker in Ohio. “You started to see insurance carriers taking this guidance and applying it to their policies.” Gum said she hoped this meant “we would eventually get surgeries and things like that covered.”

But the rule could do only so much. Gum and Liam Gallagher were still getting phone calls from as far away as West Virginia — people in small communities who were cut off from care and risked rejection or discrimination if they came out.

A few days after my trip to Mansfield, I drove two hours north, to Stark County. It was a stormy afternoon and the city sprawl gave way to farmland and woods. At the local Starbucks, I met a twenty-six-year-old trans woman named Mae who wore thick red-framed glasses and a black hoodie with a Bernie Sanders pin.

For most of her childhood, Mae had lived with her father, but she would stay with relatives when his anger and racism became unbearable. She said she started “realizing” herself online a few years after high school. She especially identified with an online comic in which a male character looked into a mirror and saw a female reflection. The idea that she was female felt scary, but it also felt right.

Mae came out to her mother and a few friends. For a while she saw a counselor who “helped me to know I’m not messed up” and connected her to a support group in the area. However, by the time I met Mae, the group had dissolved; five of the seven members had dropped out or left town.

We’d been talking for about twenty minutes when I asked Mae whether she wanted to medically transition. “Absolutely,” she said. “I would love to go to my dad, give him the middle finger, and say, ‘I’m trans, you can kick me out. Oh, wait, my stuff’s already in the car.’ ”

Equitas is poised to help people like Mae, but it can open new clinics only in places with visible patient populations. Until more people in conservative and rural areas come out — potentially exposing themselves to harassment — care may remain out of their reach.

As the trans community mobilized to take advantage of the ACA’s new rights and protections, conservatives were getting ready, too. The backlash began even before Obama left office. In August 2016, five states and two Christian health care organizations sued HHS, claiming that “sex,” for the purposes of the ACA, should be defined only as “an individual’s status as male or female as determined by a person’s biological sex at birth” — and that the 1557 rule’s definition violated the plaintiffs’ federally protected religious beliefs. The DOJ defended the rule and its LGBT-inclusive definition of sex discrimination. But on December 31, 2016, Reed O’Connor, a district court judge in Wichita Falls, Texas, issued a nationwide injunction blocking HHS from enforcing the ACA’s nondiscrimination protections on the basis of gender identity. Advocates believe that the plaintiffs had chosen O’Connor’s district to file their case because he had issued a similar injunction against guidelines allowing transgender students to use the bathroom consistent with their gender identity.

Now that Trump is president, the federal government and the plaintiffs are on the same side. In May 2017, the government asked O’Connor to put the case on hold to let HHS reevaluate the 1557 rule. Roger Severino, an outspoken opponent of abortion rights and same-sex marriage, who is now the director of the OCR, had already made clear his intentions: to reverse the LGBT nondiscrimination protections in Section 1557. As the director of the DeVos Center for Religion and Civil Society at the conservative Heritage Foundation, he wrote an op-ed claiming that protections for trans people forced citizens “into pledging allegiance to a radical new gender ideology.” In fact, the OCR has already rewritten the rule. An official change will require a period of public notice and comment.

At least one Ohio insurance company has taken O’Connor’s injunction as a sign that the trans protections are no longer in effect. Heather Mullins, a transgender woman who lives outside Columbus, gets insurance from Medical Mutual of Ohio, one of the largest insurers in the state, through her job as a production manager at a small packaging company. Medical Mutual had been covering Mullins’s HRT since 2015. In January 2017, the insurer sent a letter to companies that offered its plans, stating it would “comply with new federal nondiscrimination rules” and “cover certain services for gender transition treatment.” Mullins thought she’d be able to have surgery in the coming years.

In March, however, she received another letter from Medical Mutual. It stated that because of the injunction, the company had removed coverage for transition treatment from her plan. Medical Mutual argued that “plans cannot be required to cover gender transition treatment because the regulation cannot be enforced.” Citing “budgetary restrictions,” the company “made the difficult business decision to remove coverage for gender transition services, until required, in the individual and small group health plans.” This common rationale for denying coverage is unfounded. Research suggests that because trans people make up such a small percentage of the population, covering transition-related care doesn’t cost insurers much. (Representatives for the company declined to comment.)

Medical Mutual is still covering her hormones, but Mullins told me that it was “depressing to think that coverage for surgery was in reach and then to have it taken away.” She is considering cashing out her 401(k) to pay for the procedures.

Joshua Block, an attorney with the American Civil Liberties Union who is working on behalf of the trans community in the Christian hospitals’ case against HHS, told me that Medical Mutual’s interpretation of the injunction is wrong: “People can still sue on the basis of the fifteen-fifty-seven regulation. The injunction only affects what the government can do in enforcement.”

Harper Jean Tobin, of the National Center for Transgender Equality, sees even greater cause for concern. She said that as HHS moves to change the rule, “we expect to see some more plans going back to discriminatory practices. The Trump Administration will essentially be telling insurance companies and other entities they work with that discrimination is okay, even though most courts are saying the opposite.”

Other efforts would also endanger trans people’s access to care. A repeal of the individual mandate would likely raise the cost of insurance for people who bought policies on the health care exchanges. Paul Ryan, the Republican Speaker of the House, has said that his party plans to “reform” Medicare and Medicaid in the next legislative session — another initiative that would reduce coverage.

Attempts to eliminate other protections at the federal level have continued. In a particularly drastic move last October, Jeff Sessions, the attorney general, reversed guidance protecting transgender people under Title VII, saying the prohibition includes “discrimination between men and women but does not encompass discrimination based on gender identity per se, including transgender status.” As a result, every federal regulation the DOJ approves must comply with this view of the law. Considering that this contradicts extensive legal precedent, “that is a pretty radical position,” said Block.

These political maneuvers highlight the peculiarities of the American lawmaking process. How a law is implemented depends on interpretations by agencies, and the ideology of those agencies changes with each presidential administration. Without a precise definition encoded in federal law, the question of whether “sex” includes gender identity will likely be decided in the Supreme Court.

Though advocates are adamant that nondiscrimination protections in the ACA still include transgender people, perception can be just as damaging as policy. “Fear that the insurance coverage that has been put in place for trans folks is at risk could cause some people who would otherwise sign up to be deterred,” said Sarah Lueck, an analyst at the Center on Budget and Policy Priorities. Kellan Baker, a health policy expert who is transgender and was instrumental in publicizing the ACA in the LGBT community, told me that Republican pledges to repeal the law have likely had a disastrous effect. “They are deliberately creating an atmosphere where questions swirl, and it becomes a self-fulfilling prophecy. You would be forgiven for thinking it isn’t the law anymore,” Baker said.

Most people medically transitioning with hormones plan to be on them indefinitely. There are grave risks to abruptly stopping treatment. Hormone withdrawal can have uncomfortable physical side effects, but the most significant result is a return of gender dysphoria and distress. When twenty-three-year-old Sylvia North couldn’t find a doctor to treat her, she ordered estrogen online and paid for it with her student loans. Not only was she on the wrong dosage, but when the loan money ran out, so did the hormones. Without them, North said, “it was hard for me to even look in the mirror. It wasn’t like I wasn’t myself, it was like I was the version of myself I couldn’t stand.” Gender dysphoria can have life-or-death consequences. Forty-one percent of respondents to the National Transgender Discrimination Survey reported having attempted suicide. That rate is ten times higher than the national average. Melissa Alexander, from TransOhio, said, “Adding more stress and anxiety and depression about losing medical coverage could push people over the edge.”

One of the most immediate concerns is that the Ohio legislature will succeed in slashing Medicaid coverage. In 2015, the state budget included a plan to require Medicaid recipients to pay premiums. (The Ohio Department of Medicaid estimated that this would cause a 15 percent drop in enrollment.) By law, states must ask the federal government for permission to make changes to Medicaid eligibility requirements, and the Obama Administration rejected Ohio’s request. But the Trump Administration has signaled that it is willing to approve changes that would result in lower Medicaid enrollment. In addition to Ohio, at least six states, including Maine, Wisconsin, and Arizona, are considering work requirements; others may require drug testing — all obstacles that would limit who gets coverage.

Since the election, many people have become worried about losing not only their insurance but a slew of recently won rights and protections. Dozens reached out to TransOhio in the days following the election for help changing their name and gender on identification cards, which makes it easier to navigate employment, travel, government, and law enforcement interactions. In most Ohio counties, this requires an application to the probate court and a notice in a local paper, which costs around two hundred dollars. The organization hadn’t planned to hold another workshop on the topic until January, but demand was so great that TransOhio and Equitas scrambled to put together a clinic. In December, nearly thirty people crowded into a conference room at an Equitas office in Columbus’s Clintonville neighborhood for the largest name-change event the two groups had ever held. “A lot of people were coming in and saying, ‘Now that Donald Trump is president, I’m scared and I want to do everything I’ve been putting off,’ ” said Carly Edelstein, an attorney who assisted with the applications. Since late 2016, TransOhio has provided more than 400 people with name-change assistance.

Ramona Peel told me that she had changed her name and gender on her driver’s license in 2014, but she rushed to get her passport changed before the inauguration. The outcome of the 2016 election felt like an “existential threat” to her and the community.

When I spoke with Mae, the woman from Stark County, a few months later, she shared some good news: a counselor had helped her find a nearby doctor who prescribed hormones through informed consent. Previously, she had been told that no doctor would prescribe HRT because she lived with her grandparents but was not out to them. At this clinic, however, “they understand that trans people have problems enough,” she told me. She’s still unemployed, isolated, and at odds with family members, “but who I am is a glimmer better because the counselors I have been seeing have gone out of their way to find solutions to help. It is not easy being where I am, and some people have it even worse than I do.”

Health care and marketplace coverage remain prohibitively expensive for many. Some insurers have been slow to expand coverage. Discrimination and rejection are commonplace, and providers are often uninformed about trans people’s health care needs. Gender variance is punished throughout society. But now we’ve seen what is possible when federal policy and mainstream medicine embrace inclusive ideas about gender and refuse to pathologize or punish those outside the gender binary. As conservatives work to diminish these hard-won rights, people will continue to demand care.

In August, Connor Chase saw Mimi Rivard again. He’d been on testosterone for three months and was getting ready to move into the dorms at OSU. “I’m very, very scared,” Chase said. He’d dyed his hair pink using Manic Panic, and a recent trip to the water park had faded the color to peach.

“How was the wedding?” Rivard wanted to know. He’d taken the prescription with him to the reception. “Anybody who gave me some kind of hassle or tried to misgender me, I showed the prescription and said, ‘Look, this is me.’ ” His mother and her wife had the DJ introduce him as their son, Connor. Rivard smiled. She gestured to his chin: Chase had started to grow facial hair. “I didn’t realize until I got in the car and looked in the mirror,” he replied. Rivard then asked Chase whether he wanted to stay on testosterone. “Yes,” he said, laughing.

“You’re transitioning beautifully,” Rivard told him. “So, the biggest stressor you have right now has nothing to do with your gender, it’s going to college?” Connor nodded. “Well,” she said, “I’m right down the street.”

This article was reported in collaboration with The Investigative Fund at The Nation Institute, now known as Type Investigations.