Access, education remain barriers for people seeking gender-affirming care in rural Nevada
Oliver French, 26, grew up in Tonopah, a town of a little more than 2,000 people in central Nevada. Though he came out to a few friends in 2015, it wasn’t until a year later that he was publicly out as a transgender man and began medically transitioning.
French is well-known throughout Tonopah. He’s lived in the town his whole life and has a history of working public-facing jobs. For a time he worked as a checkout clerk at the only grocery store for miles and as an assistant for the only veterinarian in town.
Though Nye County is Republican-leaning, and more than half of voters there opposed a ballot measure in 2020 putting same-sex marriage in the Nevada Constitution — French said people in Tonopah have generally been open-minded. However, he's not sure whether it’s because they're generally open to accepting members of the LGBTQ community or because they know personally French.
“I'm not sure if they're accepting just in general, or if they're accepting because it's me,” French said. “Most of the people I came out to, they're like, ‘Alright, cool. We got it.’”
Aside from the challenges of coming out to members of his community, French faces obstacles accessing gender-affirming health care — he has to travel nearly four hours to Las Vegas to receive care to treat gender dysphoria. The hurdles come as the state struggles to maintain an adequate number of health care providers, and shortages are especially acute in rural areas.
Gender dysphoria is a condition that causes a person to experience distress when there is a mismatch between their gender and assigned sex — or the sex assigned to an infant at birth, usually based on external anatomy. It can be treated with hormone replacement therapy (HRT) and sometimes gender-affirming surgery, but treatment differs from person to person.
Nevada is not alone. People across the country trying to access gender-affirming health care are often met with barriers including a lack of gender-affirming care providers nearby and physicians who may not be educated or experienced in transgender health care, among others.
According to a 2017 study by the National Library of Medicine that surveyed 256 participants about receiving gender-affirming care, 77 percent reported experiencing barriers to accessing health care.
Of that 77 percent, 84 percent reported trouble accessing HRT, 11 percent reported not being able to access puberty blockers, more than two-thirds reported barriers to top surgery — surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance — and 43 percent said the same about bottom surgery.
Bottom surgery typically refers to three types of surgeries: vaginoplasty, phalloplasty and metoidioplasty.
“Vaginoplasty is typically pursued by transgender women and AMAB (assigned male at birth) nonbinary people, while phalloplasty or metoidioplasty, is typically pursued by transgender men and AFAM (assigned female at birth) nonbinary people,” according to an article published by Healthline.
The study said the two most common barriers to gender-affirming health care was the cost, with out-of-pocket costs for HRT ranging from $72 and $3,792 per year in 2018 and higher costs for surgery, according to the National Library of Medicine. Costs can be even higher if the person lacks insurance or their insurance doesn't cover gender-affirming health care.
The third most common barrier was availability, with some people traveling up to eight hours or even to another country to access care. This could be because of travel logistics, as it is in rural Nevada, or because of state laws making access illegal.
The lack of access can mean higher rates of physical and emotional health problems. According to a study published by the Williams Institute School of Law at UCLA, transgender people have minority stressors — which include family rejection, discrimination experiences and stigmas — on top of the risk factors of suicide for cisgender people. Around 40 percent of transgender adults have attempted suicide in their lifetime and around 30 percent of transgender youth have made a suicide attempt in the last year.
However, receiving gender-affirming health care, specifically at an early age, can reduce the likelihood of a transgender person experiencing suicidal ideation within their lifetime.
Additionally, finding a physician that understands LGBTQ health can help transgender people with preventative care. Transgender people are at higher risk for heart attack regardless if they receive gender-affirming care.
Strides in internet and telehealth access have removed some of the distance barriers.
French works around the challenges in part by attending his therapy sessions online — a requirement for some insurances — and gets his prescriptions sent to him through the mail.
“With our pharmacy, there's a lot of complaints so I just don't even go through them,” French said about the sole pharmacy in town. “I actually go through a pharmacy in Vegas, but I can call them up and be like, ‘Hey, mail it to me,’ and I'll get it in two days. So that part is pretty accessible.”
Kimi Cole, the retired chair of the Nevada Democratic Rural Caucus who ran an unsuccessful bid for lieutenant governor in 2022 which made her the first transgender woman to run for the office, said telehealth is an important part of accessing health care in rural communities as a whole. As state and federal governments invest more in improving the internet across less-populated areas of the country, telehealth is becoming more accessible to rural Nevadans.
“If you're 100 miles away from a doctor that makes it very, very challenging, just to get the same health care that a lot of people take for granted in the urban areas,” Cole said. “Using telehealth care to be able to communicate with the doctor — it can be comforting, it can help somebody rule out something major.”
However, not everything can be accomplished online. People in need of hormone therapy have to travel to get the levels of estrogen and testosterone in their blood measured regularly to ensure the right dosage is being prescribed. If there isn’t a lab within their community, they have to travel for lab tests, according to Dr. Chelsea Travers, who works at Northern Nevada HOPES, a health care provider in Reno that also serves outlying communities.
Travers said these tests have to be administered every three months, but can be spaced out after about a year of treatment, meaning those starting gender-affirming health care may have to visit a doctor in person more frequently.
Another challenge for people seeking gender-affirming care — in both rural and urban areas — is finding a doctor who is educated on LGBTQ issues.
“Getting to a primary care provider that understands them, that uses their pronouns, that just looks at them for their care as a holistic person, can be challenging,” Travers said.
French said what may be the biggest difference between his experience and someone in a more urban area is that a lot of people in rural communities don’t know much about the LGBTQ community.
“I kind of feel like, ‘Let me educate you.’ Just so you're not instantly like, ‘Oh, I'm not OK with that.’ ‘OK, well, you don't really know what it is,’” French said.
Through sharing his personal experiences with transitioning, French said he can usually come to be “roughly on the same page” with people who say they are against trans issues. Other times, people come to French just wanting to know more.
“My old boss, he was like, ‘Hey, is it OK if I ask you questions?’” French said. “And he said, ‘If I come across as rude or anything, you just tell me to shut up.’ And I was like, ‘It's fine. I'm pretty open. Like any questions you got, I'll answer them.’”
People also come to French if they are questioning their gender identity themselves or if they just need help with the process of changing their name, as one Tonopah resident did.
“It's kind of rewarding, just because it doesn't happen super often. And I research so much. So I'm like, ‘Yes, let me use these abilities,’” French said.
‘Recognized by our Legislature’
Despite the struggle to get access to gender-affirming care in rural areas, Nevadans will soon see LGBTQ policies in recent legislation protecting their right to health care.
This session brought the Legislature's first-ever LGBTQ caucus. Sen. Dallas Harris (D-Las Vegas) said in a press release that the caucus’ goal is to “send the message to LGBTQ Nevadans that you are welcome, safe, and represented here.”
Republican Gov. Joe Lombardo bucked party stereotypes by approving bills such as SB163, sponsored by Sen. Melanie Scheible (D-Las Vegas), that requires health insurance companies to cover treatments relating to symptoms of gender dysphoria that were previously exempted as “cosmetic.”
Lombardo also signed SB153 — also sponsored by Scheible — which requires gender-affirming health care for transgender prisoners in the custody of the Nevada Department of Corrections. And he approved SB211, which made it easier for people to have a name change reflected on their marriage certificate.
However, the governor vetoed SB302, which would have protected health care providers giving gender-affirming care from losing their license if other states pursued prosecution against them for treatment they gave that state's residents. It also would have prohibited Nevada's executive branch from helping another state investigate a provider for offering gender-affirming care.
In his veto message, Lombardo said he was concerned that SB302 “inhibits the Executive Branch's ability to be certain that all gender-affirming care related to minors comports with State law.”
However, supporters said SB302 would not remove existing parental consent laws and would not change the law surrounding minors consenting to medical treatment — meaning minors would still need parental consent for treatment.
Supporters argued that the veto of SB302 could lead to providers leaving Nevada, resulting in a bigger gap in access to gender-affirming care.
Cole said overall, though, she thought a lot of important legislation passed this session.
"It is encouraging, especially out in the rural areas where people have the same human needs they have in urban areas, and to know that there are treatments that are available and they've been recognized by our Legislature," Cole said.
Travers, Cole and French all emphasized the importance of community and conversation for anyone questioning their gender identity. French said despite the small population of LGBTQ people in Tonopah, they have created a tight-knit community.
“There's not a ton of people, like especially where I am. There are a couple of people and I kind of surrounded myself with them,” French said. “Funny enough, we kind of found each other.”
Cole said one thing she wants people to understand is that there is hope for people seeking gender-affirming care, despite anti-LGBTQ political rhetoric and legislation being passed across the nation.
“We're going to keep working. We're going to keep getting the word out there that there is hope,” Cole said. “Let people know that they're not alone out there in the world. There are people willing to help, there are people who care and there are people willing and working on doing the right thing.”