Reviewed by Lily Ramsey, LLM Nov 6 2023
This summer, Sophia Machado packed her bags and left her home in Oregon to move to Albuquerque, New Mexico, where her sister lived and where, Machado had heard, residents were friendlier to their transgender neighbors and gender-affirming health care was easier to get.
Machado, 36, is transgender and has good health insurance through her job. Within weeks, she was able to get into a small primary care clinic, where her sister was already a patient and where the doctor was willing to refill her estrogen prescription and refer her to an endocrinologist.
She felt fortunate. "I know that a lot of the larger medical institutions here are pretty slammed," she said.
Other patients seeking gender-affirming health care in New Mexico, where access is protected by law, haven't been as lucky.
After her primary care doctor retired in 2020, Anne Withrow, a 73-year-old trans woman who has lived in Albuquerque for over 50 years, sought care at Truman Health Services, a clinic specializing in transgender health care at the University of New Mexico. "They said, 'We have a waiting list.' A year later they still had a waiting list. A year later, before I managed to go back, I got a call," she said.
But instead of the clinic, the caller was a provider from a local community-based health center who had gotten her name and was able to see her. Meanwhile, the state's premier clinic for transgender health is still at capacity, as of October, and unable to accept new patients. Officials said they have stopped trying to maintain a waitlist and instead refer patients elsewhere.
Over the past two years, as nearly half of states passed legislation restricting gender-affirming health care, many transgender people began relocating to states that protect access. But not all those states have had the resources to serve everyone. Cities like San Francisco, Chicago, and Washington, D.C., have large LGBTQ+ health centers, but the high cost of living keeps many people from settling there. Instead, many have chosen to move to New Mexico, which has prohibited restrictions on gender-affirming care, alongside states like Minnesota, Colorado, Vermont, and Washington.
But those new arrivals have found that trans-friendly laws don't necessarily equate to easy access. Instead, they find themselves added to ever-growing waitlists for care in a small state with a long-running physician shortage.
"With the influx of gender-refugees, wait times have increased to the point that my doctor and I have planned on bi-yearly exams," Felix Wallace, a 30-year-old trans man, said in an email.
When T. Michael Trimm started working at the Transgender Resource Center of New Mexico in late 2020, he said, the center fielded two or three calls a month from people thinking about moving to the state. "Since then, it has steadily increased to a pace of one or two a week," he said. "We've had folks from as far away as Florida and Kentucky and West Virginia." That's not to mention families in Texas "looking to commute here for care, which is a whole other can of worms, trying to access care that's legal here, but illegal where they live."
In its 2023 legislative session, New Mexico passed several laws protecting LGBTQ+ rights, including one that prohibits public bodies from restricting gender-affirming care.
"I feel really excited and proud to be here in New Mexico, where it's such a strong stance and such a strong refuge state," said Molly McClain, a family medicine physician and medical director of the Deseo clinic, which serves transgender youth at the University of New Mexico Hospital. "And I also don't think that that translates to having a lot more care available."
The U.S. Department of Health and Human Services has designated part or all of 32 of New Mexico's 33 counties as health professional shortage areas. A 2022 report found the state had lost 30% of its physicians in the previous four years. The state is on track to have the second-largest physician shortage in the country by 2030, and it already has the oldest physician workforce. The majority of providers offering gender-affirming care are near Albuquerque and Santa Fe, but 60% of the state's population live in rural regions.
Even in Albuquerque, waitlists to see any doctor are long, which can be difficult for patients desperate for care. McClain noted that the rates of self-harm and suicidal ideation can be very high for transgender people who are not yet able to fully express their identity.
That said, Trimm adds that "trans folks can be very resilient."
Some trans people have to wait many years to receive transition-related medical care, even "when they've known this all their lives," he said. Although waiting for care can be painful, he hopes a waitlist is easier to endure "than the idea that you maybe could never get the care."
New Mexico had already become a haven for patients seeking abortion care, which was criminalized in many surrounding states over the past two years. But McClain noted that providing gender-affirming care requires more long-term considerations, because patients will need to be seen regularly the rest of their lives. We're "working really hard to make sure that it is sustainable," she said.
As part of that work, McClain and others at the University of New Mexico, in partnership with the Transgender Resource Center, have started a gender-affirming care workshop to train providers statewide. They especially want to reach those in rural areas. The program began in June and has had about 90 participants at each of its biweekly sessions. McClain estimates about half have been from rural areas.
"It's long been my mantra that this is part of primary care," McClain said. As New Mexico has protected access to care, she's seen more primary care providers motivated to offer puberty blockers, hormone therapy, and other services to their trans patients. "The point really is to enable people to feel comfortable and confident providing gender care wherever they are."
There are still significant logistical challenges to providing gender-affirming care in New Mexico, said Anjali Taneja, a family medicine physician and executive director of Casa de Salud, an Albuquerque primary care clinic serving uninsured and Medicaid patients.
"There are companies that are outright refusing to provide [malpractice] insurance coverage for clinics doing gender-affirming care," she said. Casa de Salud has long offered gender-affirming care, but, Taneja said, it was only this year that the clinic found malpractice insurance that would allow it to treat trans youth.
Meanwhile, reproductive health organizations and providers are trying to open a clinic — one that will also offer gender-affirming care — in southern New Mexico, with $10 million from the state legislature. Planned Parenthood of the Rocky Mountains will be part of that effort, and, although the organization does not yet offer gender-affirming care in New Mexico, spokesperson Kayla Herring said, it plans to do so.
Machado said the vitriol and hatred directed at the trans community in recent years is frightening. But if anything good has come of it, it's the attention the uproar has brought to trans stories and health care "so that these conversations are happening, rather than it being something where you have to explain to your doctor," she said. "I feel very lucky that I was able to come here because I feel way safer here than I did in other places."
It depends on the nursing school program as to how aggressive the culling will be. I went to a well regarded associate's program because it's cheap and has a good reputation in the region. The culling was ungodly. To even qualify to get into the program you needed to pass A&P I and II which were brutal classes requiring shitloads of study time because the tests were made to be "nursing school" difficult. You also needed at least a B+ if you were going to be considered for the program because entry is competitive. Then once you hit nursing school after all the prereqs and competitive entry, welcome to hell. My classmates that were successful tended to spend like 40-60 hours a week on school stuff between clinical rotations, studying, frequent classes, and whatever extra bullshit they threw at us like simulations. The tests were brutal intentionally doing trick questions and having 3 correct answers but having to pick the "most correct" because that's what the NCLEX did. Come the end of the first semester, like 2/3 of the class had been culled and that was normal. You picked up maybe 3-4 new people in semester 2 with LPNs picking up, but even then, by graduation it was like a quarter of the class that was graduating. Keep in mind that the obscene requirements never went away, if anything they got harder with requirements to pass with >78% or fail.
If I had the scratch I absolutely would've gone to be a doctor.
There's also the issue that even the medical field has been saying is probably not a good idea with the push for BSN qualified nurses to be the majority. 2 year programs provide a solid entry into the field especially with the level of 2 year education I got. The second two years are there for management and research based classes which has a purpose but doesn't make them "better" nurses. At my last job I worked with an LPN that had years of experience and picked up on stuff I would sometimes miss. Would bet good money that she was a far better nurse than those with fancy degrees that ran the place.
And then you get countless quacks that somehow got into the field and do untold amounts of harm because hospitals will sweep it under the rug to protect their reputation. Just because they can get past all the culling doesn't always mean they're good for the job and there were several people I knew in my class that would've been great if they were given a bit more opportunity to blossom under a less aggressive program.
TIL. Although, I've got a friend who recently made it through residency and it didn't sound any easier. I guess at least the pay is better.
I mean, a lot of the secret to being a good quack is to know when and how to lie. Go do a night school class at Harvard after getting your DO from a Caribbean college and then put "Harvard Educated Doctor" on your resume. Bomb out of your residency but still practice medicine under your degree. Straight up lie and say you have credentials that you never obtained. Then latch onto what marketing folks want to promote, look good in a lab coat, and hustle product.
The other side of the AMA coin is how under-policed and under-regulated the medical-adjacent fields happen to be. You can make all sorts of claims under the label of herbal supplement. So there's a real economic incentive to cheat, lie, steal whatever makes money.
The culling definitely creates a certain kind of doctor. And the stress/debt/abuse on the front end followed by all the flowery language and formality and ego-inflating on the back end, really does a number on anyone who wasn't already that way.