To Jess Attebery, left, Kody Gates, right, and many other transgender Idahoans, gender-affirming care is life saving. Attebery, president of Queer Club Idaho, helped start the Trans Lifeline Fund to help trans Idahoans pay for gender-affirming care. (Kyle Pfannenstiel/Idaho Capital Sun)

Editor’s note: This story discusses gender dysphoria, suicide and self-harm. If you or someone you know is struggling, call the Suicide & Crisis Lifeline at 988.

POCATELLO, IDAHO — In 2018, Kody Gates moved back to his hometown. But he was terrified about whether he could still access gender-affirming care.

He felt relieved when he found Dr. Neil Ragan, who founded Health West ISU’s gender-affirming care clinic in Pocatello.

But in response to a new law that took effect Monday that bans public funds for gender-affirming care, Health West will stop providing gender-affirming care to everyone. Counseling will still be offered at the Idaho-based non-profit health center.

“That beacon of hope that was Health West is being extinguished. And it’s very, very hard not to feel helpless,” Gates said.

Health West ISU’s Pocatello gender-affirming care clinic  — in partnership with Idaho State University, and located on the public university’s campus — is the go-to for gender-affirming care in east Idaho, doctors and patients told the Idaho Capital Sun.

Health West mailed patients letters last week announcing the new policy. Some patients had already learned weeks earlier from their doctor.

“We recognize the impact of this change and its effects on our patients,” read the letter, which the Sun obtained. “Health West remains dedicated to delivering the highest quality of care but is limited to providing care within the legal boundaries allowed.”

Health West did not make executives available for an interview to explain the new policy. But in an internal email and letters to patients reviewed by the Sun, it appeared that the health center network was worried about risking its funding and complying with changes in the law. 

The clinic also operates on Idaho State University’s campus; the new law bans providing gender-affirming care on public property. 

Even though they can’t prescribe hormones for gender-affirming care anymore, doctors working in the clinic say they can still treat gender-diverse patients in other ways and hope patients can access gender-affirming care at other medical offices. Health West didn’t perform gender-affirming surgeries. 

Major medical groups say gender-affirming care is medically necessary and safe. 

Judge restricts Idaho Medicaid gender-affirming care coverage ban for seven suing patients

Several legislators called gender-affirming care “medically harmful” or “at best … controversial.” Every Idaho Republican legislator voted in favor of the bill, except Idaho Senate Assistant Majority Leader Abby Lee, R-Fruitland, who didn’t run for re-election.

Preparing for the new law to go into effect, activists are fundraising to help transgender Idahoans access gender-affirming care.

One longtime Health West patient was already stockpiling hormones. Some are ready to pay out-of-pocket. Some patients moved out of Idaho.

Another barrier “doesn’t mean it is impossible to do this work,” said Dr. Jessica Rolynn, who manages Health West’s gender-affirming care clinic but stressed that she was not speaking on Health West’s behalf.

“I’m not ready to give up. And I don’t think I ever will be,” Dr. Rolynn said. “It’s hard, but it’s worth it.”

Why the Idaho Legislature passed House Bill 668

The new law, passed this legislative session through House Bill 668, bans public funds — and explicitly Idaho Medicaid — from covering gender-affirming puberty blockers, hormones and surgery procedures. 

The new law doesn’t outlaw gender-affirming care in Idaho. A previous Idaho law bans the care for minors. 

A study recently found gender non-conforming people were at higher risk for being in a lower socioeconomic status. Around 300,000 Idahoans are on Medicaid, which largely covers low-income and disabled people.

About 7,000 Idaho adults and 1,000 Idahoans age 13 and up are transgender, according to estimates from the University of California-Los Angeles.

In March, the Idaho House and Senate passed House Bill 668 with 84 votes in support, and 19 votes against, before Idaho Gov. Brad Little signed it into law. (Two Republican legislators were absent during floor votes.)

Rep. Bruce Skaug, who co-sponsored the bill and the previous law to outlaw gender-affirming care for minors, has likened gender-affirming care to lobotomies, a common but inaccurate comparison among right-wing media and politicians.

“It’s a popular fad that will pass, and we shall see. It’s not time for us to pay for these procedures, based on the science,” Skaug told the Sun in an interview on June 25.

“It is a controversial procedure,” Skaug said. “And we have authority to not use tax dollars in controversial health procedures, whatever those might be, as do health insurance companies.” But Dr. Ragan — who emphasized he wasn’t speaking on behalf of Health West — said claims that gender-affirming care is ineffective or harmful are false. 

Over a dozen years practicing gender-affirming care, Dr. Ragan said he’s seen patients whose lives have been saved and enriched by transitioning. Out of hundreds of transgender patients he’s treated, he said, he only knows three adults who de-transitioned.

“Are there physicians out there who are opposed to transgender health care? Yes. Are there patients who have transitioned and then regretted it and wanted to transition back? Yes. The numbers are vanishingly small. … That does not mean that we should not be providing care to these individuals,” Dr. Ragan said.

There were “fairly solid” arguments for and against providing gender-affirming medications to minors, Dr. Ragan said, which Idaho outlawed in 2023. But expanding the ban to public funded transgender health care for adults “is mean spirited,” he said.

“It makes me ashamed to live in Idaho. Makes me ashamed to be an Idaho physician,” Dr. Ragan said.

The new law prohibits public funding for critical parts of gender-affirming care — medication and surgeries. But the new Idaho laws don’t restrict all gender-affirming care, doctors told the Sun about last year’s ban for minors and the new public fund ban.

Even though Dr. Ragan can’t prescribe hormones, he says he can still treat patients for issues like managing high blood pressure, diabetes and depression.

Like Dr. Rolynn, Dr. Ragan stressed he wasn’t speaking on behalf of Health West. He now works for ISU but still practices in the clinic. 

Dr. Rolynn said she isn’t abandoning the 300 patients she provides gender-affirming care to. She said she wants patients to see her to help them access gender-affirming care that’s still allowed, and to find hormone therapy at other health systems. 

There are many ways to affirm a person’s gender without hormone therapy that Dr. Rolynn says she can still help with, like treating acne, irregular periods or suppressing periods.

But dozens of her patients have left the state, or are in the process, she said.

“Some people have lost hope for Idaho and have left. Some people don’t have that ability, because of either family commitments or careers or schools or just money. For those patients, that’s where, again, I’m stressing I am not leaving,” Dr. Rolynn said.

Health West’s letter to patients says the new law restricts “public funds for gender affirming care related to surgical procedures and any hormonal therapies. This includes Medicaid reimbursement and the use of state-funded facilities for these services.”

In an emailed statement on Thursday, Health West Director of Outreach Krysten Bullock said: “Health West is committed to the care and privacy of our patients and is continuously working to ensure compliance with the law; additionally, the information provided in this article was made without the authorization or review of Health West and does not necessarily reflect the position of the organization.”

In May, Health West internally announced plans to stop gender-affirming care

In a May 9 email to employees obtained by the Sun, Health West Chief Medical Officer Dr. Mark Horrocks wrote the decision wasn’t driven by Health West, but was in “response to certain political forces, including new legislation.”

“We recognize the impact of this change and its effects on our community. Health West remains dedicated to delivering the highest quality of care but is limited to providing care within the legal boundaries allowed,” he wrote. 

The new policy would apply across any Health West locations, Dr. Horrocks wrote. Health West has 19 locations across Idaho, Utah and Wyoming, according to its website.

In Idaho, Utah and Wyoming, “various legal and political events have recently transpired governing gender affirming or transgender care,” Dr. Horrocks wrote in the May 9 email. “The Health West executive team and legal team have analyzed these changes in relation to the Health West situation, including patient care, the sustainability of services, risks to funding streams, the viability of the organization as a whole, and other factors.”

Gender-affirming related diagnosis can be entered into patient charts, he wrote. “But those diagnoses cannot be addressed in any manner that could be construed as offering gender affirming care,” he wrote.

“Prescriptions and refills of prescriptions cannot carry over past July 1, 2024. This is true for prescription assistance efforts, blood draws, injection services, and related services,” Dr. Horrocks wrote.

“If you have individual questions, please contact us,” he wrote.

Dr. Rolynn replied in an email.

“We have reached out to other clinics across Idaho and have not come across anyone interpreting this law so fiercely as Health West,” she wrote in her reply, which Dr. Ragan shared with the Sun. “I don’t understand how I am supposed to cancel prescription refills that have already been signed on hundreds of patients. Can you please help me understand how I am supposed to do this? I am absolutely in shock right now.”

She said she didn’t hear back.

When Dr. Rolynn got home that night, she cried. 

At first, she thought she should get away as far as she could, she said.

But, she said, the thought that “people are gonna die” wouldn’t leave her head. 

She knows “it’s been proven — again and again — that not addressing gender dysphoria leads to increased suicide and depression,” she said.

“I don’t want to live in a world where I can do something about that and I choose not to,” Rolynn said.

Doctors hopeful for other gender-affirming care treatment options

Doctors working in the clinic say they’re hopeful their patients can continue receiving gender-affirming care.

Dr. Ragan said he is cautiously optimistic “we will be able to come up with alternatives for all of our patients that they will find suitable.”

Patients can pursue gender-affirming care through telehealth services at other clinics, he said. A plan to find local providers for patients is in progress, he said.

But other local options aren’t adequate, Dr. Ragan said.

For Gates, a transgender man, his gender-affirming care is maintenance, he said.

In Denver, he had a hysterectomy due to medical complications unrelated to gender-affirming care, he said. That means being taken off testosterone could be life-threatening, he said, since he doesn’t produce sex hormones and needs treatment to manage side effects that could risk stroke and blood pressure issues.

Gates said he’s fortunate he can still pay for his medication. If gender-affirming care isn’t covered by his insurance as a state of Idaho employee, “that’s like a double slap in the face,” he said.

But many people can’t pay on their own, he said.

And he worries what Health West’s decision to stop providing gender-affirming care means for patients in rural surrounding areas, where people traveled from to get care in Pocatello.

“What’s left for them?” Gates said. “And what about those people that can’t (privately) pay for their care? It’s terrifying.”

In an interview on June 21, Gates said he wishes the decision-makers at Health West would explain to patients why they’re terminating gender-affirming care. 

“They are abandoning some of the most vulnerable people,” Gates said.

Health West notifies patients week before new policy takes effect

Last week, some patients received a letter in the mail from Health West announcing the new policy. 

Starting July 1, Health West won’t provide gender-affirming care, including prescriptions and prescription refills, the letter read. If patients needed a 30-day medication refill, the letter advised them to contact the office before June 26.

Three Health West patient letters — provided to the Sun — were postmarked on June 24. Three patients told the Sun they received the letter with only a day or two to request prescription refills. 

“If you need a 30-day refill on your medications, please notify our office prior to 6/26/2024 so we can ensure you have proper medication coverage,” the letters read. “If you would like Health West to forward your medical records to a provider of your choice who can better serve your gender affirming medical and pharmacy care needs, please feel free to reach out to our team.”

Health West Letter

Elliott Womack, who is gender fluid, filed an ethics complaint through a third party reviewer over Health West’s delayed notification to patients. 

Womack said he wasn’t surprised by Health West’s new policy, which he’d heard about weeks earlier from Dr. Rolynn, Womack told the Sun in an interview. Womack wrote in his complaint that he received Health West’s letter on June 25. 

“This information needs to come to patients in the form of official communication from the clinic,” Womack wrote in the complaint. “Many of our transgender community members would have gone to Health West ISU without knowing about the policy change and been rejected from receiving appropriate and necessary medical care.” 

Womack is considering getting a referral to an Idaho Falls doctor for gender-affirming care.

When they first visited Health West, Womack said a staff member helped him apply to Medicaid. 

He said he recommended Health West to “not only every queer person that I knew,” but anyone looking for affordable, accessible care.

But now, Womack said, “my trust in the clinic itself has eroded away.”

Rowan Smith, a trans man who’s been a Health West patient for eight years, said he received Health West’s letter on June 26. But he had also already heard about the new policy from Dr. Rolynn.

He said he’d stockpiled eight to 10 months of testosterone. 

Dr. Rolynn said she made every effort to contact patients early. But “without having the resources of the larger office, I wasn’t able to reach everyone,” she said.

On June 26, she was at a conference. She said she spent most of the day filing prescription refills. 

Jess Attebery, president of Queer Club Idaho, helped create a fund called the Trans Lifeline Fund dedicated to help trans people pay for gender-affirming care after the new law takes effect.

But the fund shouldn’t be needed, she said.

“Certain people disagree about this. But it is supposed to be the state’s responsibility to help care for those who don’t have a way to do it themselves,” Attebery said.

Attebery, a trans female, has been a Health West patient since 2018. Now, she said, she has to look elsewhere for hormone replacement therapy — which her Medicaid insurance also can’t cover.

“For myself, and for many of us, it is not only gender-affirming. It is life-saving care,” she said.

Transitioning saved Gates’ life, he said. It gave him hope he would live past his 30s.

“It was like taking a breath for the first time when you’ve been holding your breath underwater for a long time,” Gates said. “And seeing color for the first time.”

Gates grew up in Pocatello. In 1999, he moved to Denver to feel more safe while he explored his gender and eventually medically transitioned.

Gates said he always knew “my body didn’t match what I felt.” But early on, he didn’t know the language to describe it.

“There’s a million shades of red. It doesn’t go from night to morning,” Gates said. “Everything in our natural universe is a spectrum. So why is it so hard to believe that maybe gender might be too?”

Before he had top surgery, to remove breast tissue, Gates said he couldn’t look in the mirror. He said he’d fantasize about cutting off his breasts. 

After he started testosterone, every change felt like “sunlight on my face for the first time,” he said. 

If House Bill 668 and other new Idaho laws take effect, he worries suicide rates in the area will rise. 

He remembers when he looked for a place to kill himself, where his wife wouldn’t be the first to find his body.

“I don’t want to see anyone ever in that state. And I’m afraid that these bills are going to put a lot of people there,” he said.

Smith had a similar experience.

Smith, 25, had six mental health hospitalizations. Each stay, he said, was prompted by suicidal ideations in part caused by self-harm relapses and hormone changes linked to periods — called premenstrual dysphoric disorder.

In 2016, after another hospitalization and a decade of conversations in therapy and with family, Smith said he started hormones.

For years, he said he knew he was trans. But then, he said, he knew he would not make it another year without transitioning.

“If I didn’t transition, I was going to kill myself,” Smith said.

Even if he stopped testosterone, he said, many effects would stay — like his lower voice and scruffy facial hair. But testosterone has also stopped his periods, helping him manage premenstrual dysphoric disorder, he said. 

He hasn’t self harmed in almost five years, he said.

Stockpiling testosterone has helped him “buy time,” he said. And, if he needs, he said he can continue to pay-out-of-pocket for medications and travel for health care while he’s uninsured.

But he worries about people who traveled to Pocatello for care, and those who weren’t planning for a “worst-case scenario.”

Smith said he loves Pocatello — where he’s lived since 2004, and where his mom, stepdad, sister, grandmother and two children live. 

He doesn’t want to have to move. But he’s talked with his family about whether he’d need to move without them. 

That’s “if things keep continuing to make it impossible for me to live here,” Smith said.

Idaho Legislature ‘tied the hands of these organizations,’ doctor says

Dr. Ragan said “my beef” is not with Health West or ISU — it’s with the Idaho Legislature.

“They have tied the hands of these organizations who receive state funding with the threat being that the funding will be cut off,” Dr. Ragan said.

Organizations that rely on public funds “irrespective of their beliefs” are “not in a position to be pushing back against the state,” Dr. Ragan said.

It is unclear how the new law affects other Idaho federally qualified health centers.

The Community Health Center Network of Idaho couldn’t be immediately reached for comment. 

Full Circle Health, with locations in and around Boise, is still promoting on its website primary care and hormone therapy at its gender diverse clinic, including a sliding-fee discount program based on people’s income. Full Circle President and CEO Dr. Ted Epperly told the Sun gender-affirming care will only be provided to adults, the health center will “abide by the law” and no state dollars will be spent on the care.

“An adult patient would need to become one of our patients to receive primary care services including hormone therapy,” Epperly told the Sun in a Monday email.

Dr. Epperly said he couldn’t speak to how the new law impacts other Idaho federally qualified health centers.

Idaho doctors brace for impact on impending gender-affirming medication ban

In an interview with the Sun, Terry Reilly Health Services spokesperson Claudia Weathermon didn’t directly say if the federally qualified health center with locations across southern Idaho is blocked under the law from providing gender-affirming care. Terry Reilly hasn’t performed surgeries, she said.

“We deliver primary care for everybody that we see. And we do that for everybody, no matter their income status, or their background, or their gender status, all that. We do deliver that primary care fully complying with federal and state laws,” Weathermon told the Sun.

Weathermon said she couldn’t confirm how many Terry Reilly patients would be potentially affected.

“It would be on a case-by-case basis if there’s a change of care in what we’re able to offer them,” she said.

The new law also prohibits administering gender-affirming medications and surgeries on state property. 

Health West’s gender-affirming care clinic in Pocatello is based out of ISU’s campus. 

In response to a public records request for policies for Health West ISU operations in response to the new law, ISU replied it didn’t have any records.

“Health West independently reviewed HB668 and voluntarily ceased operations at the clinic that they believe are now prohibited under HB 668,” Idaho State University Vice President for Health Sciences and Vice Provost Rex Force told the Sun in an email. “While the university was prepared to discuss operations with Health West and how the bill may affect those operations, this was ultimately unneeded.” 

Rep. Skaug said he wasn’t familiar with Health West’s clinic. He confirmed federal funding passed through state agencies would be public funds, and subject to the new legal ban on covering gender-affirming care through public funds.

“If a clinic relies substantially on taxpayer dollars of Idahoans to carry out these procedures, then this is the result that would be expected,” Skaug said.

Out of protest against what Gates calls hateful legislation, he said he resigned his job as a social worker at the Idaho Department of Health and Welfare. He said his job was open for a year before he started in October 2023.

“They’re creating their own problem. You don’t have enough providers because it’s not a safe place for providers,” Gates said.