“They would just say, ‘I can’t prescribe you anything,’ ” said Johnson, 24, a transgender woman and civil engineer who had recently graduated from the University of New Mexico. “So, I’d have to stop all my care, cold turkey, for 10 months, until I could resume it with the endocrinologist.”

The fifth physician was willing to maintain her progesterone prescription as she awaited her appointment with an endocrinologist, as long as there were no changes to her hormone replacement therapy plan.

Johnson’s experience wasn’t rare. Despite legal protections in New Mexico for gender-affirming care, many transgender residents say treatment can be difficult to come by in the state — especially with a federal administration that has sought to erode this area of healthcare. Due to changes in insurance coverage and a shortage of providers, some people have turned to do-it-yourself treatments through an online gray market — or even out-of-state travel to access surgery.

“There’s never been a time that I’ve lived here and I’ve been doing this work where there were enough providers,” said Adrien Lawyer, executive director of the Albuquerque-based Transgender Resource Center of New Mexico, which he co-founded in 2008. “And there are no surgeons that can do genital surgery, and over the years there have been up to maybe three or four people around the state doing top surgery for transmasculine people, but sometimes as few as one.”

Paige Zamora, 25, a trans woman and event coordinator who lives in Albuquerque, said she’s thankful for New Mexico’s law protecting the right to gender-affirming care against the backdrop of an unfavorable federal landscape and increasing restrictions and bans in other states. But she thinks further investment here is needed — particularly as trans people from red states are moving to blue ones.

The U.S. Supreme Court ruled last year in United States v. Skrmetti state bans on gender-affirming care for youth are constitutional.

“Having protections is still a step below properly investing into it,” Zamora said. “And by no means am I complaining — most places don’t even get that much — but it does still feel like trans healthcare is the dirty issue that gets swept under the rug a bit and people don’t like to focus on.”

Johnson, who started medically transitioning at age 20, moved to New Mexico from Missouri a few years ago, in part to get away from state-level anti-trans legislation.

Her struggle to maintain her hormone replacement therapy could have been a “death sentence” for someone who did not have the same opportunities or skills to navigate the healthcare system, she said.

Going off hormone therapy, she added, is like “major depression on steroids.”

“It’s like a constant neurological pain,” she said. “Everything is affected by it. It’s just this deep brain fog and malaise.”

New Mexico is one of at least 18 states with a “shield law” safeguarding healthcare access for trans people of all ages. The Reproductive and Gender-Affirming Health Care Freedom Act, signed by Gov. Michelle Lujan Grisham in 2023, prohibits public bodies from interfering with or banning access to care.

Under New Mexico law, gender-affirming care is “psychological, behavioral, surgical, pharmaceutical and medical care, services and supplies provided to support a person’s gender identity.”

The American Medical Association recognizes the care as “vital” in “improving the physical health and mental well-being of transgender individuals,” its website states, and studies have linked youth access to gender-affirming care with decreased risk of suicide, depression and anxiety.

Still, efforts by President Donald Trump’s administration aimed at curbing access to care — and circumventing state laws that protect access — could have an impact here.

Proposed rules announced in December took aim at Medicaid and Medicare funding for hospitals that provide gender-affirming care for minors. The rules would prevent providers from receiving Medicaid reimbursement for gender-affirming care for youth and wholly block Medicaid and Medicare funding for services at hospitals that provide the care.

One medical professional told The New Mexican the rules — if they go into effect — would likely force hospitals in the state to stop providing care for trans minors.

The U.S. Centers for Medicare & Medicaid Services is currently reviewing public comments on the proposed rules, a spokesperson wrote in an email to The New Mexican.

“CMS will communicate any potential next steps and provide additional guidance to states and stakeholders, as appropriate,” the spokesperson wrote.

Hospitals in some states have stopped providing care for trans youth amid clashes with the U.S. Department of Health and Human Services, although the decisions have not always stuck. The Colorado Supreme Court in May ordered the state’s largest gender-affirming care provider for people under 18 to resume its medical treatments, months after it had stopped, according to PBS.

Meanwhile, the Department of Justice in May announced a $10 million settlement agreement with Texas Children’s Hospital in Houston — one of the largest pediatric hospitals in the U.S. — requiring it to create the nation’s first “detransition clinic” for trans patients.

Detransitioning is a rare process that involves stopping or reversing gender transition care through social, medical or legal avenues, according to The Texas Tribune.

That’s generated fear among trans people, Johnson said: “I think now that they’ve successfully done that in one instance, they will be able to roll that out to other states.”

Johnson began her search for a primary care provider last year, shortly after she graduated from UNM. She had previously accessed care through UNM Student Health and Counseling, which notes on its website it provides routine care, labs, prescriptions for hormone therapy, referrals and education on safe injection practices for trans students.

“They have doctors trained in gender-affirming care, which is wonderful,” Johnson said. “But most primary care providers, standing care physicians, don’t do that.”

Lawyer said gender-affirming care has never been a standard part of curriculum for people studying to become nurses, physician assistants or doctors.

“You can get all the way through those trainings without one hour of cultural training about trans people, much less medical training,” he said. “I think it goes all the way to the bottom. It’s like, so far, the people who teach medical providers have not thought to include information about this and a whole lot of other minority characteristics that would allow a lot of patients to have much more safety and access within the medical system.”

Dr. Kim Nguyen, an internal medicine physician and founding board member at Comunidad de Colores — a free medical clinic in Santa Fe that will provide gender-affirming care, among other services, when it opens its doors later this year — said there are several barriers for doctors learning how to perform the care, which not every medical school teaches.

Nguyen was trained in San Francisco, where resources on providing gender-affirming care were readily available.

“If you haven’t been trained in it, it can just feel very new,” Nguyen said. “And starting anything new, and while you’re already in practice — there’s not a whole lot of time when you’re in primary care practice and seeing 20 to 30 patients a day.”

Nguyen tells her colleagues it’s fairly straightforward to learn how to incorporate gender-affirming care into primary care — at least in the beginning — and there are now numerous online resources for providers. She refers fellow providers to the University of San Francisco’s online handbook, which covers hormone therapy, cancer screenings, fertility options and more.

There are also continuing education courses for physicians that focus on gender-affirming care, Nguyen added.

Comunidad de Colores — which hopes to open by the end of the year in the low-income Hopewell Mann neighborhood — considers gender-affirming care to be a part of broad-spectrum primary care, she said.

Nguyen wants to curb the need to refer trans and gender-nonconforming patients to costly specialists for care that feels primary to them.

“If people don’t feel safe coming to get medical care for what they see as primary and what their priority is, we can’t get them in for all the other types of care, too: preventative care, cancer screenings, chronic disease care, reproductive and sexual healthcare,” Nguyen said.

“We want to make sure we’re allowing people to access all of those things,” she added. “I think when we think about primary care, we have to really think about what is primary to the patient.”

It’s difficult to quantify the state’s shortage of medical professionals who provide gender-affirming care.

The UNM Health Sciences Center — the largest teaching hospital in New Mexico — was the only major healthcare system that provided The New Mexican with the number of physicians who perform such care. Spokesperson Chris Ramirez said UNM has about 20, but many more are trained in the care because it touches so many areas of medicine.

“For many, this type of care is as essential as any other type of healthcare,” Ramirez said.

Presbyterian Healthcare Services — where Johnson receives care — did not provide a number of physicians who offer it.

“At Presbyterian, we strive to create an environment where patients feel safe, respected and supported when seeking care,” Presbyterian Chief Medical Officer Dr. David Arredondo said in a statement. “We support our patients’ ability to access care that aligns with their health needs and honor the relationship between a provider and a patient to determine each patient’s individual care plan.”

Lovelace Health System declined to comment, and Christus St. Vincent in Santa Fe did not respond to an inquiry.

The federal Indian Health Service, which has several clinics in New Mexico, including in Santa Fe, does not offer gender-affirming procedures, according to a spokesperson for the U.S. Department of Health and Human Services, which oversees IHS.

“HHS continues to fight to protect America’s children from irreversible harm outlined in the Department’s peer-reviewed report,” the spokesperson wrote in an email. “These detrimental procedures do not meet professionally recognized standards of health care, and practitioners who perform sex-rejecting procedures on minors would be deemed out of compliance with those standards.”

Ramirez confirmed there are no surgeons at UNM Health who provide gender-affirming surgeries — like chest feminization or masculinization or genital reconstruction.

Patients who wish to pursue these procedures often have to travel outside New Mexico, Lawyer said, although some insurance companies will cover surgeries in another state if there are no in-network providers.

“There are providers in Texas, actually, and in California that we know of who have utilized their billing and administrative staff to become in-network providers with New Mexico insurers because they know there’s not a provider here,” Lawyer said.

For people who have moved to New Mexico from other states, establishing care here can be turbulent.

Florian Knowles, a 22-year-old trans man and reporter at KUNM, moved from Aurora, Colo., to Albuquerque a few years ago to attend UNM. Since his insurance is based in Colorado, he has had to choose between visiting a Planned Parenthood site in Albuquerque and making a trip back to his hometown to continue accessing testosterone therapy.

He started gender-affirming care at a Planned Parenthood clinic in Colorado during the summer break between his freshman and sophomore year of college. At the time, the Albuquerque clinic didn’t have a doctor on-site who offered the care, he said.

“It was kind of luck, almost, that I was able to get my foot in the door,” Knowles said.

Now a permanent New Mexico resident, he’s set his sights on trying to find a primary care provider in Albuquerque who is comfortable with gender-affirming care.

“I feel like I have to spend more time and energy trying to find my way through the maze in the system,” Knowles said. “I just want to have a doctor, go to get my testosterone, do my blood tests and all that, but with moving and insurance and potential shortages here, it just feels like almost an uphill battle.”

His fear, he said, is that he’ll be stuck in the looking-for-care limbo forever.

“If it gets too expensive or it’s too unreliable with my healthcare providers, I might have to stop, at least for a little bit,” Knowles said. “And I don’t want to do that.”

Insurance coverage for gender-affirming care has become increasingly precarious for people of all ages across the nation. At the beginning of the year, such services were no longer considered an “essential health benefit” covered by federal Affordable Care Act-compliant plans, according to health policy organization KFF.

“For such a long time, it was a problem that insurance didn’t pay for these things, and in the current moment … the insurance companies are toying with and even trying out strategies to exclude the care,” Lawyer said.

In New Mexico, Blue Cross Blue Shield of New Mexico and UnitedHealthcare insurance plans offered through the state’s BeWell marketplace started to block coverage for so-called “sex-trait modification” procedures.

“More and more people I know are talking about their insurance providers dropping it altogether, greatly reducing it or saying, ‘We’ll provide it, but you now have to do all the copay until you reach the max amount of out-of-pocket funds and then we’ll cover it, only,’ “ Johnson said. “So, it’s getting prohibitively expensive to exist.”

Insurance companies can also deny coverage of the supplies needed for injections, a common mechanism for hormone replacement therapy. Only one pharmacy in Albuquerque provides needles and syringes over the counter, Johnson said, so many people have to get the supplies through a prescription.

“Over Christmas, I was running out of my injection supplies, and I went to the pharmacist and they said, ‘No, insurance has denied you; they will not refill it for another two weeks,’ ” Johnson said. “And I was like, ‘OK, well, I’m out.’ ”

Without insurance coverage, the cost of hormones can quickly add up.

Depending on the form, the price of estrogen can range from less than $20 per month to more than $800, according to GoodRx. The price of testosterone can range from about $40 per month to more than $500.

Knowles said his insurance would not cover testosterone until his primary care provider officially diagnosed him with gender dysphoria and deemed his use of it necessary.

When he first started hormone replacement therapy, a gel form of testosterone cost about $60 out of pocket.

Zamora said getting insurance to cover her hormone replacement therapy was a yearslong “nightmare.”

She started medically transitioning in 2021 when she was a student at UNM and still on her parents’ California-based insurance plan, which included care away from home.

The issues began when the California insurance branch and the New Mexico insurance branch did not properly communicate, Zamora said. In the beginning of a person’s hormonal transition, healthcare providers require lab work as often as every three months to monitor hormone levels, and without insurance, the testing can cost hundreds of dollars.

“There were insurance claims that just vanished,” she said. “There were insurance claims that each of them said the other would pay for. There were just flat-out denials that were for no reason — they were just denied. I literally had to spend years trying to go back and forth with them, trying to get coverage on some of these bills, because they’re not cheap labs.”

Eventually, Zamora and her mother had to get the New Mexico Office of the Superintendent of Insurance involved.

“At the time, I was a student. I was going through so much. I was in junior year — the hardest year of an astrophysics degree — and I had a lot on my plate,” she said. “At the time, I was kind of sick of it, and I was pretty much ready to give up.

“The only reason I didn’t is because, thankfully, my mom’s very supportive and very positive,” she said, “and whenever I was just too tired, too busy, too anything, she kept pushing to get all this taken care of.”

Johnson said she saw “the writing on the wall” a couple of years ago and decided to start buying estrogen from an online gray market producer. She takes estrogen and progesterone — the latter of which is harder to get online.

“The pharmacy had the prices set prohibitively high, in my opinion, for the vials of estrogen from an actual prescription,” she said. “So, I went and found several gray market sites, and they’ve been doing great for me. I buy it off there; they ship it to me; I inject, and it’s fine.”

It’s crucial, Johnson added, to make sure these sites are reputable and the people running them are trustworthy.

A 2019 study found nearly 1 in 10 trans Americans received their hormones from gray market sites, which don’t require a prescription or insurance. These sites are unregulated and often based in other countries.

An online pharmacy based in the island nation Vanuatu offers different forms of estrogen ranging from 48 cents per tablet to $151 per milliliter. Doctors have sounded the alarm about potential risks associated with gray market use, from improper dosages to injection-site infections.

Nguyen said she wants people to be able to access the care they need, but she emphasized the importance of monitoring the side effects of hormones on patients through lab testing.

“That’s always a risk-benefit conversation that I have with patients,” she said. “They know that some of these medications have other side effects, and it’s really up to them what kind of risk they’re willing to take for the benefits. But I would like them to know what they are, and you often can’t do that without some lab monitoring.”

Some patients take gray market medications for breast augmentation that can have significant long-term side effects, Nguyen said, especially if a provider is not monitoring them in person.

“I want to be mindful of the fact that when we don’t have access, people need to do what they have to do,” she added. “And that’s why it’s important to provide safe and regulated access.”