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This article was produced as part of the 2023 Data Fellowship.

Days before Texas Children's Hospital -- the last provider of gender-affirming care in Texas -- closed its doors to new patients, a pediatrician handed Jennifer, the mother of a trans teen, a list of more than 30 pediatric endocrinologists to start calling.

Jennifer's daughter, referred to as "Sarah" to protect her privacy, had come out as trans about a year earlier -- something that came as no big surprise for her parents. From childhood, thinking their child might be gay, Jennifer said that she and her husband had joked about when their child would come out to them.

Sarah's parents had made it clear from early on that no matter what, "We just want you to be happy," Jennifer said. "...Our kid never hesitated to say exactly what she felt when it finally occurred to her what was going on."

Now, at 17, after therapy, discussions with her parents, and online research, Sarah decided she was ready to begin a medical transition, something that would help her feel more at home in her body and mind. Every specialist her mother called in Texas turned them down until a receptionist told her that doctors had stopped providing gender-affirming care in anticipation of the new ban, months away from taking effect.

After more phone calls, two canceled appointments in two different states, and a plane trip months later, Jennifer and her daughter finally sat in front of a specialist in Albuquerque, New Mexico.

"She was amazing. I mean, honestly, just so high energy with us, so incredibly empathetic," Jennifer, a teacher in central Texas who asked that her last name be withheld, told 番茄社区app of the first visit. "We did not feel rushed with her.... We didn't have to wait 6 months or a year like we were hearing about clinics in Chicago and [Los Angeles, which] had year-long waiting lists."

Their doctor carefully reviewed the details of hormone treatment with them, including possible side effects. She explained how to pay for the appointment, and how to get the prescriptions.

Jennifer only paused when they were getting back on the plane to Texas, with her daughter's medication tucked away in her purse. "I thought, 'They're not going to search my bags, are they?'" Jennifer said. "I mean, I know it sounds so silly, but I just had this moment of panic where I thought, 'Is this like alcohol?' Like you're not really supposed to take alcohol across state lines."

Jennifer's family is one of many known as "medical refugees" who have had to jump through hoops to access gender-affirming care following a wave of legislation banning healthcare professionals from providing it.

Situated near Texas, one of the biggest "ban states," New Mexico has emerged as an unassuming safe haven for trans youth and families, enacting legal protections and preserving access to care despite few providers and limited resources. Existing support networks for trans youth in the state's denser areas also make life as a young trans person feel more normal than in most places.

According to the Campaign for Southern Equality's of bans on gender-affirming care, families from Nashville, Tennessee to Atlanta to Jackson, Mississippi must now travel upwards of 2 hours to receive gender-affirming care. Families of trans youth in Texas may bear the most extreme travel burden. Someone in Houston now has to travel 9.25 hours by car, or over 600 miles, to reach a clinic that serves youth.

Travel isn't an option for all families. The Campaign for Southern Equality's report estimates that a trip from Austin to Albuquerque to receive gender-affirming care, when accounting for airfare, a rental car, a hotel room, and meals, would cost nearly $900. This does not count wages lost if a parent must take time off from work without paid leave.

A 番茄社区app analysis of prescriptions for puberty-blocking medications showed a 16% decline in Texas in the 5 months after its ban took effect. The patients to "wean off the prescription drug" instead of stopping them abruptly, but not to switch to another one, if it was for gender-affirming care.

The analysis did not show a significant increase in prescriptions for puberty-blocking medications in New Mexico in the 5 months immediately following the Texas ban. This may be for a number of reasons, whether because of a lag in time to coordinate care in New Mexico or this "weaning" period; because the analysis did not capture certain prescriptions from non-pediatric specialties like family medicine and primary care, or because these medications were mostly being given for other indications.

Helping Out-of-Staters

Molly McClain, MD, a family medicine doctor at the University of New Mexico (UNM) and a provider of gender-affirming care, said the waiting list for out-of-state patients was more than 100 patients long by December 2023. Almost all of them, she added, were from Texas.

The confusion around the legality of crossing state lines for gender-affirming care meant patients and providers were afraid of unknown consequences, and reluctant to take risks.

One family, McClain said, was so worried that they bought a house in Albuquerque for the New Mexico address, not knowing that they didn't have to do that to access care. McClain has seen patients from Florida, Tennessee, and Ohio.

Luckily, UNM was ready for them, she said.

"UNM had worked really hard when the law came into effect in Texas to make it possible for people to come," McClain said.

The University's staff worked with their risk and legal department and finance departments to come up with a plan to help out-of-state patients. Because of uncertainty around insurance coverage, and without a system to bill insurers from out-of-state, they knew patients would have to pay out-of-pocket, and tried to lower the costs as much as possible. They broke down the charges for families ahead of time, and tried to find reduced hotel rates and other resources to accommodate traveling patients. They partnered with two pharmacies that were willing to ship medications out of state -- discreetly.

Ryan Harris, DNP, RN, unit director of UNM Southeast Heights Clinic, who worked to coordinate these measures, said that many places "would be like, 'Well, they're not citizens of our city, or of our state, and that's not our problem.' So [we're] really working for a forward-thinking institution, and then living in a state like New Mexico that allows this to still happen and has protected it by law."

"It was a really smart move on the part of UNM just to make it more transparent, and make it more of a system," said McClain. "They weren't just like leaving it up to us to take care of it on our own."

This was, in part, a reflection of a state that has taken extra steps to protect care for trans youth and adults.

Safe Harbor by Law

New Mexico is one of five states to enact "shield" laws in recent years, which protect from legal repercussions of both out-of-state patients seeking care and providers who are giving it. It's also sandwiched between two states that have outlawed this care: Arizona and Texas. From this unique position, New Mexico doubled down and passed two bills last year: one from civil or criminal liability related to gender-affirming care (and abortion) in the state of New Mexico.

This means out-of-state officials may not access information about New Mexico patients seeking this care, or interfere with the provision of this care. Another law from discriminating against people seeking abortion or gender-related care.

Adrien Lawyer, director of the Transgender Resource Center of New Mexico (TGRC), said his organization had also helped facilitate a number of other changes that make it easier to be trans in the state: the elimination of a surgery requirement to make changes to sex, and adding a third, undesignated option of "X" on birth certificates, which the Motor Vehicle Department also applied to licenses. TGRC also helped remove what's known as a "publication requirement" for name changes from state law.

But, Lawyer says, trans kids in New Mexico still have an outsized risk of suicide, as they do across the board. The New Mexico Youth Risk & Resiliency Survey, which is administered to public school students, found that the suicide attempt rate for kids who identified as transgender, genderqueer, or gender-fluid was 30.9% in 2019.

"As we become a shield state legislatively, at the adult level, hyper-local governmental bodies have become a battleground politically," Lawyer said, pointing to school boards that push for policies like parental notification, or outing a child to their parents without their consent.

These local bodies have become a target for enacting policies that pose risks for trans youth. "We still have to watch out for stuff like the APS [Albuquerque Public Schools] school board, to make sure that the district stays healthy in its treatment of this," he said.

A Personal Perspective

One young person who grew up and transitioned in New Mexico says there's still room for improvement when it comes to medical care in the state, but it's better than most.

Fion Alfson, 18, was born in northern New Mexico, near Taos, and then moved to Albuquerque, both relatively "big, queer" spaces, he said. Alfson went to a performing arts school, and as a small child, remembers having foam sword fights and climbing trees, but also wearing princess dresses. There weren't rigid expectations about gendered play.

Growing up, Alfson said, "It was never any big deal about trans-ness or queerness," although he didn't think either of those applied to him until around 12 or 13. Alfson came out to his parents around age 14, and considered hormones for more than 2 years before starting on testosterone, with his mom's permission.

"I was feeling pretty bad dysphoria, like just chest and voice sort of thing. And I was like, 'I am not doing great mental health wise, because these are a part of my body, and I can't change them, and this does not feel like me.'"

Alfson said he asked everyone he could find in the community about hormone therapy -- speaking with peers going through similar experiences, attending all three LGBTQ youth groups in the city, and speaking to his primary care doctor about what he was seeking from hormone therapy and how long it would take to see changes.

"All of that has to be discussed, and thought about, and talked about, and there's a lot going on that you don't even think about until you're there in your appointment and they're asking you questions," he said.

With help from the TGRC, Alfson found medical providers at the Southwest Care Center, which has services geared toward trans people, and an in-house pharmacy. They are "great with hormones, great with providing resources, whether that be mental health resources or clinical health resources," he said.

Eventually, Alfson changed his name legally, to reflect his Irish and Scottish heritage, and speaks matter-of-factly of hormones, fat distribution changes, facial hair.

The process wasn't without its own hurdles, including a pediatrician who early on kept misgendering him, calling him "a nice young woman," and a parent who couldn't get the pronouns down at first. Often, healthcare providers will scrutinize him much more closely at a visit unrelated to his hormone treatment once they realize he is trans.

"In non-trans-related healthcare, they make everything about you being trans," he said. For example, a doctor told Alfson a broken clavicle from a car accident might be healing more slowly because of the testosterone in his system. A friend of his who went in for a rash that had started before hormone therapy had clinicians who wondered if it was related to the injections.

Alfson doesn't take his access to gender-affirming care for granted. If he'd been in a state that passed a ban like Texas, "I would have probably, once I turned 18, tried to move out of those states into a state like New Mexico, where it's not necessarily 100% amazing, but it's a lot better."

Nearly 4 months after their first appointment in New Mexico, Jennifer says her daughter feels better than ever. She's anxious to finish high school, to get a summer job, and to begin her adult life. They have one more appointment in Albuquerque before Sarah turns 18 and can access care as an adult in Texas.

Jennifer's not too concerned about her daughter. Rather, she worries about how the rest of the world might misunderstand their family.

"Look -- we're a very boring, normal, middle class family, you know? We live in a cute little yellow house in a nice little neighborhood. And ... I just think people have this misconception that we are, you know, monsters in some way," she said. "We haven't done this to our kid. You know, we're not making her do anything. We have never put any ideas in her head."

She added, "We are your neighbors and your teachers."

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