Barriers, burnout, and resistance: Trans Kentuckians and the fight for healthcare

When clients walk into one of psychotherapist Sebastian Hamilton’s Louisville offices, they enter a cozy haven filled with soft lighting and pillows, nature posters, art supplies, and baskets of fidget toys. A linocut art print hanging on the wall features the Mary Oliver quote: “You only have to let the soft animal of your body love what it loves.”

Hamilton, whose pronouns are he/they, strives to create the kind of supportive environment he experienced with a trans mental health professional when he was exploring his own gender identity. This work has been complicated over the past year amid growing anxieties about state and federal anti-transgender legislation.

Hamilton, who became a Licensed Clinical Social Worker in 2023 — the same year the Kentucky state legislature passed a sweeping ban on gender affirming care for minors — said, “I’ve been seeing an increase in anxiety and exhaustion, especially since Trump’s second term. I see a lot more hopelessness and weariness.”

He has also seen a rise in the primary contributing factors that lead to suicidal ideation: perceived burdensomeness and thwarted belongingness, which he attributed to “this administration’s policies and the ways the administration has made local communities feel less safe for us.”

“I see people at all stages of their transition journey, and there is still so much joy in our community, so much strength. But sometimes, the joy is harder to access because of the ways things are impacting us on the interpersonal and national level when we have new, harmful legislation coming at us daily,” he said.

The impact on trans health and healthcare

2025 marked the sixth consecutive record-breaking year of anti-trans legislation. In Kentucky alone, 18 bills were introduced, including KY HB 495, which banned Medicaid from covering trans healthcare.

In this environment, patients seeking gender-affirming care, such as hormone replacement therapy (HRT) or surgery, are nervous about medical documentation. Colby R. Loew, MD, whose pronouns are she/they, is a queer family medicine physician in Kentucky who is passionate about trans healthcare.

“I love getting to care for my people, my community. I love getting to care for people who, in the past, maybe weren’t so excited about going to the doctor or who were too nervous to even access care,” she said.

However, over the past year, she has noticed increased anxiety in her gender diverse patients regarding medical documentation of pronouns, gender (if it differs from the one assigned at birth), and gender dysphoria.

As a result, Dr. Loew has also become more cautious about the medical codes she uses when charting. Medical codes, or ICD (International Classification of Diseases) codes, are part of an alphanumeric system for documenting patient symptoms and diagnoses.

Loew told Queer Kentucky, “I haven’t really even been using gender dysphoria much as a code because I don’t need to document it that way. I just use hormone replacement therapy.”

Loew sees this as less of a risk. While a diagnosis of gender dysphoria could identify a patient as transgender, cisgender people also receive hormone replacement therapy, such as cisgender women who take testosterone during menopause.

The U.S. Department of Justice’s July subpoena of medical records related to trans healthcare from over 20 healthcare institutions demonstrates that these records are not private or safe from government overreach. Additionally, given the government’s classification of trans people as “Nihilistic Violent Extremists (NVEs)” and extremists who adhere to “radical gender ideology” as seen in a leaked Intelligence Bulletin and a DOJ memo first published by independent journalist Ken Klippenstein, the hesitation to have one’s trans identity documented in medical records makes sense.

“People are scared. They don’t want the government to know they are trans. They don’t want the government coming after them,” Loew said.

Loew mentioned that she also practices more caution when recording names and pronouns in medical charts, asking patients, “Is it okay if I put this on your chart?” Loew explained that “a lot of people are still like ‘hell yeah!’ but lately I’ve had more people saying ‘maybe not right now.’”

Ari, whose pronouns are they/them, is a Louisville-based genderfluid death care worker who spoke with Queer Kentucky under a pseudonym for privacy and safety. At recent doctor’s appointments, they have felt anxious about documentation — not just as a trans person, but as the child of an immigrant navigating a political climate that has targeted multiple minorities at once.

“Some of my anxiety over visiting doctors is not ‘Will I be treated poorly?’ It is ‘Will I be notated in a way that’s going to come back to bite me in the ass later down the line?’”

When a doctor recently switched their name in the system to “Ari (they/them),” it showed up on their prescription. “That partially makes me happy, but also puts up more question marks than anything else. Does this feel safe to me right now?”

Barriers to access

Genderqueer photographer Emmett Valentín, whose pronouns are they/them, is no stranger to that discrimination. During their teen years in foster care in Kentucky, the state forced them to take birth control despite negative side effects. They suffered from severe endometriosis and PCOS for years before opting for sterilization as treatment. Valentín’s Indigenous identity compounded this mistreatment, they said, recalling America’s legacy of reproductive violence against Indigenous, Black, and marginalized communities.

When Valentín began pursuing HRT, they faced invasive questions, unnecessary testing, and pressure to recount their trauma. “I was terrified of having a health care provider be shitty to me because I’ve had enough healthcare trauma from being assigned female at birth.”

They explained that when they switched from the gender-affirming online prescription service FOLX to an in-person endocrinologist, “She did the whole ‘tell me about all of your trauma,’” to which Emmett replied, “I’m not doing that. You’re not my therapist. I’ve been on this for two years now, and it’s doing great. I just need refill.”

“You have been singlehandedly, absolutely the most invalidating healthcare experience I’ve ever had, and I want you to sit with that.”

Trans Kentuckians fear experiences like Valentín’s and Tammy’s could become more common with threats to federal funding for institutions that provide gender-affirming care and empowerment from state and federal governments to deny such care.

Medical providers across all levels have felt the chilling effect of these federal and state level threats. However, both Hamilton and Loew, the mental health and medical providers who spoke with Queer Kentucky, stressed the importance of not caving in to threats or executive orders, which are not legally binding.

Lack of trained physicians

Dr. Loew told Queer Kentucky that trans healthcare was not part of her medical school curriculum. During her residency, supervising physicians were often unwilling to prescribe hormones to trans patients. “It depended on who was there with me as my supervising physician on whether the patient could get what they needed,” she said.

Research corroborates her experience. While studies show that many medical schools do discuss the topic of transgender healthcare, a 2023 study from the Baylor University Medical Center found that this coverage is not comprehensive. A 2025 study with the Journal of Medical Education and Curricular Development found that medical education on transgender health is now at heightened risk of inadequate preparation for future physicians in the wake of Executive Order 14168.

Loew disclosed that much of her trans healthcare practice has been self-taught. “The minute I could get my DEA so I could prescribe testosterone, I did.” A DEA, or Drug Enforcement Administration number, allows medical providers to prescribe controlled substances like testosterone.

Tammy, a Louisville resident whose pronouns are she/her, asked to use a pseudonym for safety. At a recent appointment, a nurse questioned how she had breasts without implants, asked how to spell “vaginoplasty” multiple times, then swiveled her chair around and asked, “How do they do that?”

Tammy tried to keep it light: “You should probably ask my doctor. I wasn’t paying attention at the time.”

Years earlier, an endocrinologist told her, “Oh, I guess the estrogen is working” — apparently unaware that estrogen does not eliminate active facial hair follicles, and many trans women like Tammy use electrolysis or laser hair removal to eliminate unwanted body hair. “This wasn’t even just a primary care physician. He was an endocrinologist. At a basic level, he should know how different hormones impact the body, and he just didn’t.”

“I’m not surprised by the lack of education anymore. I’m just tired.”

Trans Kentuckians refuse to disappear

Despite everything, many trans Kentuckians are hopeful — and organizing.

“Trans people are the least nihilistic people I know,” said Jaz Brown, whose pronouns are he/him. Brown started hormones in March and had top surgery in November. As Trans Health Coordinator for the Kentucky Health Justice Network, he helps people buy binders, apply for medical grants, find housing, and pay electricity bills.

Brown urged those struggling to afford care to apply for a grant through KHJN, and drew on a longer history of resistance: “None of this is new. People need to look to their Black elders, their Black trans elders. The government is not going to save us. Organizations are not going to save us. Nonprofits are not going to save us. We have to save ourselves and each other.”

“I think that anticipatory compliance is what the federal administration” wants, Hamilton said. He continued, “Let’s see how many threats we can make to get people to do what we want to do without actually making it a law. Because some of this, we know, if it’s thrown to the courts is going to be thrown back out.”

Valentín finds empowerment in activism. Arrested in 2023 at the Kentucky state capitol while protesting KY SB 150, they shared their mugshot — wearing what they call a “shit-eating grin.” “I would love to see a full socialist revolution in my lifetime, and I am doing all I can to gear towards that.”

Ari hopes to begin microdosing testosterone this year. They limit media consumption, root themselves in community, and draw perspective from their Chinese identity. “This is the year of the Fire Horse. Fire Horse years historically have marked a disruption of the existing order. The last time this cycle occurred was in 1966, the start of China’s Cultural Revolution.”

Looking to past epochs of political upheaval and change is a stirring reminder to trans people, cisgender members of the queer community, and LGBTQ+ allies that oppressors do not grant freedom to the oppressed. Instead, the people must unite, build coalitions, and seize their rights through collective action.

As Leslie Feinberg reminds us in Trans Liberation: Beyond Pink or Blue, “Genuine bonds of solidarity can be forged between people who respect each other’s differences and are willing to fight their enemy together. We are the class that does the work of the world, and can revolutionize it. We can win true liberation.”