For transgender Coloradans living outside Denver, gender-affirming care comes with added barriers

Mar 17, 2022

DENVER — As tears trickled down his face, Xavi Saenz asked himself why it took 43 years for him to live authentically as a transgender man.

Born and raised in the small, conservative town of Delta, Colorado, Saenz identified as a lesbian woman for most of his life. The title fit him while he presented as a woman, but he still felt something was missing.

At a Delta LGBTQ+ pride event, Saenz spoke with a doctor who asked if he knew anyone interested in transitioning. Finally, Saenz felt something click for him.

“I lived my life not feeling normal, and then finally, it was like ‘this is where I belong, this is who I am,’” Saenz said. “I finally had the information that the rest of the world does.”

A revelation of understanding

Soon after the pride event, Saenz began hormone replacement therapy, the process for transgender people to take necessary hormones to help affirm their gender identity.

While Saenz said the decision to take hormones was immensely helpful for his mental health, he faced even more discrimination than he did when he presented as a woman. Those around him called him slurs while he walked around town, and other doctors refused to respect his new name and pronouns, leading him to seek community connection in larger cities further away to feel understood. As a Mexican man in a predominately white city, Saenz said his race and gender often intersected and created deeper issues with those around him.

Other transgender residents in rural parts of Colorado shared similar stories, explaining a feeling of not belonging in their assigned gender at birth, and also not understanding other options existed for them.

Wulf Wilhelm, a nonbinary person in Steamboat Springs who uses they/them pronouns, did not understand they could begin exploring their gender until they were 25 years old due to the lack of education around gender and sexuality in the rural city.

“I didn’t even know that people were gay until I was like 14, and it was like a crazy revelation,” Wilhelm said. “There was no education, so we didn’t know that people could be trans, that people could be nonbinary and we had no language to question our gender.”

Many of Wilhelm’s friends are in similar boats — exploring their gender identity after years of not feeling complete — which is how Wilhelm has received education and resources about their options, though they have not begun any process of medically transitioning. Without friends, Wilhelm said they would feel lost as a nonbinary person in a sea of cisgender people.

“I wish there was education for everybody so that it was more acceptable and seen as a health issue,” Wilhelm said. “This is important, and there should be funding for it and access to it. People shouldn’t be judged for wanting to pursue hormone therapy.”

Barriers to access

When R., a transgender man in Fort Collins who asked to be identified by only the first initial of his name for safety and privacy reasons, realized he was transgender and wanted to begin the process of seeking hormone replacement therapy, he knew his options were limited due to his bare-bones insurance, which was not yet required to cover any of his transition process. A bill signed into law in 2021 now requires private insurance companies to cover gender-affirming care.

R. knew his only option was Planned Parenthood, which charges sliding-scale fees — fees adjusted based on a patient's income — for all of its services, and would work with him regardless of his insurance. While Planned Parenthood has an office in Fort Collins, the only two offices where it offers gender-affirming services are in Denver, according to the organization’s website.

While the sliding-scale fees helped, R. said he still paid $400 each time he had to get his blood work done to keep being prescribed hormones, which was every three months for the first two years, but is now only once or twice a year. In addition to expensive bloodwork, R. paid $20 for each vial of hormones — which lasted him four weeks — and drove 126 miles roundtrip from Fort Collins to Denver. Overall, R. estimates he has spent close to $1,000 on gas, doctor’s visits, prescriptions and bloodwork.

“That’s been a huge issue for me,” said R., who just obtained a master’s degree and said he is struggling with other expenses in addition to what he described as lifesaving medical costs. “There needs to be a better way to make sure everyone can get this.”

Other transgender people who live outside the Denver metro area said they did not even consider asking their doctors about hormone replacement therapy and other gender-affirming care for fear of being judged or mistreated by the doctor.

“When I get medical care in Colorado Springs, I don’t even tell the doctor my pronouns because a lot of times, you don’t get as good of treatment if you say that you’re trans, so it’s rough,” said Sarah, a nonbinary person in Colorado Springs who asked not to have their last name published. “It just seems like there isn’t a lot of access in all of Colorado outside of Denver.”

Because Colorado Springs leans more conservative, Sarah said they are careful before sharing their pronouns or identity with a new person, including doctors and other health care workers.

“Hypothetically, I guess I could have asked my doctor if she could prescribe hormones to me, but I’m not sure how she would’ve reacted,” Sarah said. “You kind of have to go to Denver if you live anywhere else.”

Still, Sarah, who is white, said their skin color has protected them from potential harassment and violence, which they said may not be the same for other, more marginalized members of the LGBTQ community.

“I recognize a lot of my experience of not feeling unsafe is white privilege,” Sarah said. “I don’t have to worry about walking down the street and getting murdered if I look queer, but trans women and people of color might feel differently.”

Trying creative solutions

When Glenwood Springs resident Ashley Stahl realized she was a transgender woman, she knew her options for care and community would be limited in the small city of about 10,000 people.

After searching the internet for options of where to begin mental health treatment and hormone replacement therapy, Stahl came across FOLX Health, a virtual platform that provides medical care for LGBTQ folks in need of service who cannot access it in their areas. The service employs medical doctors who can provide all the same services a local, in-person doctor could.

“It was really nice to have that available,” Stahl said. “It’s a little harder to communicate because it’s not in person, but it was a great way to start out.”

FOLX prescribed Stahl hormones, but she still had to visit the UCHealth Integrated Transgender Program in Aurora once every three months to get her blood drawn, a six-hour roundtrip drive from her home in Glenwood Springs.

After getting more comfortable with UCHealth staff, Stahl said she began visiting them for surgical procedures, which she has appreciated.

Overall, having face-to-face contact has been beneficial, Stahl said, but the time and cost of driving back and forth from Aurora has added up.

“I think cost is a big element that people don’t always think about,” Stahl said.

While Stahl said she has good insurance, she has had to drive to Carbondale (about 20 minutes from her home) and Grand Junction (about an hour and 20 minutes) for mental health care and laser hair removal, as the closest LGBTQ therapist was in Carbondale and the closest gender-affirming laser hair removal specialist was in Grand Junction.

Stahl described Pitkin County, which she works for, as a progressive and affirming place, though it is home to Aspen, one of the most luxurious and expensive resort areas in the world, which has made the surrounding area quite expensive.

“You only have a few options here, so it’s hard to be picky,” Stahl said. “On top of that, this is an expensive area.”

The reward after the barriers

At 33 years old, Liana Aghajanian of Granby, Colorado, made what she called “the best decision of my life.”

After a lifetime of feeling unhappy in her assigned gender at birth, Aghajanian began reading Reddit posts about others in rural areas who felt the same way.

In Granby, a small town of about 2,000 people, Aghajanian had never met another transgender person, but knew her experiences matched those described by other transgender people in online forums.

“When I realized I was trans, it was kind of one of those revelations that this is information I’ll never forget," Aghajanian said.

Shortly after her realization, Aghajanian spoke to her primary care doctor about pursuing hormones. Aghajanian said the doctor was understanding and accepting, but was not trained in how to help patients with gender dysphoria, which the Mayo Clinic defines as “the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth.”

After one session with a psychologist, she began hormone replacement therapy with Denver Health, about 88 miles from her home in Granby. She later received multiple feminizing surgical procedures from UCHealth.

“This is the best thing I’ve ever done for myself,” Aghajanian said. “Really, it's a shame that it took me 33 years to figure it out.”

Because she is years into her transition, Aghajanian said she only has to do blood work once a year and meets with her nurse practitioner virtually for other needs, which has saved her time and money.

Still, Aghajanian said she wished her primary care provider in Granby, who she trusts and knows well, was trained on the topic.

“Unless the provider specifically pursues to gain that knowledge and actively treat these conditions, then they don't get that training,” Aghajanian said. “If I lost my provider at Denver Health, I don't know where I’d go for prescription refills and things like that, which is a little scary.”

The options available

Though driving to Denver is a disadvantage for many, Denver Health's LGBTQ+ Health Services has tried to make the process as easy as possible for those who are either in the area or are able to commute.

The health center has gender-affirming care providers in all of its federally qualified centers and several of its school-based clinics, as the center wants those who need care to be able to access it at their routine health center, as opposed to having to drive to a specialty clinic.

When patients interested in care come in, they are assessed for medical history, evaluated for gender dysphoria, counseled about the risks and benefits of hormone replacement therapy and left to make the decision for themselves. In addition to hormones, patients can also pursue various surgical procedures and other options for affirming their gender.

The length of time a patient spends on hormones is up to them, but most binary transgender people use hormones their entire life, said Dr. Liz Kvach, a medical doctor at Denver Health who specializes in LGBTQ services.

A study conducted by Denver Health and the University of Colorado School of Medicine found patients who did not live in the Denver metro area traveled an average distance of 83 miles to get care, while those who lived in the Denver area traveled only 11 miles.

To erase some of the distance barrier, Kvach said part of the health center’s goal is to get more providers cross trained on how to provide gender-affirming care, to ensure more folks have access to it outside of Denver.

“I think it’s just a gap in medical education,” Kvach said. “When you don’t have enough preceptors or faculty who are well versed and have experience to teach it, then it continues to be a gap in education for students and it then becomes a vicious cycle, because they don’t receive the training and there's nobody to teach it.”

While care in Colorado may have gaps, Ashley Browning, a transgender woman and the manager of operations at The Center on Colfax, said the care she has received in Denver far exceeds what she received in Kentucky, where she lived before moving to Colorado.

“There are a lot more resources, but the main issue I had here was finding them,” Browning said.

The center also offers Zoom support groups to transgender people across Colorado and its neighboring states, as well as keeps a list of providers offering care across the state.

Finding safety on the Western Slope

Aghajanian, Stahl, Saenz and Wilhelm each said they have to be careful of which cities and towns they visit, as some near their homes are often unsafe for transgender people.

“I feel really bad for people who live in Rifle; I can’t go near there,” Stahl said of the town where Republican U.S. Rep. Lauren Boebert — who has come under fire for offensive comments about many minority groups — was raised and made a name for herself.

Similarly, Aghajanian said she is careful to avoid the western side of Grand County.

“The places that are more worldly and tend to have more people around tend to be more accepting,” Stahl said.

Those "worldly" and more populous places on Colorado’s Western Slope tend to be home to ski resorts, which bring visitors from around the world and invite a greater diversity of people and ideas. These areas, however, also tend to be expensive, which Stahl said has caused problems for transgender people looking for services like laser hair removal, facial surgery and hair cuts from gender-affirming stylists.

“As far as the counties of the state go, Pitkin County is one of the more progressive ones,” Stahl said. “Which is great, but it’s also one of the most expensive ones.”

Saenz has built a community with other transgender people in Delta, but he said he refers them to Grand Junction — a 45-minute drive away — for mental health services.

“I shouldn’t have to send people so far away just to see a person so they don't kill themselves,” Saenz said. “It’s not fair.”

A national problem hitting home

While Colorado Gov. Jared Polis, a Democrat, has affirmed his support for transgender people, Republican Texas Gov. Greg Abbott recently issued an order calling for parents and health care providers who provide gender-affirming care to minors to be investigated for child abuse. A Texas judge last week blocked enforcement of the order. In Idaho, the state House passed a bill that would have criminalized gender-affirming care for trans children, but on Tuesday, Republican leaders in the Idaho Senate killed the measure.

Transgender Coloradans felt the issue came down to a lack of education about what options are available for transgender youth. Transgender youth are typically given puberty blockers, which temporarily stop the production of hormones that occur during puberty. When children turn 18, they can make the decision about whether or not to seek hormones or surgery.

“If lawmakers actually talked to people who were trans and knew about the process and what puberty blockers are, it might be easier for them to understand why, then, what they’re doing is not good,” R. said. “I think if you never really put a face or an emotion to something, then it’s easier for you to just say you don’t like it.”

While discriminatory laws are not being passed in Colorado, Saenz said such laws are emboldening transphobic behavior closer to home.

“Up until last year, I have never been scared to go to my own pride events,” Saenz said, adding that his group had never seen counter protests until its 2021 event. “I’m at a loss again, it seems every few years, my community gets beat up.”

Saenz, who also had a transgender child, said he is worried about his child being bullied at school or facing discrimination in other areas.

“We have so many different things that are hurting our kids, but the transgender community has been beat down physically and emotionally,” Saenz said. “Society has pushed us away.”

Browning said Colorado may not be able to control what happens in other states, but it can welcome those needing community and support into the state with open arms.

“We don’t know what's going to happen in all the states and we can’t control the outcomes,” Browning said. “But what we can do is tell them that they’re not alone and that we’re here.”

Ready to put up a fight

Saenz is beat down, frustrated and vulnerable, but he said now is more important than ever to stand up for his community.

“I’m ready to scream, I’m ready to be that sound board for the rest of the people to say we’re human, god made me special just the way that I am, and it’s time that we have a safe place,” Saenz said. “I will use every platform that I can to save our kids from the adults making the rules.”

Alison Berg is a multimedia journalist at Rocky Mountain PBS. You can reach her at alisonberg@rmpbs.org.