The law is taking effect as tens of thousands of trans people and their families are moving to places like Oregon from states that have restricted gender-affirming care

By Jake Thomas, Oregon Capital Chronicle

Two years ago, Oregon lawmakers hailed the passage of legislation meant to ensure that costs or red tape would no longer keep transgender Oregonians from medical treatments that would ease their transitions. 

Supporters including state Rep. Travis Nelson, D-Portland, even said the new law would help save lives of a population at a higher risk of suicide. 

“Transgender Oregonians are still to this day forced to wait years for the care they need, and, in some cases, are unable to afford care that is not covered by their insurance plan,” Nelson said on the House floor, noting that many medical organizations recognize such care as medically necessary and evidence-based.

Two years later, that law’s promises are colliding with a scarcity of medical professionals able to provide gender-affirming care and a federal government openly hostile to transgender people.  

The law is taking effect as 160,000 trans people and families are leaving states that have restricted gender-affirming care for places like Oregon, according to an Oregon Health Authority policy committee focused on health disparities.  

In response, state authorities completed their first look earlier this year into whether the state has enough gender-affirming care providers to meet what’s expected to be a growing need. That look focused on the state’s Medicaid-funded Oregon Health Plan, which covers about 1.4 million people, and revealed no clear answers about whether there are enough of these providers, documents obtained through a public records request show.

A bigger problem is that Oregon does not have enough medical professionals to provide gender-affirming care, according to a state report released in January. While the report found no data about the number of gender-affirming care providers in Oregon and their qualifications, it found evidence that rural Oregonians had more limited access and that waitlists for surgeries can last years.

That aligns with what Basic Rights Oregon, the state’s leading LGBTQ+ advocacy group, hears from transgender people about difficulties finding providers and long wait times, said Seth Johnstone, the group’s transgender justice program manager, in an email.

“This can and does have incredibly harmful impacts, including to the physical and mental health of our community,” he said, adding that trans Oregonians face higher rates of violence while struggling with housing and jobs because of mismatches between their identity and appearance. 

HB 2002 is also at risk of getting caught in the national political crosswinds before it can take hold. State health officials have launched efforts to increase the number of gender-affirming care providers as the Trump administration seeks to reduce the availability of care, particularly for minors, by trying to withhold funds, sending ​​subpoenas to clinics and threatening prosecution.

“As a trans person and as someone trying to advocate for trans people, it’s a profoundly terrifying time living in America,” said Jenn Burleton, a longtime Beaverton-based advocate and consultant who founded the TransActive Gender Project, an organization that provides support services to families and consulting. 

One family’s journey

HB 2002 has been a source of relief for one parent who moved to Oregon with her family in 2023 after feeling increasingly under attack in her home state of Texas. 

The parent, who requested anonymity for fear of persecution, said she and her husband knew they had a transgender child when the youngster was around 4. At first, the parent thought her child was confusing an interest in the color pink and princesses with being a girl. 

“Oh, honey,” the parent recalled saying. “You don’t have to be a girl to like girl things.” 

On the first day of kindergarten, another student shamed the child after she put on a purple dress from a box of costumes during play time. The child appeared sad and withdrawn after coming home, the parent said. When at home, the child would wear a scarf around her head as if it was long hair, and was happier during the summers when she didn’t have to keep up the performance of being a boy. 

As the start of second grade approached, the child became withdrawn and quiet. The parent recalled how one evening before the school year, the child approached her and said, “I know I am a girl who likes girl things.” 

“And she just held my stare, and it was obvious to me that she meant what she was saying,” the parent said. 

The school’s counselor, vice president and teachers supported the child socially transitioning to a girl, and the kids got used to the idea, the parent recalled. 

But state leaders weren’t so supportive. 

Texas Gov. Greg Abbott in 2022 directed child protective services to investigate parents of children who receive gender-affirming care, including hormone treatments, drugs that delay the onset of puberty and surgeries, which research has found to be very rare. Over the objections of major medical associations, Abbott signed a bill a year later banning those treatments for minors. 

By then, the family had left Texas, having moved to Oregon in 2022. The  parent said they no longer felt safe living in Texas and wanted her child to grow up in a place where she wouldn’t be discriminated against for being herself. 

Gender-affirming care in Oregon

Gender-affirming care applies to a broad range of medical and psychological treatments for people deeply distressed from the incongruence between the gender they live as and the sex assigned at birth. Those treatments can include counseling and hormone therapy, as well as surgeries for reducing the prominence of the Adam’s apple, facial feminization and sex reassignment. 

Virtually every major medical group — including the American Medical Association, the American Academy of Pediatrics,  the American Psychiatric Association and the Endocrine Society —  recognizes the care as medically necessary, including for minors. 

HB 2002 requires private and Medicaid insurers to cover a range of gender-affirming procedures and to have provider networks with enough medical professionals who can provide that care. 

Earlier this year, the Oregon Health Authority gave the state’s 16 regional Medicaid insurers known as coordinated care organizations initial feedback on the number of gender-affirming care providers in their networks.

That feedback, obtained through a public records request, shows that coordinated care organizations did not know how many of their members required gender-affirming care, and the authority directed them to find out.

Oregon is home to roughly 23,000 transgender people, including 3,000 minors, according to a 2022 estimate by the Williams Institute at the UCLA School of Law. A 2015 survey found that 12% of transgender Oregonians were unemployed and nearly a third lived in poverty, increasing their eligibility for Medicaid. 

Counting how many people need gender-affirming care in each network is complicated by rural residents being less likely to come forward out of social stigma even though they need the care, Burleton said. 

“Providers will say, ‘We don’t have these people,’” she said. 

Records show a wide and unexpected variation in the number of gender-affirming care providers in their networks. For instance, AllCare, which serves rural southwest Oregon, had more than 2,000 gender-affirming care providers — twice as many as HealthShare, which serves the Portland area. 

Coordinated care organizations either did not respond to questions or declined to comment. 

The Health Authority did not make anyone available for an interview despite repeated requests. A spokesperson said in an email that the Health Authority directed coordinated care organizations to determine how many of their members require gender-affirming care. By early next year, the authority and coordinated care organizations will determine if they have enough providers to meet demand, the spokesperson said. 

Those that don’t have enough providers will get advice from the Health Authority on how to boost their numbers, the spokesperson said. That can include expanding training or contracting with more providers. 

Costly delays

Burleton said she couldn’t get gender reassignment surgery until she was 45, after living for over two decades as a woman. Insurance didn’t cover it, so she paid thousands of dollars out of pocket. 

HB 2002 seeks to do away with costly delays in care like that. While Burleton supports the law, she said she worries it’ll be like someone offering to pay to fix a car without enough mechanics. 

Health Authority Director Sejal Hathi wrote in a letter last year to the Oregon Health Policy Board that it is “essential for Oregon to prioritize” the availability of gender-affirming care. Since then, a state workgroup has outlined initial strategies to increase provider training and to make medical settings more welcoming for transgender patients. 

But Johnstone, of Basic Rights Oregon, said his group’s work “has completely shifted since the passage of HB 2002” in response to the Trump administration’s efforts to “dramatically decrease the number” of providers. 

“Access to critical health care has been completely undermined by the Trump administration,” he said. 

Clinics and hospitals in Chicago, Los Angeles and elsewhere have paused some gender-affirming procedures for patients under 19. 

Oregon Health & Science University and Legacy Health — two of the state’s largest gender-affirming care providers — have stated publicly they have not made any changes to services in response to the Trump administration. However, Kaiser Permanente, another large provider in Oregon, announced it would halt gender-affirming surgeries for patients younger than 19 starting in August. 

Burleton said there needs to be more provider training to help them deliver gender-affirming care. But she said fewer providers are interested because they are worried about being targeted by the Trump administration. 

“The fear factor has been added on to the scarcity of providers that has always been there,” she said.  

One woman’s story

Jenn Burleton, 71, said she started to realize she was transgender in 1966, when she saw a book for sale in a drugstore by Dr. Harry Benjamin titled “The Transsexual Phenomenon.” Burleton stole the book and read it cover to cover. 

Months later, she read an article in the local paper in Milwaukee about Johns Hopkins Hospital opening one of the country’s first transgender care clinics.

Burleton figured that doctors would help her with the discomfort she felt from her male body. So one day, she stayed home sick from school and took the bus wearing one of her mother’s dresses and heels to a hospital across the city. 

She recalled the heels clacking against the marble floor as she walked to the psychiatry department’s front desk. She plopped down the book and the article and said she was ready to start treatment. Hospital staff instead called her mother to the hospital, where a doctor said she should be referred to child protective services. 

“I was so filled with desperation,” Burleton said. She recalled dreading the bodily changes of puberty that “were going to take me further away from being able to be perceived by people as a girl.”

As an adult, Burleton said, getting hormones and other treatments meant being a “guinea pig” at clinics in Chicago and Nashville that were researching what would become known as gender-affirming care. 

Jake Thomas is a Portland-based journalist who has over a dozen years experience mostly working at newspapers in Oregon and Washington. Along the way, he’s won multiple awards for in-depth reporting and breaking news. This story previously appeared in the Oregon Capital Chronicle.