As the safety net shrinks and political attacks worsen, trans Kentuckians pay the price

Mo Viviane

Sep 21, 2026

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This story was co-published and supported by the journalism non-profit, the Economic Hardship Reporting Project’s New Narratives Fund.

Evan is a white trans man from a rural town in the bluegrass state of Kentucky. He has a queer therapist who provides him with thoughtful and affirming care. His therapist has been a safe haven, he said, a space where he can honestly discuss his experience as a trans person in the South.

But Evan has had a hell of a time finding gender-affirming care in his small Kentucky town.

Like many other trans people who live in rural areas, he has turned to Folx, a virtual healthcare provider with LGBTQIA+ specialists who accept people without insurance. The membership-based platform offers primary care, gender-affirming care, therapy, and additional services for as little as $29 a month, plus the cost of medication, lab fees, and other typical healthcare expenses. 

Evan, who is only using his first name for safety reasons, currently drives nearly an hour and a half to see a specialist, though the costs of both travel and gender-affirming care add up. For example, top surgery can cost anywhere from $8,000 to $15,000 without insurance, and finding a specialist in Kentucky who will perform the surgery is another challenge. While organizations such as Kentucky Health Justice Network (KHJN) offer resources that identify healthcare providers across the state, most providers are based in larger cities such as Louisville and Lexington, remaining inaccessible for low-income trans Kentuckians in rural areas.

This is especially critical because access to gender-affirming care can be a matter of life or death. While there is no public data that tracks the number of trans people who die by suicide each year because they could not access gender-affirming care, there is plenty of research that confirms gender-affirming care reduces suicidality. 

According to Evan, there is no “readily available” gender-affirming care in his small town, such as hormone replacement therapy (HRT), for people who haven’t changed their gender marker. There is also no state law requiring an adult to change their gender marker to receive HRT. 

Prism contacted his town’s hospital for comment on whether the facility is misinforming patients of their right to access gender-affirming care. Hospital administrators did not respond by publication time.

Evan is 1 of 21,900 trans people in Kentucky—just 1% of the state’s population. This tiny, vulnerable population has faced an onslaught of anti-trans bills in the state. The reelection of President Donald Trump made Kentucky’s already dire landscape even deadlier for trans people. 

“A numbing experience” 

Kentucky’s House Bill 495, passed last year, nullified an executive order restricting a ban on conversion therapy and bans Kentucky Medicaid from funding certain gender-affirming care. Senate Bill 2, also passed last year, prohibits the Kentucky Department of Corrections (KY DOC) from providing HRT to the 67 trans people incarcerated in the state.

More broadly, the Trump administration also issued an anti-trans executive order last year defining sex in strict binary terms and cutting gender identity from federal protections across agencies. 

Then came Trump’s so-called Big Beautiful Bill (BBB), which imposed historic cuts to Medicaid by nearly $1 trillion. The law also changed funding and availability rules for Medicaid, the Affordable Care Act marketplaces, and the Children’s Health Insurance Program, which could affect access to healthcare that many trans people depend on. 

Today, a little more than a year after the budget bill was passed, nearly 446 hospitals are at risk of closure and funding cuts. Thirty-five of those hospitals are in rural Kentucky. According to a recent statement from Kentucky Gov. Andy Beshear, “The federal government laid out five models, and states were encouraged to follow those if they wanted to get approved. … None of those five models gave an opportunity to provide direct funding to rural hospitals. None.”

For a state that is 41% rural, and where 16.4% of the population live below the federal poverty level, Kentucky cannot afford to lose more providers. The confluence of state and federal anti-trans attacks and the Trump administration’s massive defunding of healthcare hits rural trans Kentuckians among the hardest—and this includes incarcerated trans people. 

Maddilyn Marcum is a 37-year-old trans woman incarcerated at the Northpoint Training Center, a medium-security prison that, according to sources incarcerated inside, houses a large LGBTQIA+ population. 

Last year, KY DOC revoked Marcum’s access to HRT as a result of Senate Bill 2. She sued the agency, alleging the law subjects trans people inside to cruel and unusual punishment and violates their Equal Protection rights. In September 2025, a judge for the Eastern District of Kentucky denied her request for a preliminary injunction and class-action status.

Earlier this year, hospitals such as Ephraim McDowell Health in Danville, Kentucky—the closest hospital to Northpoint Training Center—also faced funding cuts, just the first stage in what will eventually amount to $45 million in federal Medicaid losses over the next 10 years. 

KY DOC did not comment on the care or services that incarcerated trans people currently have access to. However, trans women inside told Prism that state and federal policies, coupled with continued impacts from the BBB, have had serious ramifications for their health.

“I have been at Northpoint Training Center for the past two years. When I first arrived, my health was in relatively good shape. But after being removed from hormones, I have had multiple issues [and] declining health,” Marcum said.

While Marcum does have access to mental health providers who offer therapy and medications to help treat the anxiety and depression she experiences due to gender dysphoria, SB 2 means that she cannot actually address her gender dysphoria with gender-affirming care. This is especially difficult when coupled with the general poor state of healthcare offered inside Kentucky prisons.

According to Marcum, to simply submit a “sick call request” to be seen by a nurse, people inside have to first visit the medical office at 6:30 a.m. Seeing the nurse then typically takes around five hours—and it’s not free. Marcum said incarcerated people must pay an out-of-pocket fee, though their request for medical care may be outright denied or deemed unnecessary by the nurse. In those instances, incarcerated people are typically referred to the canteen for over-the-counter medication, also at their own expense.

While it was already difficult for incarcerated trans people to advocate for themselves, Marcum said things have gotten exponentially worse, with some prison healthcare providers using her dead name during appointments.

“To have something so basic such as your name taken from you … it’s a numbing experience,” she said. “Deep down, I’m afraid this is the new norm.”

Jeanne, another trans woman incarcerated at Northpoint, is only using her first name for fear of retaliation. She told Prism that, though the prison’s mental healthcare is helpful to trans people, it amounts to little more than “moral support” and pales in comparison to the gender-affirming care they require. To help bridge some of these gaps, trans people inside have formed a gender dysphoria support group that meets monthly with one of the prison’s two psychologists.

Jeanne, who has been incarcerated at Northpoint for 20 years, also noted how understaffed the prison’s medical unit is.

“When they do manage to hire someone, it is always a nurse practitioner, not a doctor, and they only have one in a facility that should have at least three,” she said. “This lack of medical providers directly resulted in a delay for me to start hormone treatment, so I was only able to receive part of the treatment due to the pending [SB 2] ban at the time.”

Abruptly pausing HRT can be dangerous, resulting in rapid physical changes that cause severe dysphoria and trigger anxiety, depression, and symptoms similar to post-traumatic stress disorder, sometimes resulting in suicidal ideation.

“Intentional barriers” 

As part of a survey of LGBTQIA+ Kentuckians conducted by Prism, one anonymous respondent from a rural southeastern part of the state said that healthcare providers who are “explicitly welcoming” of LGBTQIA+ patients are few and far between. This is especially true now that healthcare facilities are shuttering due to the Trump administration’s budget bill.

The same respondent shared that their previous therapist was helpful for trauma recovery, but as they came out, their sessions felt “less attuned.”

“I would have to spend part of my session trying to explain something like what gender dysphoria means because she never had a client mention that before,” they said. 

Chris Hartman, the executive director of Fairness Campaign, an LGBTQIA+ advocacy organization, agreed that Kentucky’s trans community is facing “severe problems” due to the “many bad bills” the state has passed over the past five years. At the same time, Hartman said Kentucky lawmakers have specifically chosen to target “Medicaid for trans adults who relied on state Medicaid to cover HRT.”

National LGBTQIA+ organizations also struggle to bridge gender-affirming care gaps in states like Kentucky. Aydian Dowling, co-founder of Point of Pride, which provides financial aid and direct support to trans people in need of health and wellness care across the country, told Prism that the organization’s work in each state is impacted by local and federal legislation.

“We serve people in all 50 states, and each state having different legislation coming out means that the care for our HRT access program for somebody in Florida, for instance, looks greatly different than somebody in Michigan,” Dowling said, noting that for LGBTQIA+ people in rural areas, there are additional hurdles. “They’re not close to any big cities, and they’ve got to get there. What if they don’t have a car?”

Advocates say anti-trans policies are designed to implement overwhelming barriers to accessing gender-affirming care so that people simply give up. But for some trans Kentuckians, these barriers are having the opposite effect: It’s pushed them to take their healthcare into their own hands. 

“Do it yourself”

Jaz Williams, a Black biracial trans disability organizer in the state, told Prism that the lack of healthcare infrastructure in Kentucky creates a backlog, even for primary care. He said he was told by his local healthcare facility that it would take nearly three months just to get an appointment with a primary care physician to discuss HRT. So, he figured things out on his own.

“I started testosterone DIY,” he said. “I couldn’t wait—and when I say ‘I couldn’t wait,’ I needed it for my mental health.” 

Within three days of obtaining testosterone gel, Williams said “all of the impending sense of doom and depressive symptoms” he previously felt “went away.”

Historically, trans people have utilized mutual aid, do-it-yourself (DIY) approaches, and underground clinics to access HRT and other forms of gender-affirming care. While some find these approaches empowering, they can also be risky—and these efforts are not “a strategic answer to transphobia.”

Nevertheless, there are now even DIY HRT guides from reputable organizations to help mitigate these risks, and some trans Kentuckians are discreetly sharing strategies to assist their community in safely accessing DIY healthcare resources, from needle exchanges to community hormone therapy information sessions. 

As various states implement new criminal penalties tied to various aspects of trans life, participants in underground efforts are, in some cases, taking a significant risk. But some feel as if they have no choice, given how severely state and federal policies exclude trans people from healthcare access.

Knowing these barriers, the need for resources such as KHJN’s Trans Health Program—which offers $5,500 in funding to trans people in need of care each month—has recently exploded. But, in a recent Instagram post, KHJN revealed that just five days into August, the organization was already out of funds. With Medicaid cuts going into effect Oct. 13, the number of trans Kentuckians in need of resources for gender-affirming care will soon skyrocket. Organizers and advocates who spoke to Prism said they are concerned about how they will meet the community’s growing needs and what risks people may take to access care.

Fighting for a “life worth living”

Alexander, a Black trans Louisville resident who is using his first name only, told Prism that trans people are still affected by anti-trans bills that don’t become law because these bills instill fear in healthcare providers.

Nationwide, the Trump administration’s fear-mongering and youth-targeted anti-trans attacks have influenced even the oldest and largest pediatric gender clinics to shutter. This includes the Children’s Hospital Los Angeles’ Center for Transyouth Health and Development, which provided gender-affirming care to thousands of young people before abruptly shutting its doors last year, drawing criticism from advocates and patients.

While there is a broad history of allies in healthcare failing trans communities when they are most in need of care, medical professionals say there are valid reasons why some have recently had to stop providing gender-affirming care, especially in the South. For example, in states such as Alabama, Florida, and South Carolina, it’s a felony to provide certain forms of gender-affirming care to youth. 

Still, trans people who spoke to Prism urge providers to consider the life-changing possibilities that gender-affirming care offers. Dr. Keisa Fallin-Bennett, who is a provider at the University of Kentucky’s Transform Health initiative that works to improve the health of Kentucky’s LGBTQIA+ communities, previously detailed the immediate difference she sees in patients who access gender-affirming care for the first time.

“I see people really just come into themselves and get so much of a sense of confidence and this comfort in their body that they didn’t have when they first started seeing me,” she said in a 2023 article published with WKU Public Radio.

Some LGBTQIA+ healthcare providers are also developing their own workarounds to draconian anti-trans laws. 

For example, Kentucky-based family medicine physician Dr. Colby R. Loew recently told Queer Kentucky that, over the last year, she noticed increased anxiety among her patients when it comes to documenting their pronouns, gender identities, and gender dysphoria. As a result, Loew, who is queer and says she is passionate about trans healthcare, decided to be more cautious with her medical documentation, especially considering the Department of Justice’s recent efforts to obtain the medical records of young people who accessed gender-affirming care.

“I haven’t really even been using gender dysphoria much as a code because I don’t need to document it that way,” she said, referring to the medical codes physicians use in patient charts to document their symptoms and diagnoses. According to advocates, even minor interventions such as those taken by Loew can drastically improve physician-patient relationships and lead to tangible protections for trans people. 

But it’s also true that physicians shouldn’t have to develop these workarounds at all. 

The American Medical Association, the American Academy of Pediatrics, and the World Professional Association for Transgender Health all support that gender-affirming care is medically necessary and that clinical decisions belong exclusively in the landscapes of healthcare professionals and patients. But until gender-affirming care for trans people is adopted across the state, Kentucky healthcare professionals must continue to perform a difficult balancing act, juggling legal compliance and ethical obligations alongside statutory requirements and pending legislation. 

Organizers say the health and well-being of trans Kentuckians depend on collective action across healthcare settings, community spaces, legislative committees, boardrooms, mutual aid networks, and professional societies. Williams, the Kentucky trans disability organizer, told Prism that the stakes are too high to give up.  

“I’ve seen the difference that care networks have made in my life,” he said. “It has made my life [one] that I can actually—with confidence—say is a life that’s worth living.”

Editorial Team:
Tina Vasquez, Lead Editor
Carolyn Copeland, Top Editor
Rikki Li, Copy Editor