*Editor’s note: Sam Moore is a journalism student in SF State’s Journalism 575 Community Media this spring. Taught by professor Jon Funabiki, the class is a collaboration with El Tecolote

Jacob Cook, a 22-year-old retail employee from Orange County, was on track to start hormone replacement therapy last month—until his clinic ran out of testosterone. 

“When I arrived, I had to wait for two and a half hours just to be told I wouldn’t be receiving treatment. All the testosterone had expired and no one had noticed or checked,” he said. “All backorders on T had been cancelled because of COVID-19.” After waiting for nearly three hours, he said, he was sent home with no prescription. 

Cook isn’t alone: as the coronavirus pandemic continues to upend almost every part of the healthcare system, many trans and gender non-conforming people are faced with the daunting task of pursuing increasingly inaccessible gender-affirming medical services—services which, for many, weren’t easy to access in the first place. 

“I’m going to be off testosterone for the next month because of delayed shipping, and since my pharmacy doesn’t have a physical location I can’t go pick it up,” said Ace Gimeno, 19, who works as a barista in Fairfield and attends Solano Community College. Since the pandemic started, he said, he’s been unable to find alcohol prep pads for his testosterone injections, and has been using incorrectly-sized needles since the size he normally uses hasn’t been available at any drugstore. 

“I’m worried about mental and emotional changes, since my body will be adjusting to not having that amount of testosterone in my system,” Gimeno said. “My mental health is my biggest concern there.” 

Setbacks like this are happening across medical lines, from lupus patients unable to access hydroxychloroquine after it was approved by the FDA as an emergency coronavirus treatment, to patients with chronic illnesses facing increasing shortages of sedatives, anesthetics, painkillers, and muscle relaxants, all of which are used to treat people on ventilators. But to a community intimately familiar with how an inequitable society can enable a dangerously inadequate healthcare system, these sort of challenges sting especially hard.

“The most extreme or dangerous thing there is suicidality, when there are people who are at a point of feeling like it’s life or death,” said Danny Schnittman, who works as a family therapist and intake coordinator at the Pacific Center for Human Growth, an LGBTQ+ community center in Berkeley which operates the only sliding-scale mental health clinic for LGBTQ+ people in Alameda County. “The biggest thing, I think, is just the general well-being and mental health aspects of isolation, of not having affirming or validating care, not having access to something that potentially can be life-changing for someone.” 

Illustration: Valeria Olguín

The higher rates of suicidality in trans communities, compounded with the feelings of isolation and inaccessibility of gender-affirming care brought on by the pandemic, could cause an influx of mental health challenges among trans communities, Schnittman said. 

“(Gender-affirming) surgeries aren’t happening right now,” he said. “People have had surgery dates pushed back indefinitely. They don’t know when they’re going to be able to have surgery. They might have been on a waiting list for a long time. There’s that hopelessness and helplessness of like, when can this happen?”

The pandemic has affected Schnittman’s own place of work: since shelter-in-place orders were put in effect, the Pacific Center has transitioned most of their services to an online format, and has stopped taking in new clients. Therapists have lowered the cost of their sessions and offered some sessions pro-bono in order to accommodate clients who have experienced a loss of income. Clients who attend the center’s support groups and programs—especially trans youth—face their own challenges, Schnittman said. 

“I co-facilitate a preteen trans group that was regularly getting 8 to 12 kids per session,” he said. “We started doing it over Zoom, and at this point it’s been 1 to 3 kids each time. There’s not that same regularity, and for a lot of the kids, they don’t know other trans people outside of the group. They’re not in spaces where they feel affirmed, and those spaces are so critical for development with trans youth. Cisgender, heterosexual youth, they see themselves all over the place—trans youth don’t.” 

San Francisco’s trans community is currently facing its own healthcare challenges. Lyon-Martin Health Services, a Mission District clinic that offers healthcare primarily to low-income trans people and cisgender women, has been struggling since February to combat a relocation and reduction of medical staff that could result in a 50-90 percent decrease in the number of patients they’re able to serve. 

HealthRIGHT 360, Lyon-Martin’s parent organization, announced plans in February to move the clinic from their present location at 1735 Mission Street to a separate clinic at 1563 Mission Street this month. While funding from the city and concerns surrounding the pandemic have put those plans on hold, the move could still take place at the end of July. 

“All of these changes are really unfortunate because it would mean that we wouldn’t be able to see as many folks as we do now,” said a Lyon-Martin employee, who has requested to remain anonymous. “We were told that only one team would be able to move on to the new location. That means one medical provider, one nurse and one medical assistant. We were also informed that our volunteer program would be cut.”

The change in location, the employee said, might be their biggest concern. Many of the clinic’s patients rely on the safe and inclusive environment that Lyon-Martin has fostered since opening in 1979. Merging with a clinic that doesn’t serve a large trans population means losing that environment—something that could drive many patients away from seeking healthcare entirely. 

“I thought I would stick with Lyon-Martin through anything, but the loss of the front desk is the one thing I don’t think I could handle,” said artist Scout Tran, 38, who has been receiving medical care from Lyon-Martin for five years. “I’m starting to get old enough that not regularly seeing a general practitioner isn’t a good idea, but I’d rather chance it than have to deal with a regular clinic. When I had a major illness last year I refused to go to an emergency room, and insisted on going through Lyon-Martin first.”

The clinic’s informed staff is Tran’s main rationale for this loyalty.

“The phone receptionist expects I’m trans and doesn’t get freaked out by my voice,” Tran said. “The front desk is staffed by trans people, who know how to navigate uncomfortable questions without ever making me anxious. I can speak openly to the medical assistant without worrying about their reaction. At Lyon-Martin they see trans people all day long, and no other place can synthesize that.”

Some anticipate a return to more alternative, community-based modes of healthcare as medicalized care continues to become more inaccessible. 

“I remember a time, too recently, when only about half of us had real hormone prescriptions, and we all rationed our supply so we could share,” said Tran. “I’ve already seen an instinctive return to that method since the community heard that Lyon-Martin was being reduced.”

The patients impacted by the changes the most, Tran said, will likely be those who have to “out” themselves as trans in order to receive adequate care—“namely trans women who don’t ‘pass,’ trans men who ‘pass’ too well, non-binary people as a category; compounded by other factors that might make someone instinctively take them less seriously, like being Black or Brown, disabled or having language barriers, and especially anyone who doesn’t have a private bathroom and lots of extra energy to put themselves together before going out to see a doctor.”

This is already the reality of medical care for trans and gender non-conforming people throughout the country. And with plans announced by the Trump administration last month to roll back a section of the Affordable Care Act that protects trans people from discrimination in healthcare and insurance coverage, the situation could worsen exponentially—for trans people everywhere, not just patients at Lyon-Martin. 

“It’s very much a feeling of going backwards,” said Schnittman about the Trump administration’s announcement. “I think that would just continue to isolate trans people, especially trans people in rural areas or less resourced areas, because they already have trouble accessing the resources they need. There’s definitely a feeling of helplessness here. We can just hope that it doesn’t happen.”