It’s gynecological care in particular that gets complicated. As a remedy for dysphoria resulting from bodily functions like menstruation, Courey E, 34, who’s nonbinary, tried to find a doctor who would perform an endometrial ablation — which reduces or fully prevents uterine bleeding — or a hysterectomy. “I have attempted to try to find a gyno that will remove my uterus, but without a 'problem' it seems like they won't,” they say. “If I say that it's for gender-related reasons, insurance will not pay for it and it is prohibitively expensive.” A hysterectomy often costs somewhere between $7,000 to $12,000. According to the American Congress of Obstetricians and Gynecologists (ACOG), most health insurance plans do not cover gender affirmation surgery.

Courey is not alone in this battle. Megan Knouff, who is nonbinary, is also adamant about having a hysterectomy done. “I think there is that paternalistic idea of ‘Well, you will change your mind someday,’” says Knouff. Terry, 26, who’s genderqueer, is another person who has no intention of procreating and is seeking someone to perform the surgery. “I'm still trying to figure out a way to convince a doctor that yeah, I have a uterus, but no way in hell am I ever going to use it.”

Dr. Cecile Unger, a pelvic reconstructive surgeon at the Cleveland Clinic, is part of a multidisciplinary team that treats transgender patients. Unger frequently performs hysterectomies on people who are in their twenties or younger. “The reason some GYNs are reluctant to perform hysterectomies on patients at such a young age is because of the risk of regret in the future,” Unger tells BuzzFeed News. “Patients need to understand that they will not be able to carry their own biological children if they have a hysterectomy. The other important consideration is the effect this may have on bone health in such young patients. They need to remain on their cross-sex hormones, vitamin D, and calcium to avoid detrimental effects to their bones from not having estrogen. These are important considerations, and providers may shy away from performing surgery because of the importance of these factors.”

Even if Courey or Knouff found a health care provider who would perform a hysterectomy, that medical clinic might be many miles away from their homes. Quite a few of Unger’s patients do not live close to the Cleveland Clinic, but they come to her because they have been denied elsewhere.

Not every trans or gender-nonconforming person is uncomfortable with their uterus, however. Many feel right at home in their bodies. But even those who don’t experience dysphoria come up against difficulties in the health care system, particularly when it comes to gynecology. “I know a trans man whose insurance refused to cover a pap test because his ID said ‘male,’” Devine tells BuzzFeed News. “How can a trans man, in the aforementioned example, take care of himself if insurance refuses to see him for who he is?”

“I don't know why this is a revolutionary idea,” he added, “but health care needs to care for someone's body AND mind, even when those two things don't ‘match’ by commonly accepted standards. Many trans people, nonbinary people especially, feel like our bodies are fine. It's the public perception of our bodies that's messed up.”

Public perception makes all the difference. According to Transfaith, a transgender faith and spirituality organization, 36% of nonbinary people have refused to seek health care out of fear of facing discrimination. Sekera, the RN in San Francisco, tells BuzzFeed News that sometimes providers will flat-out refuse to provide care or will act aggressively toward a patient because of that person’s gender identity. Even if a patient is able to find a competent provider, Sekera says, trans and gender-nonconforming people “often then face having to fight to have their medical needs covered by their insurance.” In order for a trans person to be prescribed hormone replacement therapy (HRT), for example, they oftentimes must first must be diagnosed with gender identity disorder, which many trans people feel reduces their gender identities as a whole — rather than just the symptoms of dysphoria — to a disease that needs curing.