"I thought I could fix it, but there’s no fixing what isn’t broken,” Jo Ellen “Ruby” Petrichor says. “It’s like throwing paint on the ‘Mona Lisa.’ What’s the point? I’m not improving it. It’s a masterpiece by itself. And I was throwing paint on me everywhere I could.”

That’s how the 60-year-old Petrichor describes her life before she began to transition into the woman she is now. Sitting before me at a neighborhood Starbucks—piercing blue eyes, perfect cheekbones and a soft, welcoming smile—the Air Force veteran is the epitome of grace and elegance. Her last name, the word for the liquid that runs through veins of gods in Greek mythology, is also the name of the smell after rainfall. The calm after the storm.

“I was so afraid to come out. I made a huge mess of my life,” Petrichor says. For most of her adult years, Petrichor stayed in the closet, hiding her true identity from her partner, family and friends. Her relationships suffered, she sank into an ongoing depression and she took antidepressants and mood stabilizers to cope. But nothing could change how she felt inside.

It wasn’t until a near-fatal suicide attempt in 2014 that Petrichor accepted that she was transgender and came out to her family and the VA. With years of suffering behind her, she finally began her journey to happiness.

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For many trans people, that journey is a difficult one, made harder by the limitations and complexities of trans health care. The medical needs of those who are cisgender (when one’s gender identity corresponds with their birth sex) are deep and differential enough; for trans folks, they’re even more complicated and varied.

Typically, the first step is having a supportive therapist. Because trans people experience different and unique levels of gender dysphoria, they require individualized care. An endocrinologist is often required if a person desires to undergo hormone replacement therapy (HRT). Many, but not all, trans people require gender confirmation surgery (GCS), which refers to any surgical procedure that a trans person might require to more closely reflect their gender identity.

Walter Bockting, a clinical psychologist, says “being transgender is not a disorder,” and that surgery is contingent on an individual’s needs. Petrichor, for example, receives HRT through the VA and was able to finance her facial reconstructive surgery—something not covered by her health care plan. “I’ll be digging myself out of debt for the rest of my life,” Petrichor says, “but it was worth it.”

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For many trans people in the United States, access to financially viable health care isn’t an option, and those who have access might be denied GCS by insurance providers. Many trans people must travel long distances to receive what are typically cheaper or medically unsafe procedures—or go without care completely.

According to a 2016 report by the Williams Institute, transgender Nevadans make up less than 1 percent of the state’s population (0.61 percent). In a 2014 report, the WI also found that only 0.6 percent of American adults—1.4 million total—identify as transgender. With these numbers, many argue trans health care exclusions aren’t an issue of cost but of stigma, one that stems from a lack of understanding from and even prejudice by the general public, employers and the medical industry.

And yet, a report conducted by the Johns Hopkins Bloomberg School of Public Health found that it is cost-effective to cover trans-related expenses. “Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society,” researchers reported, and would only cost “approximately $0.016 per member per month.” Meanwhile, GCS procedures commonly cost trans people without health care coverage anywhere from $10,000 and $100,000, while hormones can range from $70 to $120 per month.

The Affordable Care Act of 2010 made it illegal for federally funded programs to discriminate against individuals based on race, national origin, age, disability and sex. Nevada’s Public Employee Benefits Program board voted in 2015 to cover medically necessary transition-related procedures including mental health treatment, hormone therapy and genital reconstruction surgery for all trans state employees, but excluded procedures deemed to be “cosmetic.” Non-state employees would still have to fund trans-related procedures out of pocket.

In 2016, then-President Barack Obama announced new ACA regulations that would prohibit insurance companies from discriminating against transgender people. There is still no federal requirement for insurance companies and employers to include trans health coverage. Under the new administration, a federal requirement isn’t likely to be introduced anytime soon.

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Given that federal law does not provide protections for trans workers, the lack of affordable health care is extremely problematic for trans people. Next to homelessness, it’s one of the biggest issues the trans community—nationwide and in Nevada—faces.

Informed consent is also an issue in Nevada. Many local health providers require trans people to provide two letters from mental health professionals before granting surgery, a rule widely considered outdated.

“We’re our own best advocates when it comes to healthcare,” says Blue Montana, transgender programs manager at the Gay and Lesbian Community Center of Southern Nevada. "It's nice to have doctors who listen."

The National Transgender Discrimination Survey found that trans people are almost four times more likely to have a yearly household income under $10,000, and that the unemployment rate for trans workers is twice the rate of that for cis-gender workers. With such high instances of poverty and unemployment, many trans people are simply forced to go without the care they need to survive.

Before she transitioned, Petrichor spent years of her life in and out of hospitals, sometimes for 30 to 60 days at a time. “Look at what it cost to have me [in] inpatient [care]. Every year, I was in there like clockwork, and that was usually after a medical stay—a gunshot, a poisoning, an overdose. I had electroconvulsive therapy treatments.” Years of depression and traumatic, expensive treatments could have been avoided had Petrichor had access to trans health care, she says.

“Being trans is not an issue. Not being trans was my issue. What I did to circumvent [and] delay this created such a drain on the health-care system, so I find it kind of ironic I ask for something simple [and am not granted care]. What it costs is so small for the benefits.”

Montana echoes Petrichor’s statement. “It’s probably one of the leading causes, besides family issues, of trans suicide. It’s so difficult to not be able to get your body conform to what you need it to be, so when you look in the mirror it doesn’t make you want to just keel over and die,” he says.

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In 2015, the American Medical Student Association reported that one in five transgender people did not attempt to secure health care in the past year out of fear of discrimination, something with which Montana has dealt. “Every time I go in the emergency room, I’m a little bit terrified because I don’t know how they’re going to treat me.”

His husband, Owen Miller, has had a mixed experience. “Right now, the doctors that I have are phenomenal, but it wasn’t always like that. In California, my primary doctor was fantastic, but my mental health doctors were not."

In the same AMSA report, 29 percent of transgender people reported having to teach their health-care provider about transgender health issues.

Brianna Robinson, a 47-year-old disabled veteran from Punta Gorda, Florida, is one of those statistics. She moved to Las Vegas partly because she couldn’t find an endocrinologist in her small coastal town.

Robinson located a doctor and started HRT within three months of arriving in Las Vegas, but her transition hasn’t been without roadblocks. Like many trans people, she has continually had to negotiate her care. Robinson, like Petrichor and many other trans women of post-menopausal age, worries that she is being underdosed.

Rob Phoenix, nurse practitioner and founder of the Huntridge Family Clinic, says his clinic follows the World Professional Association for Transgender Health guidelines, which recommends keeping hormones in a cisgender range.

“That’s where physiologically it’s safest,” he says, adding that much of his time is spent devoted to educating and discussing safe levels for hormones. “A lot of [patients] come in with the misconception that higher [is better]. That’s not true. … We’re trying to prevent complications,” including high-risk diseases like cancer. The dosage, he maintains, should not change with age. “Whether they’re 11 or 60 years old, we’re generally going to put them into the same range.”

Robinson still hopes to be on a more effective dosage, though she acknowledges that, “[The VA is] really trying. Where they fall short is not allowing gender [confirmation] surgery.”

Another issue, Phoenix says, is finding surgeons. “For [lower-body] surgeries for trans females, there's nobody in Vegas that does it, so they all have to go out of state.” Trans males, on the other hand, have a few Nevada options when seeking upper-body surgery or a hysterectomy.

Finding a provider that is gender sensitive, knowledgeable about trans care and respectful of a patient’s preferred gender pronouns is also paramount, he says. “Patients will come in and be like, ‘They refused to call me by my preferred name,’ or ‘They would call me ‘mister’ or ‘he’ and refer to me in the wrong pronouns.’ It’s disrespectful. Some places do it intentionally.” Others simply “are not knowledgeable.”

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The state of trans health care is slowly improving, but any progress could be derailed under the new, decidedly more conservative presidential administration.

“Health-care providers are more willing to treat and learn about transgender health care, and large segments of the population are learning to be more accepting in gender issues,” Robinson says. “But [given] the current political climate, it’s hard knowing if that forward way of thinking is going to continue. There is a bulk of data out there on transgender health, [but] because of people’s own prejudices, that ball is moving so slowly. Is the ball going to stop? Is it going to roll backwards? That’s where we’re at.”

Despite strides in the medical community, trans people continue to be some of the most marginalized and victimized in the country and world. From workplace discrimination and violence to increased rates of homelessness, trans issues are part of a broader fight toward justice and equality. It only makes sense that the fight for better trans health care begins with education and the acceptance and visibility of transgender people.

More importantly, for folks like Robinson and Petrichor, transitioning wasn’t a choice—it was essential for their survival. “The public just doesn’t understand,” Robinson says. “Most people’s perceptions are skewed by Saturday Night Live skits … people don’t just uproot their life over a whim.”

Petrichor agrees wholeheartedly. “Why would someone be upset with me being happy? The benefits of treating this instead of shoving it under the rug far exceed …” she trails off. “I wouldn’t be here.”

Want to learn more about trans health care? Contact these local resources for more information.

Huntridge Family Clinic 702-979-1111

Gender Justice Nevada 702-425-7288

The Center 702-733-9800