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In recent years, states across the Mountain West have passed laws that limit doctors from providing transgender children with certain kinds of gender-affirming care, from prohibitions on surgery to bans on puberty blockers and hormones. Colorado families say their state was a haven for those health services for a long time, but following executive orders from the Trump administration, even hospitals in Colorado limited the care they offer for trans patients under age 19. KFF Health News Colorado correspondent Rae Ellen Bichell spoke with youth and their families.

GRAND JUNCTION, Colo. — On a Friday after school, 6-year-old Esa Rodrigues had unraveled a ball of yarn, spooked the pet cat, polled family members about their favorite colors, and tattled on a sibling for calling her a “butt-face mole rat.”

Next, she was laser-focused on prying open cherry-crisp-flavored lip gloss with her teeth.

“Yes!” she cried, twisting open the cap. Esa applied the gloopy, shimmery stuff in her bedroom, where a large transgender pride flag hung on the wall.

Esa said the flag makes her feel “important” and “happy.” She’d like to take it down from the wall and wear it as a cape.

Her parents questioned her identity at first, but not anymore. Before, their anxious child dreaded going to school, bawled at the barbershop when she got a boy’s haircut, and curled into a fetal position on the bathroom floor when she learned she would never get a period.

Now, that child is happily bounding up a hill, humming to herself, wondering aloud if fairies live in the little ceramic house she found perched on a stone.

Her mom, Brittni Packard Rodrigues, wants this joy and acceptance to stay. Depending on a combination of Esa’s desire, her doctors’ recommendations, and when puberty sets in, that might require puberty blockers, followed by estrogen, so that Esa can grow into the body that matches her being.

“In the long run, blockers help prevent all of those surgeries and procedures that could potentially become her reality if we don’t get that care,” Packard Rodrigues said.

The medications known as puberty blockers are widely used for conditions that include prostate cancer, endometriosis, infertility, and puberty that sets in too early. Now, the Trump administration is seeking to limit their use specifically for transgender youth.

Esa’s home state of Colorado has long been known as a haven for gender-affirming care, which the state considers legally protected and an essential health insurance benefit. Medical exiles have moved to Colorado for such treatment in the past few years. As early as the 1970s, the town of Trinidad became known as “the sex-change capital of the world” when a cowboy-hat-wearing former Army surgeon, Stanley Biber, made his mark performing gender-affirming surgeries for adults.

On his first day in office, President Donald Trump signed an executive order refuting the existence of transgender people by saying it is a “false claim that males can identify as and thus become women and vice versa.” The following week, he issued another order calling puberty blockers and hormones for anyone under age 19 a form of chemical “mutilation” and “a stain on our Nation’s history.” It directed agencies to take steps to ensure that recipients of federal research or education grants stop providing it.

Subsequently, health care organizations in Colorado; California; Washington, D.C.; and elsewhere announced they would preemptively comply. In Colorado, that included three major health care organizations: Children’s Hospital Colorado, Denver Health, and UCHealth. At the end of January and in early February, the three systems announced changes to the gender-affirming care they provide to patients under 19, effective immediately: no new hormone or puberty blocker prescriptions for patients who hadn’t had them before, limited or no prescription renewals for those who had, and no surgeries, though Children’s Hospital had never offered it, and such surgery is rare among teens: For every 100,000 trans minors, fewer than three undergo surgery.

Children’s Hospital and Denver Health resumed offering puberty blockers and hormones on Feb. 24 and Feb. 19, respectively, after Colorado joined a U.S. District Court lawsuit in Washington state. The court concluded that Trump’s orders relating to gender “discriminate on the basis of transgender status and sex.” It granted a preliminary injunction blocking them from taking effect in the four states involved in the lawsuit.

Surgeries, however, have not resumed. Denver Health said it will “continue its pause on gender-affirming surgeries for patients under 19 due to patient safety and given the uncertainty of the legal and regulatory landscape.”

UCHealth has resumed neither medication nor surgery for those under 19. “Our providers are awaiting a more permanent decision from federal courts that may resolve the uncertainty around providing this care,” spokesperson Kelli Christensen wrote.

Trans youth and their families said the court ruling and the two Colorado health systems’ decisions to resume treatments haven’t resolved matters. It has bought them time to stockpile prescriptions, to try to find private practice physicians with the right training to monitor blood work and adjust prescriptions accordingly, and, for some, to work out the logistics of moving to another state or country.

The Trump administration has continued to press health providers beyond the initial executive orders by threatening to withhold or cancel federal money awarded to them. In early March, the Health Resources and Services Administration said it would review funding for graduate medical education at children’s hospitals.

KFF Health News requested comment from White House deputy press secretary Kush Desai but did not receive a response. HHS deputy press secretary Emily Hilliard responded with links to two prior press releases.

Medical interventions are just one type of gender-affirming care, and the process to get treatment is long and thorough. Researchers have found that, even among those with private insurance, transgender youth aren’t likely to receive puberty blockers and hormones. Interestingly, most gender-affirming breast reduction surgeries performed on men and boys are done on cisgender — not transgender — patients.

Kai, 14, wishes he could have gone on puberty blockers. He lives in Centennial, a Denver suburb. KFF Health News is not using his full name because his family is worried about him being harassed or targeted.

Kai got his period when he was 8 years old. By the time he realized he was transgender, in middle school, it was too late to start puberty blockers.

His doctors prescribed birth control to suppress his periods, so he wouldn’t be reminded each month of his gender dysphoria. Then, once he turned 14, he started taking testosterone.

Kai said if he didn’t have hormone therapy now, he would be a danger to himself.

“Being able to say that I’m happy in my body, and I get to be happy out in public without thinking everyone’s staring at me, looking at me weird, is such a huge difference,” he said.

His mom, Sherry, said she is happy to see Kai relax into the person he is.

Sherry, who asked to use her middle name to prevent her family from being identified, said she started stockpiling testosterone the moment Trump got elected but hadn’t thought about what impact there would be on the availability of birth control. Yet after the executive orders, that prescription, too, became tenuous. Sherry said Kai’s doctor at UCHealth had to set up a special meeting to confirm the doctor could keep prescribing it.

So, for now, Kai has what he needs. But to Sherry, that is cold comfort.

“I don’t think that we are very safe,” she said. “These are just extensions.”

The family is coming up with a plan to leave the country. If Sherry and her husband can get jobs in New Zealand, they’ll move there. Sherry said such mobility is a privilege that many others don’t have.

For example, David, an 18-year-old student at Western Colorado University in the Rocky Mountain town of Gunnison. He asked to be identified only by his middle name because he worries he could be targeted in this conservative, rural town.

David doesn’t have a passport, but even if he did, he doesn’t want to leave Gunnison, he said. He is studying geology, is learning to play the bass, and has a good group of friends. He has plans to become a paleontologist.

His dorm room shelves are scattered with his essentials: fossils, Old Spice deodorant, microwave macaroni and cheese. But there are no mirrors. David said he got in the habit of avoiding them.

“For the longest time, I just had so much body dysphoria and dysmorphia that it can be kind of hard to look in the mirror,” David said. “But when I do, most of the time, I see something that I really like.”

He’s been taking testosterone for three years, and the hormone helped him grow a beard. In January, his doctor at Denver Health was told to stop prescribing it. His mom drove hours from her home to Gunnison to deliver the news in person.

That prescription is back on track now, but the mastectomy he’d planned for this summer isn’t. He’d hoped to have adequate recovery time before sophomore year. But he doesn’t know anyone in Colorado who would perform it until he is 19. He could easily get surgery to enhance his breasts, but he must seek surgical options in other states to reduce or remove them.

“Colorado as a state was supposed to be a safe haven,” said his mother, Louise, who asked to be identified by her middle name. “We have a law that makes it a right for trans people to have health care, and yet our health care systems are taking that away.”

It has taken eight years and about 10 medical providers and therapists to get David this close to the finish line. That’s a big deal after living through so many years of dysphoria and dysmorphia.

“I’m still going, and I’m going to keep going, and there’s almost nothing they can do to stop me — because this is who I am,” David said. “There have always been trans people, and there always will be trans people.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Rural hospital leaders are questioning whether they can continue to afford to do business with Medicare Advantage companies, and some say the only way to maintain services and protect patients is to end their contracts with the private insurers. 

Medicare is the main federal health insurance program for people 65 or older. Participants can enroll in traditional, government-run Medicare or in a Medicare Advantage plan run by a private insurance company. 

The private plans offer lower premiums and out-of-pocket costs for some patients. Nearly all offer extra benefits, such as vision, hearing, and dental coverage. Many also offer perks, such as gym memberships, nutrition services, and allowances for over-the-counter health supplies. 

But in recent years, average Medicare Advantage reimbursements to rural hospitals were about 90% of what traditional Medicare paid, according to a new report from the American Hospital Association. And traditional Medicare already pays hospitals much less than private plans, according to a recent study by Rand Corp., a research nonprofit. 

“The vast majority of our rural hospitals are not in a position where they can take further cuts to payment,” said Carrie Cochran-McClain, chief policy officer at the National Rural Health Association. “There are so many that are just really in a precarious financial spot.” 

Nearly 200 rural hospitals have ended inpatient services or shuttered since 2005. 

Jason Merkley, CEO of Brookings Health System in rural South Dakota, worried reimbursement losses would spark staff layoffs and cuts to patient services. So last year, the system dropped all four contracts it had with major Medicare Advantage companies. 

Great Plains Health, which serves parts of rural Nebraska, Kansas, and Colorado, has dropped all contracts with the private insurers. So has Kimball Health Services, which is based in two small towns in Nebraska and Wyoming. 

Rural hospital leaders are also concerned about Medicare Advantage payment delays and a resistance to authorizing patient care. 

Susan Reilly, a spokesperson for the Better Medicare Alliance, said a recent report published by her group, which promotes Medicare Advantage, found that private plans are more affordable than traditional Medicare for rural beneficiaries. That analysis was conducted by an outside firm and based on a government survey.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

In January, a teenager in suburban St. Louis informed his high school counselor that a classmate said he planned to kill himself later that day.

The 14-year-old classmate denied it, but his mother, Marie, tore through his room and found a suicide note in his nightstand. (She asked KFF Health News to publish only her middle name because she does not want people to misjudge or label her son.)

His parents took him to Mercy Hospital St. Louis. According to his mother, providers told them they didn’t have beds available at their behavioral health center, so the teen spent three days in a room in a secured area of the emergency department and saw a doctor twice, one time virtually.

Joe Poelker, a Mercy hospital spokesperson, declined to answer questions from KFF Health News. Leaders of Mercy and other local hospitals have described the shortage of beds for inpatient pediatric psychiatric care in the St. Louis area as a crisis for years.

Nationwide, psychiatric “boarding” — when a patient waits in the emergency room after providers decide to admit the person — has increased because of a rise in suicide attempts, among other mental health issues, and a shortage of inpatient psychiatric beds, according to a study of 40 hospitals in the journal Pediatrics. It found the number of cases in which children spent at least two days in pediatric hospitals before being transferred for psychiatric care also increased 66% from 2017 through 2023 to reach 16,962 instances.

St. Louis Children’s Hospital leaders aim to address that problem by opening a 77-bed pediatric mental health hospital in the suburb of Webster Groves. But as often happens with such proposals, neighbors objected. They worry it would worsen safety and lower property values.

Over the past decade, proposed psychiatric facilities for minors in California, Colorado, Iowa, Nebraska, and New York have also faced local resistance.

Behavioral health care advocates counter that such concerns are largely unfounded and rooted in stigma. Locating such facilities in remote areas — as neighbors sometimes suggest — reinforces the misconception that people with mental illness are dangerous and makes it harder to help them without their support system nearby, doctors say.

“We wouldn’t take children with cancer and say they need to be two hours away, where there is no one around them,” said Cynthia Rogers, a pediatric psychiatrist at St. Louis Children’s. “These are still children with illnesses, and they want to be in their home city, where their family can visit them.”

In the United States, the number of suicides among minors increased 62% from 2002 to 2022, according to a KFF analysis of data from the Centers for Disease Control and Prevention.

At St. Louis Children’s, the crisis has fueled more emergency room visits, Rogers said, with behavioral health visits nearly quadrupling from 2019 to 2023, jumping from 565 to 2,176. She attributes the increase to factors such as social media engagement, isolation caused by shutdowns during the covid-19 pandemic, and the political climate, which she said has been particularly hard on LGBTQ+ children.

“The pandemic seemed to throw gasoline on the fire,” Rogers said.

In the middle- and upper-class suburb of Webster Groves, St. Louis Children’s and KVC, a behavioral health provider, want to use a site that served as an orphanage in the 19th century to create 65 inpatient beds for children needing care for about a week and 12 residential beds for people requiring longer stays. KVC now runs a school there for students who struggle in traditional classrooms and offers services to help children in foster care.

“Introducing a hospital into this historically significant residential area disrupts its stability by undermining” its character, one resident testified at a January City Council meeting.

Tim Conway, who has lived across from the site for three decades, told KFF Health News that his opposition is primarily because the facility and its parking would take up more space than the existing structures.

The detailed security plans have not eased his concerns. “It makes me wonder why it needs to be that robust,” Conway said.

Samer El Hayek, a psychiatrist at the American Center for Psychiatry and Neurology in the United Arab Emirates, has studied how stigma impacts the locations of psychiatric facilities around the world and said people often don’t want the hospitals nearby because they associate them with violence or unpredictable behavior.

“The misconception of increased danger often stems from outdated stereotypes rather than factual evidence,” El Hayek said.

Little evidence suggests that people with mental illness are more likely to commit a crime or be violent than the general population, with the exception of people with a severe illness such as schizophrenia, who, while it’s still rare, are likelier to commit a violent act.

But residents near mental health hospitals have been rattled by encounters with patients who escaped or reports from law enforcement and local news about missing patients.

In Oklahoma City, Richard Scroggins in 2014 opposed the expansion of Cedar Ridge Behavioral Hospital, which then treated youths and adults, because of its security issues.

Scroggins, who raises horses and cattle on his property, told The Oklahoman newspaper at the time that he once found a stranger raking leaves in his yard. After determining the person was suffering from mental illness and harmless, Scroggins said, he called the police, who retrieved the person.

The Cedar Ridge provider ultimately dropped plans to expand the facility after community opposition.

Scroggins has since encountered other patients from the facility on his property but none in recent years, he told KFF Health News in February. His perspective on the hospital has changed because its staff addressed his security concerns.

“Nobody wants it in their neighborhood, but it’s a necessity,” Scroggins said. “I’m a Christian, so we are supposed to reach out and help.”

Carrie Blumert, CEO of the Mental Health Association Oklahoma, said psychiatric facilities make surrounding areas safer by providing medical care and “treating the root of people’s issues rather than just throwing them in a jail cell.”

In Marie’s case, her son was ultimately admitted to Mercy-affiliate Hyland Behavioral Health Center and spent a few days there until a physician told the family he probably just needed to speak with a counselor, she said. He was discharged.

A day later, she said, the teen said he still wanted to kill himself, so his parents took him to St. Louis Children’s, where he was admitted the same day. After a 15-minute visit, Marie said, a doctor pulled her aside and asked, “Have you ever thought that he might be on the autism spectrum?”

“‘Oh my gosh, you’re the first person to validate my feeling,’” Marie told the doctor.

Her son stayed two weeks at the hospital, during which providers diagnosed him with autism and prescribed antidepressants. He returned to the classroom and baseball field, Marie said, but learning he has autism upset him.

“He’s still trying to process that, and he’s very sensitive. And they are teenagers, so when kids are mean to him at school or make fun of him, he takes that to heart way more than a typical teenager would,” Marie said. “I have hope for him that he will be OK.”

And soon, she knows, kids like her son could have another option in St. Louis if they need acute psychiatric help.

Despite community pushback, the Webster Groves City Council unanimously approved the rezoning needed for the hospital in January. The officials described opponents’ concerns as legitimate but said the hospital would benefit children’s mental health and the surrounding community.

“This is by far and away one of the easiest votes I’ve ever had to take,” said Councilmember David Franklin, adding that the approval demonstrates that “Webster Groves cares not only about its own citizens but the citizens of this region.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).