I Believe You Can Survive The Most Recent & Ongoing Attacks on Trans Healthcare. Here's How.

I’m just going to start by saying it is supremely fucked up that the House passed a bill that would ban Medicaid from covering healthcare related to “gender transition” starting in 2026 and would remove the ACA requirement that insurances offered in the healthcare exchange cover gender-affirming care starting in 2027. To me it is even more fucked up to see this move with devastating potential impacts go untouched by nearly all news and political analysis of the spending bill. And to be clear for folks who understandably are in the dark - because again, almost no coverage - this is for everyone. What was originally going to be harmful enough as a ban on youth care was changed right before the House vote to include adults, as well.

The impacts of this vote on trans people have been really difficult to witness. As a client of mine put it, “I made the mistake of going to the Erin in the Morning live chat after she broke the news.” I was there, too. “I don’t think I can survive this.” “I’m not sure I can make it through four years of this.” “I don’t want to live without my hormones.” “I’m supposed to get surgery next year - what will I do?” People are terrified that this move signals a certain end of access to the medical miracle of gender-affirming care that made their lives liveable. And we are witnessing a society that seems all too ready to drop this fight, failing to recognize or seemingly care about the human cost — seemingly failing to care about us.

The beliefs expressed in that chat, and that I have heard and seen echoed in the days since, make sense to me. I understand how people are arriving at a belief that this isn’t survivable. There are a couple of theories of suicide that help me as a psychologist and as a person surviving this life understand what drives people to want to die and make moves toward that. One is the theory core to Marsha Linehan’s work with Dialectical Behavior Theory: suicidality is a way of imagining an escape from unbearable affect and emotional dysregulation. The other is Joiner’s interpersonal theory of suicide: suicidal desire emerges from thwarted belongingness and sense of burdensomeness when a person believes those states are unable to be changed. Gender dysphoria is incredibly painful for people and when it crescendos it can be overwhelming and experienced as unbearable. Imagining a future where the main tools to reduce that dysphoria are taken from us is going to both heighten dysphoria and could lead people to believe they are trapped in this heightened dysphoric state, or will be. We also know that one of the consequences of anti-trans discourse is worsened experiences of gender dysphoria and internalized transnegativity (which can in turn worsen someone’s dysphoria), so yeah. That all is a recipe for feeling overwhelmed by affect and feeling hopeless about getting meaningful relief. And then you throw in this experience of people turning your back on us, and the risk of that thwarted belongingness is going to start climbing too.

It all fucking sucks. If you are feeling overwhelmed and unconvinced that you want to or can make it through this, I truly understand.

I also believe you can.

I believe this so strongly, even though I haven’t met most of you who will read this.

I believe you can survive — we can survive, and I feel confident in this because 1) this isn’t the end of our story in terms of accessing care, 2) even if this bill advances to become law, it is not a life sentence of unbearable affect, and 3) there are lots of people who believe we belong here and are fighting for our survival, too.

To expand briefly:

1. This is not a scenario where we are passively going to be forcibly detransitioned. We still have access to care, there are means for developing alternative access paths, and there will be organizing to support further alternative access paths in the future should we need them. We have incredible histories of trans people finding ways to access medical interventions before they were endorsed and many of the trans people alive today (yours truly, included) began our transitions and had the bulk of our medical care before insurance paid for it. There often are ways.

2. Additionally, reduced access to certain medical care does not have to mean being trapped in dysphoric states. This is tricky to discuss because I unequivocally believe that preserving easy access to gender-affirming medical care is the best, most effective, safest way of reducing gender dysphoria. And we are not helpless in the face of dysphoria. There are ways of coping. Of building comfort in our bodies and roles and expressions through other forms of affirmation. Of learning ways to live alongside dysphoria that aren’t unbearable. Of living meaningfully while experiencing gender dysphoria.

3. We are not alone in this. At the very least, there is home and belonging for you among your trans family, and “across space and time” (as my faves at Pony Sweat say) in the legacies of all the trans people who came before us and in the futures of all the trans people ahead. But we’re not alone beyond that, too. There are a lot of cis people who are upset about this. More on that in a bit.

It’s okay if you’re not convinced of any of the above. But I’m glad you’re still reading. Because I also want to share with y’all a bunch of suggestions for things you can do to get through this.

They will be in no particular order except the first one, which is very important and should maybe be done first:

• Stay grounded in the facts and avoid emotion-fueled speculation. Out of what appears to me to be a combination of expression of very valid experiences of fear and anguish and rage, catastrophic thinking that often comes from an unconscious self-protective place, a lack of coverage from traditional media and not enough information from trusted sources, and an online discourse culture that is fueled both consciously and unconsciously by a desire to drive up engagement with our content, there is a lot of misinformation going around about the impacts of this bill. In terms of impacts on trans folks and coverage for gender-affirming care, here is what what the house passed would do: make a lot of people, including trans people, ineligible from benefits due to stricter eligibility requirements, potentially starting in 2026; ban Medicaid from paying for gender transition related care - i.e., affirming hormones and surgeries, starting in 2026; remove the federal mandate that ACA exchange plans cover gender-affirming interventions, starting in 2027. Importantly, there is no ban on this care being prescribed for adults and there will be states whose ACA exchange plans are required by state law to cover this. Private insurance (e.g., through workplaces) is not mentioned in the bill. I do not dismiss the devastating impacts this would have on making many forms of gender affirmation cost prohibitive for many trans people. I do think this is a very different picture to prepare for than one in which there is an outright ban on prescriptions and procedures.

• Remember that there is still room to resist - this hasn’t passed the Senate yet. Mira Lazine and Mady Castigan wrote a great piece about the facts of this bill and different resistance strategies trans people and our allies can take. I will note here, as Mira and Mady do, that the bill as a whole is horrific and will be devastating for many, many people if it moves through. Some resistance routes are about calling attention to and attempting to change the specific item related to trans healthcare and some are more broad. Advocacy orgs have also noted that this will certainly be taken up by lawyers and the courts.

  Don’t Panic–the Battle Over the Trans Medicaid Ban Is Far From Over. Here’s How To Fight Back.

  Resistance is functional both systemically and personally. Taking action can help counteract feelings of helplessness and hopelessness.

• Learn about how trans people accessed affirming care before insurance coverage. I am very committed to fighting this freaking bill and see room for a Medicaid ban to not become law. And there are people in power who really want to see this part of Project 2025 go through, so it behooves us to be prepared for a future without insurance coverage. This also just helps us psychologically now if we can shift our thinking about worst case future outcomes from “I won’t be able to access the care I need” to “it will be harder to access the care I need and here are the strategies I will employ.” Prior to 2014 and 2016, insurance did not cover anything related to gender dysphoria diagnoses (which of course back then had more unfortunate diagnostic labels). I came of trans-age in an era where we paid out of pocket for hormones and threw parties to crowdfund surgeries. There was a mail order pharmacy that had the best deals on testosterone - in 2010 I think I spent $50 for a 3-month supply. Supportive doctors billed under different diagnostic codes. People went overseas and accessed hormones through non-legal routes to save money. These were not glory days, to be clear. People had to delay or forego care based on their means; some people received poorer and/or less safe care because it was more affordable. So even as I acknowledge these alternate routes, I will be so angry and sad if we regress to a similar state. I just want to be clear that there are alternatives to the way many of us have gotten used to doing things.

• Recognize the ways in which our gains will still benefit us in preservation of access to care even in the face of insurance restrictions. In the above point, I said similar state - similar but not the same. We have had an undeniable increase in social visibility and support for trans people. And we have seen a marked reduction in trans people’s marginalization over the decades allowing for more financial stability for many (but not all) of us and more of us holding power in various relevant systems (e.g., medical care). I see a very different landscape in terms of funding options for supporting gender-affirming care. There is a large and growing network of organizations that offer grants for gender-affirming care and there are cis people and wealthy trans people who will want to give money to these efforts (many already are, in terms of efforts for trans youth - orgs are redistributing hundreds of thousands of dollars annually). I am on multiple listservs of medical providers (some trans, many cis) strategizing providing care and making care accessible in the face of various restrictions, and that’s just what people are willing to put in an email.

• Regulate or re-regulate panic responses. Practice recognizing when panic is starting or has set in and then practice settling your nervous system. If you feel overwhelmed by or unskilled at the prospect of emotion regulation, find a DBT group in your area or get Marsha Linehan’s DBT handouts and worksheets book and learn on your own. There are also mannyyyy websites and workbooks that aim to help people develop coping strategies and emotion regulation skills for calming an activated nervous system. I’m not going to suggest any specifics because what works for one of you will totally turn off someone else, but I encourage you to go look and find resources that fit. You will need different approaches for when you’re starting to become overwhelmed vs. when you’re already in full blown overwhelm, flooding, or panic. In the latter, you need accessible and often avoidance based soothing and distraction. The ice cube in a hand to zap your attention away from your internal panic or anguish. The weighted blanket that tells your body-mind that you are safe. Deep breathing that tells your nervous system you can get enough oxygen and it can chill out. When you’re less at the height of emotional overwhelm, regulation can be more cognitive or affective: self-talk that challenges ruminative misinformation, identifying whether you’re in need of food, water, or rest. Problem-solving. Recognizing the feeling, experiencing it, and letting it go. Journaling. Again, what works for one of you, will be unhelpful or unappealing to someone else, so I’ll stop throwing out specific suggestions.

• Look for stories of resistance and groups of non-trans people fighting back and expressing solidarity. Trust me that I know that it is easy to scroll through article after article and supposedly allied politicians’ talking points and see nothing about trans people and feel completely abandoned. That is devastating and we need to counter that impression because it’s not the whole story. Groups for parents of trans people are a great place to start if you want to see cis folks caring and taking action. You might even reach out and see if your local pflag chapter has volunteer opportunities or if the peer support spaces would be appropriate for a trans person experiencing sociopolitical distress. (I wouldn’t just go without checking because sometimes peer support is an important place to help parents move into accepting positions and if that’s what’s going on it might feel not great to be a trans person witnessing it.) Check out bloggers and journalists who make an effort to report on resistance and victories, like Ben Greene and KB Brookins.

• Engage in others-focused efforts (without over-committing and burning yourself out). An incredibly effective way to interrupt spiralling about our own plight in life is to show up for others. This can be as large as getting involved in efforts like volunteering for an ICE hotline or actions to facilitate trans people traveling or relocating away from more hostile areas. But it can also be small. In a moment of grief on Saturday morning, I decided to go to the local bakery and asked some neighbor friends if they wanted me to get them any pastries. A surprise gift of cardamom buns seemed to brighten their days and it recast my grief into a larger kaleidoscope of feelings that included joy, connection, gratitude, pleasure, etc. Hold the door for the person entering the store after you and smile at them. Pick up something that you see another person drop. Return someone’s shopping cart at the grocery store. If you’re feeling overwhelmed by interpersonal interaction or feel unsafe (physically or psychologically) being witnessed, there are still ways to be others-focused. Give $5 to a mutual aid fund. Or send an acquaintance a note of appreciation. This all helps us experience additional emotions, and also feel connected to the fabric of our communities which reifies the belonging that already exists but may not be felt or at least feels frayed right now. Many of these also reaffirm one of our near-universal purposes in being alive: helping the world suck less for others even to a seemingly small degree. Note: if you overextend on the big offerings, you’re at risk of burning out and/or becoming resentful and this becomes way less helpful to you, so be mindful of your resources/capacity.

• Ask for help, ideally in places where you are likely to receive some help in response to your ask. Offering help, as suggested above, is one way of reifying that we are a meaningful part of a community. Receiving help from that community takes that even further and helps us feel less alone with the battles we face. Find the discord channels or facebook groups (queer exchanges are what I’m thinking of) or signal threads that are attached to mutual aid and try asking for help when you need something. I just got connected to a rideshare signal, for example, and I’m part of a buy nothing group on facebook where you can offer and request free items. Ask friends and trusted acquaintances directly. Give them explicit and implicit permission to say no, but ask them for a hand if you’re overwhelmed with a task. Specific to the topic of this post, maybe it’s time to start asking the cis people in our lives to consider stockpiling hormones for us if we anticipate not being able to afford out of pocket options. (Of course this would be illegal and different people have different risk tolerance for breaking the law so I probably would not hold it against someone if they’re uncomfortable doing this, but it still might be worth asking…) Ask folks if they can help you research and brainstorm funding and access alternatives to prepare. If trans-specific asks feel uncomfortable, then recognize that you navigating all of this takes a lot from you and maybe it would be helpful to have someone body double or meal swap with you (where you take turns cooking for each other one day a week or something) — something that makes it even just a little easier to take all this on. This is also all part of how we strengthen relationships - seeking, receiving, and giving help, so it has multiple layers of benefit.

• Have fun. Play. This is all so freaking serious. Our spirits need feel the psychological safety and freedom that comes with creativity and levity. I mentioned Pony Sweat earlier. They’re a “fiercely non-competitive” dance aerobics class that encourages letting go of the moves if you can’t or don’t want to follow, and they have recorded and live online classes if you’re not local to the LA area where they’re based. They also have a lot of different kinds of content, accessible to different bodies and abilities. I find it a great opportunity to combine joyful movement with silliness. There are lots of other ways to do this too. How can you add a few more minutes of goofiness in your life? How can you increase time spent being creative? What’s something really fun you can plan in the next month?

• Seek awe. Even when a lot of the world sucks to extents beyond description, there are also incredibly cool elements to this planet and humans and our lives. Awe may come in the form of an incredible vista after a hike — or when you pull off at a scenic view in your car. It can also come from thinking about all the anatomical systems at play to make your cat be able to jump up on the counter they’re not supposed to be on. I think trans people finding awe in our bodies is both healing and radical, because most of us have some troubled histories with these flesh sacks and miraculous anatomical systems. Watch a youtube video about how breathing works and then think about that while you breathe. Holy shit. It’s truly incredible that you can breathe. Look closely at the bloom of a flower - literally any flower. Or the leaf — leaves don’t get enough credit. No bloom supremacy here! Truly, study the plant life around you: you might be amazed at what you see. Pay attention to the birds in your neighborhood, the insects. How do they do what they do?! Incredible! Awe-inspiring. Technology, too. How the heck am I hitting keys on this piece of metal and plastic and then it’s forming words on the screen of a device it’s not wired to - and then will be published and somehow end up on all of your screens?! Sorry, that’s WILD. I recently posted to my private instagram a selfie with the celebratory note that I am a marvel of nature, modern medicine, and community. The fact that our society has decades and decades of knowledge about how to help people with presumably no Y chromosome grow beards and lower their voices and safely remove body tissue that causes us pain…. that we know how to help people who never developed breasts in puberty grow them later in life. Come on? That’s wonderful. Now, none of this makes having to fight for access to healthcare less shitty but it transforms what it means to have shitty things be a part of this life. They don’t get to be the whole story.

• Seek pleasure. Similarly, suffering and struggle don’t get to be the whole story. Remember that you are equipped with the biological mechanisms to feel good. And take advantage of that when you can. Savor that cup of coffee and that warm breeze. Have an orgasm! Close your eyes and let the endorphins wash through you after a bit of cardio. Feel the laughter echoing in your body and spirit while you watch or read or hear something funny. If you’re miserable, your brain is more likely to seek misery-inducing inputs and interpret neutral or even positive inputs negatively. So we have to practice pleasure-seeking and experiencing with intentionality. And I like to start small.

• Think of the ones ahead. Trans elder and beautiful musician Beverly Glenn Copeland has an album called The Ones Ahead that I treasure and return to again and again. The poetic lyrics to the title track convey a message about the importance of engaging in life at least in part for the sake of the ones who follow us:

  In the dark night turning
  Beneath the star fields burning
  I see the ones, I see the ones ahead
  Circling on the reader
  Round the teacher, the giver
  I see their hearts and all the fear they've shared
  They beckon me
  
  [Refrain] Come, love can redeem
  Life is an art
  You have a part that's yours to play
  Come, show us your dreams
  Life needs your hand to do what you can
  In your own way
  
  This world is our combined imagination
  Your life, a precious personal creation
  What have you lеarned?
  What lessons earnеd, they say
  "Each of us to others is connected"
  If one of us is lost, we're all affected
  How will you live? What will you give today?
  They beckon me
  
  (roll on, river, roll on river)

  [Refrain]

  
  I'm casting my life on you, river (roll on, roll on, roll on, roll on)
  As it tumbles along to the sea
  (roll on, roll on, roll on, roll on)
  On the ribbon of stars to the giver (roll on, roll on, roll on, roll on)
  It's all of you
  It's all of me

  Similarly, Kai Cheng Thom — therapist, thinker, and trans woman — wrote a beautiful piece about trans community suicide intervention titled “We Must Live for One Another,” and in it she shares “It is often this commitment to the future of trans people around me—the future of my loved ones, my trans sisters, brothers and siblings, the future of my trans mentees and daughters—that keeps me going and gives me strength in the midst of hopelessness and horror.”

• Practice recognizing the ways your life matters. From that Kai Cheng Thom piece:

  Something I have learned about suicide through these moments is that it is deeply human to think about ending your own life, particularly when the dominant culture is doing its level best to crush you and destroy everything you love. Something else I know is that suicide and suicide prevention are deeply political: our lives do in fact matter, in the grand scheme of things, and it is in the interest of fascism, imperialism, transphobia and every other kind of oppression to try and convince us otherwise. In a world that wants so badly to kill us, every breath we take is a rebellion, and every time we walk another trans comrade or sibling back from the brink of despair is a victory beyond measure.

  Take note of the rebellion of your living. Of the impact your presence has. Of the impact staying alive has as your resistance to bending to the will of fascism. Celebrate the roles you play in others’ lives, even in the lives of those who you will never meet but may be looking back into history in some distant future and for whom your survival (perhaps even unnamed) will mean something.

• Find things that feel really good from a gender standpoint that aren’t contingent on hormonal or surgical care and really lean into that. Clothing, activities, people it feels good gender-wise to be around, ways of talking, voice training, hair styles, sex and/or kink stuff, makeup, ways of moving, accessories, tattoos. Get creative, experiment, and invest time and emotional energy in mastering elements of this that take skill if the end result is appealing to you. If you’re in an area with active trans community there are often clothing swaps or “community closets” and sometimes orgs offer micro grants for haircuts, makeup, binders, tucking underwear, etc.

• Identify things to look forward to. I wrote a whole thing about this so I’ll just direct y’all there:

  An Intervention For the World Weary Who Are Terrified of What's To Come

• Root into trans history and art. In addition to turning to our histories for practical guidance on how to access care outside of insurance coverage and/or traditional medical pathways, trans history also teaches us that vibrant and meaningful lives can be lived in the margins and within periods of violent oppression. The org Queer AF recently hosted an incredibly rich Trans History Week and has a hub on their website with articles, videos, podcasts, and even a workbook. Their instagram has shareable content about our histories, as well. There’s incredible trans-led, researched, and authored trans history work coming out these days, from the new biography of Marsha P. Johnson by artist Tourmaline to the historical fiction novel Lilac People. I actually have a handful of suggestions of excellent trans history media on a resource page I recently developed here: https://sebastianmbarr.substack.com/p/references-and-resources-from-my . In that resource list you’ll see some references to trans musicians and visual art. I have found art (including music) to be an incredible source and expression of trans beauty and power.

• Read Kate Bornstein’s classic text that is basically a master class on this subject. In 2006, self-proclaimed transsexual genderfreak Kate Bornstein published a book titled Hello Cruel World: 101+ Alternatives to Suicide for Teens, Freaks, and Other Outlaws. The second edition was just released last month. This is a book about staying alive in cruel world and it’s beautiful.

I offer all this with so much love and rage and pain, friends. Solidarity. We will see this through.

By Coyote Snout

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Post script for the cis readers:

Thanks for being here. We need your help, too. First, tell everyone you know about this element of the spending bill. Take up the actions suggested by Mira Lazine and Mady Castigan in the substack I linked to above. See what local or national trans orgs are doing about this and figure out how to support them. Show your support for trans folks publicly, as well as your outrage about this particular action and the whole mess of anti-trans actions taking place — so trans people see that you care. And read this incredible guide by Anna Marie, PhD (aka Dr. Anna Marie LaChance), and share it far and wide!

Every Way Cis People Can Help Trans People Right Now (Ordered by Level of Engagement)