When someone set ablaze the only Planned Parenthood health clinic in Knoxville, Tenn., earlier this year, the center was immediately inundated with patients' questions of what will happen to their care – but it wasn't just about abortion services.
"We were flooded with calls more from our gender-affirming hormone patients than from any other type of patient because we are a continuing source of care for gender-affirming patients," Ashley Coffield, the chief executive officer of the Planned Parenthood of Tennessee and North Mississippi, told NPR.
"It was very upsetting and scary to them when we were suddenly gone."
When reproductive health clinics close, it's not just access to abortions that are lost, but also an array of services — like birth control, sex education and gender-affirming treatments — that can disappear.
And some of those services, like hormone replacement therapy, require patients to see their physician more regularly than typical patients visiting for abortion or birth control services, Coffield explains.
That's why she and other providers are particularly worried about how future clinic closures may impact transgender and nonbinary patients, who already face many barriers to health care. The threat of losing access also comes as some states ramp up legal efforts to restrict such care, particularly for transgender youth.
Gender-affirming care includes medical, social and psychological support to help a person understand and appreciate their gender identity. That care could be helpful to anyone but is especially life-saving for transgender and nonbinary people.
Dr. Bhavik Kumar, the medical director of primary and trans care at Planned Parenthood Gulf Coast, told NPR the community faces a crisis.
"With trans care, this is not a drill," he said. "As much as people are concerned about abortion care and access to abortion – which is very important – we should also be concerned about trans people and preserving their humanity and dignity."
Both gender-affirming treatments and abortions are essential but stigmatized health care, providers say
Before the fire, more than 700 of the Knoxville clinic's 4,000 patients sought hormone replacement therapy in 2021, according to Coffield.
That makes sense, she added, because clinics that perform abortions are often well-positioned to provide gender-affirming care.
"Both gender-affirming hormone care and abortions are essential health care that aren't offered by most providers, and both are stigmatized services," she said. "So the same values we use in abortion care — like self-determination, respect and a nonjudgmental approach to health care — translate really easily into serving our gender-affirming hormone care patients."
Kumar said that's why more than half of all Planned Parenthood health centers offer gender-affirming care including hormone replacement therapy, mental health services and support with legal processes like name changes.
Over 35,000 of Planned Parenthood's patients nationwide sought gender-affirming hormone replacement therapy in 2021, and that number doesn't include trans and nonbinary people who relied on other services, according to Kumar.
After the fire, transgender and non-binary patients scrambled to find new providers
When Jake Gutridge received word that his Planned Parenthood health clinic burned down, his immediate thought was, "Oh God, what am I gonna do?"
Gutridge told NPR he had been relying on the clinic to receive hormone replacement therapy for nearly two years. At the time, Planned Parenthood was the only provider he knew of that was nearby and didn't require insurance.
For weeks, he tried to refill his medication with the Planned Parenthood centers in North Carolina and Georgia, both of which are over four hours away. But appointments were booked up to a month, he said. Gutridge quickly fell into withdrawal, suffering from mood swings and anxiety.
Eventually, he was connected to a gender-affirming physician in east Tennessee but Gutridge largely chalked it up to luck. Eight months later, people seeking hormone replacement therapy are still reeling from the fire and reaching out to Gutridge for help.
Since the reversal of Roe, Gutridge said he wouldn't be surprised if other communities experience a similar fallout.
"There's a lot of people who think gender-affirming care is more of a privilege, but it's necessary health care," Gutridge said. "I used to feel trapped in my body, like I was constantly fighting against myself. When I started testosterone, I finally felt like I was in control. It saved my life."
Providers also prepared for a rush of new patients
After the fire, the Planned Parenthood affiliate continued to offer services through telehealth. But even then, Coffield said only a fraction of their transgender and nonbinary patients could be served because of capacity constraints.
That's when local physicians began to see a surge of inquiries about gender-affirming care.
"We had an extremely huge influx of folks that had been displaced," Dr. Annie Kolarik told NPR. She is a primary care doctor whose office is located a few miles from the former Planned Parenthood location.
At Cherokee Health Systems, Kolarik estimated that she now serves over 150 patients who had relied on gender-affirming care from Planned Parenthood – many of whom travel at least an hour to receive services. Before the fire, she had about 30 patients seeking that kind of care.
To meet the demand, Kolarik said Cherokee Health Systems set up an online appointment system to expedite scheduling and began using telehealth services. Doctors and other practitioners are meeting with patients on their lunch of administrative breaks.
"People should expect similar surges if places where Planned Parenthoods or abortion clinics that offer gender-affirming care end up closing," she said.
Choice Health Network, a provider in the area that exclusively serves HIV-positive patients and those at risk of contracting the virus, has also seen a higher call volume about gender-affirming treatments. It's considering expanding such services, a nurse practitioner at Choice Health Network told NPR.
"The fire seemed designed to send a message to all of us who support Planned Parenthood or who use its services – that we are not safe," Meg Gill said. "We need to continue to offer those services and, as much as possible, to expand them."
Even in states where abortions are outlawed, clinics are fighting to provide gender-affirming care
In areas where gender-affirming care is few and far between, clinics like Planned Parenthood are often the only place where transgender and nonbinary people access any kind of health care, said Kumar, who is in the Gulf Coast.
"When that's taken away, they're left sometimes with no options," he added.
So far, no Planned Parenthood clinics have closed since the Supreme Court's decision in June to overturn Roe v. Wade. Even in states imposing abortion bans, a spokesperson for Planned Parenthood's national organization told NPR their clinics are determined to stay open to continue offering services like gender-affirming care.
In that vein, the Planned Parenthood health clinic in Knoxville, Tenn., is planning to rebuild its office as well as launch a mobile health unit in the fall to keep providing support. That's despite the state planning to ban all abortion at the end of August.
"Everyone who knows us in Knoxville isn't surprised that we're reopening whether abortion is banned or not because they count on us for so many other services," Coffield said.
Independent providers, who tend to more financially rely on abortion services, are also fighting to keep their doors open.
In West Virginia, the Women's Health Center recently expanded its services to provide hormone replacement therapy– even as it might lose nearly half of its revenue if lawmakers enact an abortion ban, the clinic's executive director told NPR.
"We believe in patient-centered health care that honors autonomy and dignity of our clients. Expanding our service array to include gender-affirming hormone therapy is completely in line with that vision," Katie Quinonez said.
"No matter what happens to legal abortion in our state, we will continue doing everything in our power to expand and meet the health care needs in our community."