In March 2023, Minnesota established itself as a “trans refuge state” when it enshrined protections for patients seeking gender-affirming medical care and healthcare providers alike. Minnesota is joined by 13 other states and the District of Columbia (D.C.) in maintaining this type of ‘shield law,’ referring to legal protections that would shield genderaffirming healthcare from federal changes from President Donald Trump’s administration.
For trans people living in states without shield laws, access to care can hinge on personal circumstances. Much of the anti-trans legislation has specifically targeted gender-affirming medical programs for people under 18. 27 states currently have laws in place that limit access to pediatric gender-affirming care.
While the majority of Macalester students are over 18, the rise in antitrans legislation nationwide still complicates access to healthcare for trans college students. One trans student, who wishes to remain anonymous for safety reasons and will be referred to as Student A, receives gender-affirming medical care from the Laurie Hamre Center for Health and Wellness and is considering what that care will look like after graduation.
“It’s so easy [to be trans] at Mac,” Student A said. “I do sometimes wonder what it’ll be like after [graduation]. Having to navigate that kind of makes me uneasy, and I’m not looking forward to it.”
How did Minnesota get here?
In the past ten years, gender-affirming care has become a household term across the United States and is frequently in the political spotlight. However, its prominence tends to obscure its meaning, according to Women’s, Gender and Sexuality Studies (WGSS) Chair Myrl Beam.
According to Beam’s definition, gender-affirming care is any way that people “bring their gender embodiment closer to their sense of self.” By that definition, most people, transgender or not, benefit from some form of gender-affirming care, whether that means undergoing surgery for gynecomastia or using a gym membership or makeup. Still, gender-affirming medical care for trans people receives the most political attention.
While other gender-affirming care providers, such as Children’s Minnesota, have faced legal challenges resulting in temporary pauses to gender-affirming care programs, Hamre has remained unaffected by these developments. According to Beam, that’s because Hamre is less reliant on federal funding and research grants.
In March, Minnesota’s Attorney General Keith Ellison, joined by 21 other states and D.C., filed a lawsuit against the United State Department of Health and Human Services (HHS )for withholding federal funding to hospitals that bill Medicare and Medicaid with pediatric genderaffirming healthcare programs. A federal court’s ruling in Ellison’s favor last month allowed Children’s Minnesota to resume these services.
But the impacts of HHS’s policy, outlined in Trump’s “Big Beautiful Bill,” are not unique to hospitals in Minnesota. HHS and Centers for Medicare and Medicaid Services rolled out the decision to prohibit the allocation of Medicaid funding to gender-affirming care for minors in December 2025. Reports following the decision indicated that this would impact the majority of U.S. hospitals. 4,832 hospitals and their off-campus clinics would be impacted, affecting more than just patients seeking gender-affirming care.
“The number of trans people that [most hospitals] serve is minuscule compared to the number of people that they serve who are diabetic Medicaid recipients,” Beam said. “If [those hospitals] receive federal funding, … or [their] medical services are paid for through Medicaid reimbursement, then [the federal government] can refuse to give [hospitals] that funding if [they] provide [gender-affirming care]. If they’re treating 100 trans kids and 50,000 diabetic Medicaid recipients — I don’t want those 50,000 diabetic Medicaid recipients to no longer be able to afford insulin.”
Hamre’s Executive Director Jen Jacobsen and Medical Director Steph Walters confirmed that these developments have not led to any changes in Hamre’s gender-affirming care services.
The Hamre Center’s genderaffirming care program includes estrogen-based and testosteronebased hormone replacement therapy (HRT), but does not include any gender-affirming surgical procedures. It also doesn’t include some cosmetic forms of gender-affirming care, like laser hair removal.
“Our clinical commitment to our students remains unwavering,” Walters wrote in an email to The Mac Weekly. “Because we provide medical consultations at no cost to students, we are able to maintain a consistent safer haven for care, regardless of the shifting federal landscape.”
Macalester’s position as a private college in Minnesota makes it uniquely situated to withstand these attacks, according to Beam.
“[Macalester] is not primarily funded through public funds in the way that the Fairview [Health Center] at the University of Minnesota is,” Beam said. “It’s not supported primarily through Medicaid reimbursement.”
Still, for international students and students coming from states with more restrictions on gender-affirming healthcare, seeking gender-affirming care at Macalester and afterwards can come with more considerations and complications.
“The primary barrier is often ‘legal uncertainty’ — students worry about the continuity of their care when they leave campus,” Walters wrote. “We deal with this by being proactive: we provide bridge prescriptions where [it is] legal, offer robust documentation of their medical history if they need to transfer care to another provider, and utilize our referral network to help students find ‘safe harbor’ providers in other jurisdictions or in online services when possible.”
Beja Puškášová ’26, an international student from the Czech Republic, decided that she wanted to seek gender-affirming medical care during her time at Macalester. For Puškášová, Hamre’s program removed one of the largest barriers to gender-affirming medical care — getting a prescription.
Last year, the Czech Republic stopped requiring surgery for an individual to legally change their gender marker. Prior to the law’s enactment, this surgery involved castration for trans women. However, Czech legal and medical progress towards more accessible genderaffirming medical care does not match the social environment for Puškášová.
“Back home, maybe the laws are better now, but the people are not,” Puškášová said. “I still get called slurs. People call me ‘it’ pronouns like I’m some animal. Right now, I don’t feel physically unsafe [back home], but here, I feel more physically safe.”
A trans student, who wishes to remain anonymous for safety reasons and will be referred to as Student B, came to Macalester from Missouri. Their home state has seen numerous restrictions on gender-affirming care and proposed bills that would bar many transgender people from public restrooms.
“Growing up in a city in a conservative state is hard because the city itself is maybe more progressive and pushing for certain things, but it’s getting pushback from the state legislature,” Student B said.
Student B also began accessing gender-affirming medical care through the Hamre, and has since switched to a provider in Missouri who specializes in trans healthcare.
Community-led gender-affirming care
Scout ’22, who has asked to use her first name only for her physical safety, co-founded Twin Cities Trans Mutual Aid (TCTMA) in 2023 to address barriers for transgender people and foster spaces for queer and trans communities. Since its founding, the grassroots organization has distributed more than $150,000 to transgender people requesting financial support. These funds primarily come from benefit shows at which TCTMA tables for donations.
“We have an ethos of trusting people, and especially trusting poor people to know what is best [for themselves] and not assigning that you have to use this money on gender-affirming care,” Scout said. “There are trans mutual aid projects in the country that restrict [how funding is used], and … we recognize that transness comes with a massive intersection of marginalizing factors in your life, namely financial marginalization.”
A 2022 report from the Human Rights Campaign shows that transgender women, on average, earn roughly 60 cents for every dollar earned by the average American. In this dataset, the ‘average American’ refers to the average reported by the U.S. Department of Labor Statistics. Transgender men and nonbinary individuals see similar disparities, earning roughly 70 cents for every dollar the average American earns.
Although Minnesota has designated itself as a transgender refuge state, many transgender Minnesotans still face financial and legal barriers to accessing gender-affirming medical care. MinnesotaCare, the state-funded healthcare program for residents with lower incomes, offers full coverage for the majority of gender-affirming medical treatments. However, as a part of a bipartisan budget deal at the end of the 2025 state session this past January, most undocumented Minnesotans are no longer covered under MinnesotaCare.
In addition to her work with TCTMA, Scout helps transgender people access health insurance through the Aliveness Project, an organization that supports Minnesotans living with HIV and AIDS. As a mentor coordinator for Aliveness Project, Scout sees healthcare barriers for undocumented transgender people placed firsthand.
“I had a couple of clients that had booked an appointment with me when they could have gotten [MinnesotaCare], and then by the time the appointment came, I had to tell them the law changed and they could no longer get on health insurance,” Scout said. “That was a horrible conversation to have.
Gender-affirming care at Mac
For trans students looking to access gender-affirming medical care at Macalester, the move to college is often a fresh chance to explore their goals for transition.
Student A was raised in a conservative community in the U.S. In that community, Student A described an environment where living as a trans person would have made him subject to familial and social rejection, in sharp contrast with the social environment he found at Macalester.
“Growing up, you hear a lot of the time ‘It’s okay for other people to be this way, but you can’t be this way,’” Student A said. “Coming to Mac, that was kind of a difficult adjustment. All of a sudden, [being openly trans is] okay.” Even now, sometimes “it’s still kind of odd to know that [being trans] is okay” for Student A.
Student A, Student B and Puškášová each described accessing gender-affirming medical care through the Hamre Center as ‘easy.’
Puškášová started hormone blockers, decreasing the levels of testosterone in her body without increasing estrogen levels, before taking HRT. Before coming to Macalester, she had never met another openly transgender person receiving HRT, and was apprehensive about the effects.
“Here, it was very easy [to get access to gender-affirming medical care],” Puškášová said. “I [said] I just want to be a girl,’ and I’ve been [socially transitioning] for a year, and … I like it. And then [the practitioners at the Hamre center] asked me things like ‘Do your friends support you? Do your parents support you?’ Just relevant questions that, back home, they wouldn’t ask you. That is a big privilege.”
In an email to The Mac Weekly, the Hamre Center said that they use the “Gender Affirming Lifespan Approach (GALA)” approach to clinical gender-affirming care.
“[GALA is] a holistic, evidence-based approach where we partner with students — using an informed consent model — to align their physical selves with their gender identity, whether through hormones, referrals, or simple validation of their lived experience,” Walters wrote. “We use a ‘meet the student where they are’ approach. While we respect that many Macalester students are highly informed, our role as clinicians is to ensure a comprehensive ‘informed consent’ process.”
“Usually my opening line… is something like ‘what, if anything, do you already know about these medications’ or ‘when you picture yourself on these meds, what do you understand to be [the] timeline of effects, possible unwanted effects, etc’” Walters wrote in an email to The Mac Weekly.
The physical impacts of HRT, such as those in muscle mass, voice and hair growth, onset somewhere between 1-3 months, and often don’t reach maximum effect until three or more years of continuous HRT. Student A explained that these changes often accompany a degree of personal growth.
“You take the medication and then it helps you adjust to being a person a little better,” Student A said. “My goals and my identity are shifting, and that’s something that’s really easy to reckon with at a place like Mac that’s so accepting.”
For Puškášová, Macalester’s identity collectives, the greater trans community and her own studies have been pivotal in her experience of gender-affirming care.
“I have mostly been just trying to accept my body in terms of my relationships, reimagining my body, reading trans stories, trans philosophy,” Puškášová said. “I think that’s helped me the most.”
Hamre’s counseling services, which come at no additional cost for all enrolled Macalester students, also serve as a form of gender-affirming care for some students, according to Hamre’s Director of Counseling, Sara Pournoor.
“We also understand that social and medical transition are not mutually exclusive; it’s up to you what feels most comfortable and aligned,” Pournoor wrote in an email to The Mac Weekly. “Hopefully, this allows space for students to ask questions and build gender literacy. Thankfully, Hamre uses an integrated healthcare model; this increases the possible clinical support and care coordination.”
Gender-affirming care after Mac
Although the Hamre Center has established practices to make the transition in primary care providers easier for trans students after graduation on a clinical and legal level, many of the biggest challenges facing students after Mac are difficult to solve with documentation and paperwork.
“In Missouri, there’s a lot of legislation being passed right now that is pretty scary, … whereas in the Twin Cities, it’s a [trans refuge state,] and so I feel more myself up here,” Student B said. “It’s easier to just exist and feel normal, so I plan on staying up here. In terms of gender-affirming care, I feel secure in still being able to access it for now, and I have great communication with my provider, which is helpful. But even if that sort of stuff goes away, I feel confident in community resources. I know that I’ll be okay.”
Scout started HRT at Family Tree Clinic during her time at Macalester, and found connecting with the greater Twin Cities trans community to be a pivotal form of non-medical gender-affirming care. She spent the first two years of her transition, coinciding with the COVID-19 pandemic and remote learning at Macalester, “without being around any other trans women.” That changed after graduation.
“I connected a lot more with trans people who didn’t experience some of the most pivotal experiences of transness in a relatively sheltered academic environment because I felt like there was a layer of understanding of the realities of being a trans person in this world,” Scout continued.
For Scout, the general lack of knowledge about gender-affirming healthcare and how it interacts with other medications has been a problem across providers. In a 2024 study of barriers to healthcare for trans people, 25 percent of respondents reported being called by their previous name or misgendered by a healthcare provider.
“There’s just so much that I was forced to learn on my own that I didn’t get from peers, that I didn’t get from Macalester, that I didn’t get from any institutional health care — that I genuinely got from talking to other trans girls on the internet and reading Reddit and compiling anecdotal experience,” Scout said. “But I’m very happy with where I’m at in my transition now, and it’s empowering. But I cannot tell you the amount of times where, for example, a psychiatrist would start me on a new med without knowing how it interacted with estrogen.”
In an already uncertain medical landscape, recent legislative restrictions and insurance issues only threaten to compound that knowledge gap. What’s more, barriers to gender-affirming care often accompany broader forms of oppression for trans people. Beam views current attacks on gender-affirming care as just one piece of a broader attempt to control trans access to public life, visible in waves of accompanying legislation across the country that attempt to control gender expression and trans presence in bathrooms, homeless shelters and schools.
Beam also notes that the scope of these attacks expand beyond just trans people. To right-wing politicians, Beam points out, “‘gender ideology’ encompasses a bunch of things. For them, it also encompasses things like reproductive freedom.”
According to Beam, current attacks on gender-affirming care aren’t really about gender-affirming care at all.
“It’s about limiting the lives of the people who might challenge them,” Beam argued. “Whether it’s young people who are raising kids at 16 because they couldn’t get abortions, or people who are struggling with jobs because they don’t have unionized workplaces, or people who are unable to vote because of voter suppression or people who are struggling with with like depression and dysphoria because they’re not able to access gender-affirming care, it does the work of concentrating and maintaining their power.”
