As soon as he turned 18, old enough to determine his own health care, Henry Trettenbach began medically transitioning with hormone replacement therapy (HRT). He was able to continue the process without interruption after starting his freshman year at the Rochester Institute of Technology (RIT), thanks to Dr. Annamaria Kontor: the staff physician at the university’s student health center, who was trained to prescribe and monitor gender-affirming hormones.

“I really liked her,” Trettenbach, now 20, told Rewire.News. “She was more thorough than my previous doctor. When I wasn’t feeling well, she even gave me a recipe for soup. She had a basic decency.”

Early last summer, however, Kontor contacted Trettenbach to say she could no longer treat him: She had been fired for providing HRT to transgender students.

“I was devastated,” Trettenbach recalled. “I had just been denied health care. I felt like I didn’t matter for a few days.”

Trettenbach’s initial hurt at being denied HRT turned to anger. “I need to fight [the policy]. It creates a hostile environment,” he said. “If you deny health care to trans students, it’s a way of saying we are less human or are invalid.” Trettenbach spoke out to local reporters criticizing RIT’s actions, and he testified on Kontor’s behalf at her internal hearing. He also filed a Title IX complaint with RIT, on the basis that federal law states that it is illegal for any institution that receives federal funding to discriminate on the basis of sex. (The Affordable Care Act also mandates that providers can’t deny health care on the basis of sex, although there are indications that the government will not move to enforce that.) But the suit, he says, “went nowhere.”

Last July, the Reporter, RIT’s student newspaper, obtained a copy of Kontor’s termination letter, which stated: “The Student Health Center’s practice prohibits prescribing hormone therapy for the purpose of gender transition.” Kontor countered that she had been treating transgender students for months, with the university’s support. An internal grievance committee found that RIT had not given Kontor a written warning before her dismissal, per policy; the committee recommended that the Student Health Center “move as quickly as possible to offer hormone therapy to transgender students.” Kontor also filed a complaint with the New York State Division of Human Rights on the basis that she had been discriminated against for providing care to transgender students. Last December, a state investigator found that RIT had “no policy regarding hormone therapy for transgender students” and no documentation to prove Kontor had been ordered to stop prescribing hormone therapy. However, the university did not reinstate Kontor.

RIT has declined to comment on Kontor’s dismissal. But spokesperson Bob Finnerty stated via email, “Students can expect the Student Health Centers’ staff to be sensitive and responsive to Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex and Asexual students’ medical issues. In terms of hormone replacement therapy, we are currently reviewing services that exist on the RIT campus today.”

RIT is hardly unique in its decision to block student access to HRT on campus. Only about 85 of 4,700 colleges and universities in the United States reported to Campus Pride—a national nonprofit that rates how well U.S. colleges serve the needs of LGBTQ students—that they cover gender-affirming surgery and HRT under their student health insurance. Another 23 schools reported they cover only HRT. Genny Beemyn, coordinator of Campus Pride’s Trans Policy Clearinghouse and director of the Stonewall Center at the University of Massachusetts at Amherst, was unsure what to make of these numbers, given how many schools express solidarity with trans students in other ways.

“Hundreds of schools have name change and housing options, so it is noticeable that the hormone list is so much shorter,” Beemyn told Rewire.News. “If a school is going to do some important trans support, it seems like they would do hormones too.” But they added that most U.S. colleges do not offer HRT on campus, including some that cover the medical treatment under their student health insurance.

Transgender advocates say colleges are under increasing pressure to make HRT available, as more students come out and seek the medical treatment. “The last five years there has been a real growth and awareness of youths learning about transgender issues,” said Ren Massey, an Atlanta-based psychologist who has treated hundreds of transgender patients. “They are better able to articulate their needs and concerns to parents and institutions.”

Not all transgender or gender-nonconforming individuals experience gender dysphoria: the distress one feels if the sex they are assigned at birth does not match their gender. And among those who do, there is a wide range in preferred treatment, says Faughn Adams, an Atlanta-based psychologist who worked at Emory University’s counseling center for nine years. “Some people may take a low level of hormones and never socially transition and that’s enough to alleviate the gender dysphoria. Some have intense distress that can’t be alleviated without surgery.”

For those who experience significant dysphoria, HRT can be lifesaving. In 2015, the National Center for Transgender Equality conducted an anonymous online survey of nearly 28,000 transgender people in the United States and U.S. military bases overseas. Forty percent reported having attempted suicide at some point in their lives, compared to 4.6 percent in the general population. Forty-one percent of trans people said the age they were at their latest suicide attempt was 18 to 24. One-third of the respondents reported having a negative interaction with a doctor in the previous year related to being transgender, “such as verbal harassment, refusal of treatment, or having to teach the health care provider about transgender people to receive appropriate care.” And 23 percent didn’t seek health care when sick because they feared being mistreated.

It is unclear to what extent the extraordinarily high rate of mental health issues in the transgender community is due to untreated gender dysphoria versus the stress caused by discrimination in accessing housing, employment, and health care. Many transgender individuals also face bullying, violence, and rejection by family and friends. “This all adds up,” said Adams. “If you have multiple stressors, you have higher rates of depression, suicide attempts, and [suicide] completions. That said, trans people have intense resilience and many find and get success and feel happy.”

But by denying hormone therapy on campus, colleges create additional complications for transgender students at an already high-stress time in young lives. “It may make them feel not worthy or that it’s too much trouble to provide them services,” Massey said. Transgender youth who can’t safely access hormone therapy sometimes self-medicate with alcohol or illicit drugs, says Massey, who himself transitioned at 47. Others buy hormones illegally on the internet or the street.  “Sometimes they get desired effects,” said Massey, “but there’s always the risk you can overdose or experience other complications.”

After he was able to begin hormone therapy, life got appreciably better for Reed O., a a 2017 graduate of Cornell University. “Prior to, and during the early stages of my physical transition, I was isolated, anxious, and depressed,” said Reed, a trans man who asked that Rewire.News not use his last name. “I made few friends, avoided new activities, and struggled to maintain a 3.2 GPA.”  After he began transitioning, he became more sociable, assumed a leadership role in several campus organizations, and began earning straight As.

“Physical transition gave me something which so many people take for granted: the ability to exist in my own body, and to be seen by others, in the most fundamental way, for who I was,” said Reed, adding that Cornell’s willingness to provide hormone therapy made him feel “safe, welcome, and respected.”

Some schools direct students off campus for care. After Kontor’s firing, RIT referred transgender students to community providers, like Trillium Health about seven miles away. But that comes with complications: Back in May 2017, new patients had to wait five months for an appointment, said Patrick Pitoni, Trillium’s transgender care coordinator. Pitoni was hired last October to streamline intake. Now the wait for a first appointment is about 30 days, he says.

By contrast, some university representatives say that offering HRT on campus streamlines care for students who need it. “One of the main reasons colleges and universities have student health centers is to support the health of students in a way that they can be successful, graduate, and have productive lives after college,” said Dr. Giang Nguyen, executive director of Student Health Service at the University of Pennsylvania. It’s been more than five years since Penn began offering HRT to transgender, gender-nonconforming, and nonbinary students. “If they have barriers to care and need to navigate a complex health system, it’s harder for them to focus on academics.”

Student health center staff interviewed for this article described gender-affirming HRT as relatively easy and inexpensive to learn and provide. Some health centers enlist a knowledgeable physician to train their medical staff; others send health-care providers to national conferences where HRT is taught. Over the past three years, the World Professional Association for Transgender Health has trained 2,000 primary care doctors and physicians assistants to provide HRT. Physicians can also visit the website of the Center for Excellence for Transgender Health at the University of California, San Francisco to learn the guidelines for prescribing gender-affirming hormones.

Columbia University began monitoring hormone therapy in 2011 for incoming students who were already transitioning. Two years ago, the university brought in a physician and a mental health counselor to train medical staff how to initiate hormone therapy. Staff say this service is covered by student health insurance.

When students can access hormone therapy in the same place their other health needs are met “the process seems much more accepting and supported,” says Daniel Chiarilli, assistant director of the Gay Health Advocacy Project for Columbia Health. “It reinforces the idea of continuity in care.”

While the services available at many student health centers have expanded greatly over the years, smaller schools—some of which have staff nurses but no physicians—may not have the resources to provide gender-affirming hormone therapy, Chiarelli says. Only physicians, physicians’ assistants, and nurse practitioners can monitor and prescribe hormones, though nurses or social workers can help with assessments conducted before treatments.

Grayson Stevens, 18, is a rising sophomore at Ithaca College in upstate New York, which has twice made Campus Pride’s list of the top-ten most transgender-friendly schools in the nation. The school, which has an undergraduate student enrollment of about 6,200, has offered transgender housing for almost 15 years, uses gender-affirming names in student rosters and on ID cards, and employs mental health counselors knowledgeable about LGBTQ issues. Yet, its health center does not offer hormone therapy. Transgender students seeking it in town must take a bus to the local Planned Parenthood. So Stevens continues to be treated by his doctor in Rochester, New York, during visits home.

Stevens has no regrets that he chose Ithaca College, but wishes that administrators would reconsider their policy on HRT. Referring students off campus for hormones sends the message that transgender students are “kind of a burden to the campus, and the health center, specifically … in the sense of time, resources—almost that we’re not worth it in a way,” noted Stevens.

Like Reed at Cornell, Stevens has found that hormone therapy decreased his depression and boosted his overall mental well-being. “Just being comfortable in my own skin … navigating the world … is so much easier because I’m living as the person I really am inside,” he said. “Before, I struggled to do everything. Just getting up and out of bed, going to school, interacting with people—was all very exhausting for me. Now, I’m enjoying life.”

“A lot of people think we’re such small portion of the [student body] it doesn’t matter that much, but to that small portion of people, it matters quite a bit,” he said. “It’s really important to treat us with the same respect and care.”