Photo essay: Reproductive health and gender-affirming care in post-Roe Texas

Published

I’m not a morning person, but I bolted out of bed at 4:20 a.m. on November 22, 2022. The long awaited day was finally here.

When I arrived at University Hospital in San Antonio later that morning, I was asked the same question over and over: “What are you here to do today?” Each time, I was confident in my answer. I was there to evict my fallopian tubes and IUD.

Last year, in a post-Roe v. Wade Texas, I chose to have my fallopian tubes removed. The journey to that decision was the culmination of prior choices I’ve made for myself and an urgency that Dobbs v. Jackson Women’s Health Organization — the case that overturned federal abortion protections — set into motion. It was the biggest choice I could make for my body and future, because the surgery was more than a form of birth control: It was also gender-affirming care as I continued to transition away from woman to being more me — neither a boy nor a girl.

In the medical landscape, hurdles abound for trans people. Experiences of dehumanizing comments, having to educate health care professionals and their staff, intrusive questions, refusing to acknowledge a person’s gender identity or to even provide care can make it hard for trans people to pursue medical care.

When seeking medical care, trans patients face “overt discrimination, fear of discrimination and past discrimination, experiences which limit your ability to want to walk in the door,” said Dr. Clayton Alfonso, an obstetrician and gynecologist at Duke University Hospital in North Carolina. Alfonso practices full-scope obstetrics, but finds abortion and gender-affirming care to be some of the most rewarding aspects of their work.

Click an image to read captions and view the full gallery.

Josie Norris poses in a patient room at UT Health during a pre-operative appointment. — Josie Norris poses in a patient room at UT Health during a pre-operative appointment on November 21, 2022 in San Antonio, Texas. “In the days leading up to surgery, I was feeling stressed. I didn’t know what to expect as a first time hospital patient. I felt certain yet nervous.”

Norris’ post-operative appointment on December 5, 2022, felt like a whole new experience from other visits to UT Health. “I felt the most at ease at the appointment than I had at any other visits. I felt so much more connected to my body.” (Josie Norris)

At their post-operative doctors appointment, Josie Norris poses in a patient room at UT Health OBGYN. — Josie Norris poses in a patient room at UT Health during a pre-operative appointment on November 21, 2022 in San Antonio, Texas. “In the days leading up to surgery, I was feeling stressed. I didn’t know what to expect as a first time hospital patient. I felt certain yet nervous.”

Norris’ post-operative appointment on December 5, 2022, felt like a whole new experience from other visits to UT Health. “I felt the most at ease at the appointment than I had at any other visits. I felt so much more connected to my body.” (Josie Norris)

Norris grabs medication from the medicine cabinet in their bathroom. — Norris takes medication before bed on September 29, 2022. “My mental health hurdles are in the lens I see the world from. However, I want to be clear — it is not a factor in my decision to not have children. My mental health wellness journey has so much to do with the person I am today,” Norris said. “Diagnosis and meds that worked allowed me the space for things other than anxiety and depression. It has been a part of becoming whole and able to imagine a future without kids, let alone a future.”

“I love being a source of a safe space that someone can come in and access care in a nonjudgmental way,” Alfonso said.

But that judgment-free space is rare. One-third of respondents of the 2015 U.S. Trans Survey reported at least one negative experience in the last year related to their gender identity while seeking health care, and 23 percent did not see a doctor when they needed care for fear of mistreatment. The Trevor Project found that 1 in 3 gender diverse young people reported not feeling safe to go to the doctor or hospital when sick or injured.

Abortion care and trans care are often siloed in conversation and news stories, but there are many people, like myself, who exist in the intersection of the two.
Josie Norris

Abortion care and trans care are often siloed in conversation and news stories, but there are many people, like myself, who exist in the intersection of the two. LGBTQ+ people who don’t identify as women but can become pregnant account for up to 16 percent of abortion patients in the country, according to a recent patient survey from the Guttmacher Institute. A 2021 study found that nearly 1 in 5 transgender, nonbinary and gender-expansive respondents who have ever been pregnant have considered ending the pregnancy without clinical supervision. A subset of those respondents, 19 percent reported attempting to end their pregnancy on their own. Reasons given ranged from structural barriers such as cost, insurance and legality of abortion to desire for privacy.

Norris goes through pre-op procedures for their salpingectomy at University Hospital. — Norris goes through pre-op procedures for their salpingectomy at University Hospital on November 22, 2022. “My mom is a nurse, and I have a huge admiration and respect for all the health care workers who took care of me,” Norris said. “This was my first time being a patient at a hospital and I felt very taken care of by my care team. I felt incredibly seen when a resident asked me my pronouns and made a note in my chart. After that point, I noticed an effort by people to refer to me in neutral ways. It made me feel safer.”

Grinning from under their mask, Norris is wheeled into surgery on November 22, 2022. “When my mother was 26 years old, she had me, her first born who could fit in her hand. When I was 26 years old, I had surgery to permanently never have children. I thought about that a lot, especially surgery day,” Norris said.

Norris grimaces in pain after their salpingectomy surgery. “The anesthesia was the most painful part of surgery. The pain from the salpingectomy itself was minor and manageable,” Norris said. “I’ve realized the most significant moments of pain in my life have been around my reproductive system.”

Norris checks out some bruising and swelling around one of their incision marks from their fallopian tube excision in their bedroom mirror at home on November 23, 2022.

Afternoon sun illuminated Norris’ lower abdomen a little over a month after having their fallopian tubes removed. “The scars were tiny but also my favorite of the many scars I have collected on my body,” Norris said.

Grinning from under their mask, Norris is wheeled into surgery. — Norris goes through pre-op procedures for their salpingectomy at University Hospital on November 22, 2022. “My mom is a nurse, and I have a huge admiration and respect for all the health care workers who took care of me,” Norris said. “This was my first time being a patient at a hospital and I felt very taken care of by my care team. I felt incredibly seen when a resident asked me my pronouns and made a note in my chart. After that point, I noticed an effort by people to refer to me in neutral ways. It made me feel safer.”

Grinning from under their mask, Norris is wheeled into surgery on November 22, 2022. “When my mother was 26 years old, she had me, her first born who could fit in her hand. When I was 26 years old, I had surgery to permanently never have children. I thought about that a lot, especially surgery day,” Norris said.

Norris grimaces in pain after their salpingectomy surgery. “The anesthesia was the most painful part of surgery. The pain from the salpingectomy itself was minor and manageable,” Norris said. “I’ve realized the most significant moments of pain in my life have been around my reproductive system.”

Norris checks out some bruising and swelling around one of their incision marks from their fallopian tube excision in their bedroom mirror at home on November 23, 2022.

Afternoon sun illuminated Norris’ lower abdomen a little over a month after having their fallopian tubes removed. “The scars were tiny but also my favorite of the many scars I have collected on my body,” Norris said.

Shortly before I moved from my home state of Michigan — which last year adopted a constitutional amendment to protect reproductive rights — to San Antonio in 2018, I had an abortion. At the time I thought I was a woman, and yet being pregnant brought a sense of disconnection and betrayal that I felt in my body. I realize now that can be described as dysphoria.

I never regretted that decision I made when I was 21. I am now working as the first out transgender staff photographer at the San Antonio Express-News. Over my time in Texas, I’ve documented the state’s six-week ban in abortion — the first in the country — and near-total ban post-Roe. I’ve photographed unique stories of pregnancy and choice, including a woman grappling with the risks of continuing to try to become pregnant and a woman who had to self-manage her medication abortion at home.

Watching all of this happen around me, I knew I needed to take major steps to never be pregnant again. At the time, I’d had an intrauterine device (IUD), but no form of birth control is 100 percent effective, and IUDs pose a high risk of complications should one become pregnant while using one. I became very concerned about the lack of options for options should I somehow become pregnant.

I was not alone in this fear: Google searches for female sterilization doubled from the week after news of Dobbs was leaked in May 2022. Alfonso saw a “pretty significant” increase of requests for sterilization surgeries in both his cisgender and transgender patients, often with a sense of urgency. In the six months after Dobbs, they estimate they did 10 to 15 more sterilizations a month than before the historic legal decision. A year and a half after the overturning of Roe v. Wade, Alfonoso has seen a decrease in sterilization among cisgender patients, but is still seeing a demand among trans patients.

Norris practices yoga in their living room at home. — Norris practices yoga in their living room at home on September 26, 2022, captured in a long exposure photograph. “After years of occasionally doing yoga, I started 2022 with over four months of daily yoga practice,” Norris said. “The benefits I felt were holistic and hard to sum up but I started hearing my intuition louder than before. When I step off the mat, I feel my body and mind reunited.”

With their cat Tillett checking in, a shaft of light shines on Norris’ face as they hang out at home. — With their cat Tillett checking in, a shaft of light shines on Norris’ face as they hang out at home on October 30, 2022. “When I was 21 years old, a condom broke in a casual relationship right before spring finals my first year of college,” Norris said. “I spent final weeks of class obsessively googling what the odds of me being pregnant were and taking pregnancy tests. After the semester ended, I took the last pregnancy test I had. I was about to move to Texas for an internship and had to act quickly. I was able to be seen two hours away a few days later for a medication abortion. My experience was a lonely one — at the time of my abortion only one person knew I was pregnant — due to shame and the stigma of abortion I had witnessed growing up a fundamental Christian. Later on, it was important to tell all my close friends what happened, because what is mentionable is manageable.”

Growing up homeschooled and fundamental Christian, child bearing was painted for me as the epitome of womanhood. It made me uncomfortable to see child birthing scenes and scared that it was expected of me, the oldest born and assigned female at birth in my large family. Now as an adult, I’ve realized that I was a trans kid who didn’t want to be a “mommy,” despite intense external pressures. In a post-Dobbs world, imagining the gender dysphoria I would face if I became pregnant again put knots in my stomach. The idea of creating a body that was incapable of becoming pregnant felt like a step of transition away from woman.

I was not alone in this. For some of Alfonso’s gender-diverse patients, the idea of pregnancy is one of the most dysphoric and classically feminine characteristic experiences they fear.

“The number of post-op visits where people cry in my office out of just pure joy that that part of their life is finished and they can continue to move on with themselves is very rewarding,” Alfonso said.

In a post-Dobbs world, imagining the gender dysphoria I would face if I became pregnant again put knots in my stomach.
Josie Norris

Gender-affirming care refers to a range of social, psychological and medical steps that transgender people take to express their gender that does not line up with the gender they were assigned at birth.

In the field of obstetrics and gynecology, such care is a spectrum. The gender-affirming care Alfonso provides largely centers on uterus tubes and ovaries, and whether patients want them to function or be a part of their bodies. But Alfonso also notes that gender-affirming care also includes providing pregnancy care that doesn’t assume gender in a field that is traditionally centered on cisgender women.

Josie Norris draws an artistic interpretation of their anatomy post-salpingectomy at their home. — Josie Norris draws an artistic interpretation of their anatomy post-salpingectomy at their home on December 19, 2023. “This artwork was important for me to make as I’ve seen so much beautiful artwork depicting uteruses, but none of them looked anything like my new system,” Norris said. “The surgery was not only a decision not to have biological children but also a claim of bodily autonomy and a moment of gender affirmation as a transgender nonbinary person who describes themselves as ‘not a boy or a girl — just me.’”

Ellie (whose parents asked her full name not be used) and Norris hang out on the floor as they play at Ellie’s home on January 24, 2023, in San Antonio. “About the same time I decided to remove my tubes as a permanent birth control option, one of my good friends and colleagues had her first baby, my first ‘niece.’ I am so excited about being this kid’s Auntie Josie. I adore babies, but I just don’t want one of my own.”

Photographed through a glass table with a puzzle in progress, Norris poses for a self portrait on January 21, 2023, at their home. Norris has come to realize they are on the spectrum in recent years. “The way my brain works as a neurodivergent person is a super power I am still getting to know.” (Josie Norris)

Baby Ellie (whose parents asked her full name not be used) and Norris hang out on the floor as they play at Ellie’s home. — Josie Norris draws an artistic interpretation of their anatomy post-salpingectomy at their home on December 19, 2023. “This artwork was important for me to make as I’ve seen so much beautiful artwork depicting uteruses, but none of them looked anything like my new system,” Norris said. “The surgery was not only a decision not to have biological children but also a claim of bodily autonomy and a moment of gender affirmation as a transgender nonbinary person who describes themselves as ‘not a boy or a girl — just me.’”

Ellie (whose parents asked her full name not be used) and Norris hang out on the floor as they play at Ellie’s home on January 24, 2023, in San Antonio. “About the same time I decided to remove my tubes as a permanent birth control option, one of my good friends and colleagues had her first baby, my first ‘niece.’ I am so excited about being this kid’s Auntie Josie. I adore babies, but I just don’t want one of my own.”

Photographed through a glass table with a puzzle in progress, Norris poses for a self portrait on January 21, 2023, at their home. Norris has come to realize they are on the spectrum in recent years. “The way my brain works as a neurodivergent person is a super power I am still getting to know.” (Josie Norris)

Going into the consultation in mid-September, my anxiety was heightened. For my first appointment, I dressed in a floral skirt to be more conventionally feminine. I was apprehensive about showing up as my full self in health care. I didn’t know how the OB-GYN, whom I’d never met, would react to my typical masc-of-center presentation. Would this provider have an issue with or ignorance about trans people? There was such a brief amount of time to make an impression on the doctor, and I didn’t have to be confusing or have to explain how I do gender. So I focused on what I could control, which is how I present myself.

We had a conversation about non-permanent birth control options, the increased risk of regret in patients under 30 and what could go wrong — which included pain, infection, internal organ damage and bleeding that could require a hysterectomy rather than just a salpingectomy, or the removal of my fallopian tubes. My ears perked up when my doctor told me that salpingectomies also may decrease risk of ovarian cancer. My OB-GYN proposed a surgery date in late November that I rushed home and put on my calendar. But still, I marked the date with a question mark. I was still afraid something would happen — that the surgery to gain control over my body would somehow be stopped.

More Like This:
More Like This: What it’s like to be a pregnant trans man in America

The surgery day arrived. Up to this point, no one had asked me my pronouns, and my visit summaries misgendered me in the notes, which did not feel good. At the hospital, a resident who did ask my pronouns and made a note in my chart helped me feel seen on this momentous day. Up until that moment, I had so many other things to ask and take in that I hadn’t worked up the nerve to correct a stranger on my pronouns.

Surgery was successful, and I woke up to see the residents, who got to learn from my “great anatomy” as my doctor put it, and thanked them with tears of relief in my eyes. Looking under my gown to see my new scars, I saw a body that felt a less woman and more me.

My experience navigating medical care as an out trans person was largely positive on the whole, despite a deep fear of being misunderstood and not believed by my doctor. I felt listened to and united with my OB-GYN. I felt like we were a team. I am privileged to have access to a doctor who looked like me, listened to me and my desire to take control of my future. With entire ZIP codes of San Antonio, the second largest city in Texas, lacking access to adequate health care and medical facilities, being able to access an OB-GYN, let alone one who listened to me and trusted my decision, is not always a guarantee for those with a uterus.

While savoring a slice of key lime pie, Norris reads a book at their kitchen table. — While savoring a slice of key lime pie, Norris reads a book on November 2, 2022, at their home. “Ever since I was a kid, I have been a voracious reader. Being a high school and college student kept me from being immersed in a book. Now that I have a ‘big kid job,’ I prioritize reading because I find it stretches my imagination.”

Norris repots a basil plant on November 17, 2022, outside their home. Norris has a green thumb and tends to a host of indoor and outdoor plants.

Sabra Renner and Norris watch TV together in Norris’ apartment on November 29, 2022. “My friends are my chosen family and I love being able to celebrate the joyous moments and know that they will also be there for me in the hard times too,” Norris said. (Josie Norris)

Norris repots a basil plant. — While savoring a slice of key lime pie, Norris reads a book on November 2, 2022, at their home. “Ever since I was a kid, I have been a voracious reader. Being a high school and college student kept me from being immersed in a book. Now that I have a ‘big kid job,’ I prioritize reading because I find it stretches my imagination.”

Norris repots a basil plant on November 17, 2022, outside their home. Norris has a green thumb and tends to a host of indoor and outdoor plants.

Sabra Renner and Norris watch TV together in Norris’ apartment on November 29, 2022. “My friends are my chosen family and I love being able to celebrate the joyous moments and know that they will also be there for me in the hard times too,” Norris said. (Josie Norris)

Six months after my surgery, I watched and documented the Texas legislative session. Numerous bills targeted trans people, such as Senate Bill 14 — which banned gender-affirming care for minors — and Senate Bill 15, which prohibits trans athletes from competing as their gender identity. Both laws are now in effect.

I saw Texans forcibly removed from the Capitol when they showed up to advocate for trans people in the state. From the House floor, camera in hand, I heard misinformation about gender-affirming care and lawmakers reducing people to their biological parts.

The politics in legislative bodies and public statements politicians make have a profound impact on trans people, particularly young trans people. According to a poll earlier this year by the Trevor Project, 86 percent of young trans and nonbinary youth say their mental health has been negatively impacted and 55 percent reported their mental health was “very negatively” impacted by legislation targeting trans people.

Given the landscape of Texas and the attacks and attempts around the country to delegitimize trans existence, it has never been more important to share stories of the diverse and nuanced lives trans folks lead.
Josie Norris

In Texas, the transphobic rhetoric and legislation has a direct impact on health care across the state. Days after SB 14 was approved by the House, doctors staffing Dell’s Children Medical Center in Austin, which provided services to cisgender and transgender youth, left after Attorney General Ken Paxton announced an investigation citing allegations made by conservative activist group Project Veritas. Paxton also launched a similar investigation into Houston’s Texas Children’s Hospital, the largest children’s hospital in the country, after leaked medical records of minors published by the conservative Manhattan Institute claimed gender-affirming care was being provided. Texas Children’s Hospital stopped offering hormone therapy to patients last year. After intense political pressure, GENder Education and Care, Interdisciplinary Support (GENECIS), the University of Texas Southwestern Medical Center and Children’s Medical Center Dallas, closed quietly in 2021, leaving patients without affirming care.

After a multiple hour tattoo session, Norris admires the tattoos on around their surgery scars and stomach. — After a multiple hour tattoo session, Norris admires their enhanced surgery scars and stomach on January 9, 2023, in San Antonio. “The sparkles I had tattooed on my stomach celebrate my surgery scars and a reclamation of my stomach — an area I have had a long and difficult relationship with alot of shame and self hatred towards the literal core of my body,” Norris said. “My tattoo is helping me see my soft tummy with love and compassion. My scars and tattoo feel like a celebration of this incredibly important part of my body that I am learning to love and trust.”

After a long day, Norris sits in thought before bed on November 8, 2022. “As a photojournalist, I have the honor of documenting history in San Antonio and Texas. However, from a personal safety perspective, I never can forget that I have Texan neighbors who I photograph that don’t think I should exist as my proud and authentic self,” Norris said. “Coming home to my personal space from assignments where I don’t feel totally safe is extra sweet.”

To help relieve the lingering effects of anesthesia, Norris walks laps around their driveway on November 24, 2022. “I was encouraged to walk — even when I didn’t feel like it — by other people who had similar surgeries, so I made sure to walk as much as I could handle everyday while also listening to my body and its limits.” (Josie Norris)

Norris sits in thought on their bed. — After a multiple hour tattoo session, Norris admires their enhanced surgery scars and stomach on January 9, 2023, in San Antonio. “The sparkles I had tattooed on my stomach celebrate my surgery scars and a reclamation of my stomach — an area I have had a long and difficult relationship with alot of shame and self hatred towards the literal core of my body,” Norris said. “My tattoo is helping me see my soft tummy with love and compassion. My scars and tattoo feel like a celebration of this incredibly important part of my body that I am learning to love and trust.”

After a long day, Norris sits in thought before bed on November 8, 2022. “As a photojournalist, I have the honor of documenting history in San Antonio and Texas. However, from a personal safety perspective, I never can forget that I have Texan neighbors who I photograph that don’t think I should exist as my proud and authentic self,” Norris said. “Coming home to my personal space from assignments where I don’t feel totally safe is extra sweet.”

To help relieve the lingering effects of anesthesia, Norris walks laps around their driveway on November 24, 2022. “I was encouraged to walk — even when I didn’t feel like it — by other people who had similar surgeries, so I made sure to walk as much as I could handle everyday while also listening to my body and its limits.” (Josie Norris)

Given the landscape of Texas and the attacks and attempts around the country to delegitimize trans existence, it has never been more important to share stories of the diverse and nuanced lives trans folks lead. Hearing stories directly from those who have been marginalized and targeted is powerful. It expands the narratives of people who are often reduced to talking points — which I have witnessed countless times covering a range of assignments.

Trans and reproductive issues are often discussed in silos, but they both affect many. Some of the most visceral pain I’ve experienced in my life, physically and emotionally, has been related to my reproductive system. If my story can help empower someone or make them think about people in a new way, it will have been worth opening up my life in one of the most intimate moments of my life.

Republish this story