This article was produced as a project for the USC Annenberg Center for Health Journalism’s 2026 National Fellowship Dennis A. Hunt Fund for Health Journalism. It’s part of a series on LGBTQ+ health in rural areas.
Rural residents have lower access to mental health care, and the list of providers grows even smaller when seeking someone experienced with LGBTQ+ issues.
“There were zero search results,” said Zephyr Kao of their effort to find a therapist on the Nevada side of Tahoe.
LGBTQ+ residents in rural areas struggle with the lack of providers and specialists who understand their lived experiences in a medical context, as well as the costs of traveling to those who do. Some providers don’t advertise their LGBTQ+ expertise to avoid outing clients or becoming targets of homophobic or transphobic hate.
The need for mental health support of LGBTQ+ people is growing for the same reason access to it could become even more difficult: the last decade has seen a sharp increase in anti-LGBTQ+ policies, primarily targeting transgender people.
The Tahoe Basin is no exception to the national trends.
Like most rural communities, residents here rate their mental health worse than urban counterparts. Community health reports from Tahoe Forest Health System and Barton Health showed that almost a quarter of adults self reported their mental health status as fair to poor in 2024-2025. And a 2026 report from the Community Collaborative of Tahoe Truckee showed those outcomes were worse for LGBTQ+ residents in North Tahoe: almost 70% said there were three or more days in the past month where they had poor mental health. That’s
A Tribune survey of 15 LGBTQ+ respondents as well as follow up interviews, provide additional insight on the challenges in the Basin, such as specialized medical training, treatment costs and legal barriers for both patients and providers.
Changes on the federal level are unlikely to happen in the near future. But passionate providers say they are willing to fight for the LGBTQ+ community and their healthcare on a local and state level, which is a much needed measure to protect them now.
“While policy at the federal level, and many states, is currently hostile toward LGBTQ+ health, some of the most promising avenues may be at the local level for now,” said Carrie Henning-Smith, a researcher focused on rural health. “And, of course, voting and getting involved in the political process is important to effecting change.”
Mental health outcomes in Tahoe/Truckee
Rural, mountain towns like Tahoe and Truckee often have worse mental health outcomes than urban areas, exacerbated by social isolation and affordability issues. They also suffer from higher rates of suicide, a phenomena called the “paradise paradox.”
A 2026 report from the Community Collaborative of Tahoe Truckee showed those outcomes were worse for LGBTQ+ residents in North Tahoe. 69.8% of their LGBTQ+ respondents reported three or more days in the past month where they had poor mental health, and 67.1% of those surveyed said they needed mental health services in the past year.
The Tribune’s own survey showed that nearly half of respondents were seeking mental healthcare. Over 70% said they had to find healthcare elsewhere because there were waitlists for providers knowledgeable about LGBTQ+ issues or because they worried they would be unable to find adequate care locally.
Availability and accessibility
A shortage of providers with LGBTQ+ experience affects community health at multiple levels. Some respondents told the Tribune they simply took a gamble on who could help. Lauri Kemper, who has been in South Lake Tahoe for decades, said that when she was seeking a therapist, she wanted someone with experience and knowledge of lesbian experiences. “The couples’ therapist we went with actually had never counseled lesbians before, but no one else in town was doing it.”
Finding who actually offers these services can be challenging. A search on Psychology Today shows providers who serve the Tahoe area, but some of them are telehealth only or require a trip down the mountain to Reno or Sacramento—both hours away from Lake Tahoe.
An Hoang, a gay man who lives in Truckee, said that the therapist/patient relationship was an important determinant of mental health outcomes, and finding the right therapist was a needed step.
But, Hoang said, “That requires choice and going through different mental health providers and a lack of choices is just inherent in a small town. But if people don’t talk about [being LGBTQ+ friendly] and the resources that are available, you won’t know how to get help. You’ll feel like you’re alone in it.”
Local providers said the average wait time for mental healthcare is typically four to six months.
Brian Crane, a clinical social worker in Reno, previously served as the clinical director for Tahoe Youth and Family Services. He said that long waitlists were the norm for rural areas like Tahoe, Gardnerville and Minden, nearby communities in Nevada. “When you do find care after being on a waitlist for six months? You’re put in front of a resident who may leave, and you start all over again.”
Crane noted that often, people turn to telehealth when they don’t have local providers. And while it opens up options to find providers that are caring, it can come with its own set of issues. Patients often want more connection than they get through a screen. And online providers are limited in what they can do. For example, it can be a challenge to get letters supporting gender-affirming surgeries through online services.
Others said they were limited by what their insurance covered and what side of the state lines they were on. Zephyr Kao, who lives on the Nevada side of Tahoe, tried to find providers who could speak to the intersection of their experience as an Asian person and as a member of the LGBTQ+ community.
“I originally started with the mental health providers that you get assigned from insurance… but that was a total failure,” said Kao. “I could at least get a list of providers that matched my criteria if I searched in California, but I could not do that in Nevada.” Eventually, they decided to pursue care outside of their insurance network.
Increasing providers with LGBTQ+ competencies is hard work, particularly in mental healthcare. Eastern Sierra Counseling founder David Ranson and CEO Sarah Vigilante founded their practice after seeing the need for accessible mental health services in rural communities.
“We are trying to reach across the aisle and get more access in these places, to connect our mountain communities because we are stronger together,” said Ranson. Eastern Sierra Counseling actively hires providers that identify as LGBTQ+ or have training in LGBTQ+ care to serve rural areas. They also attempt to provide competitive pay rates to ensure that providers can stay and serve the communities with a high cost of living.
Affordability
Finding the right kind of care is important, but it can also be exceedingly expensive to get the right kind of care. To get mental health care that fit their needs, Kao said they saw a provider out of their insurance network and paid out of pocket.
“Therapy was my biggest expense in a year. I was paying $275 per session every other week,” said Kao. “It was expensive. And it sucks because you know you want to get the help. At some point, you have to decide if you have that money and if you’re going to spend it on getting that help.”
Another respondent said they paid more for their out-of-network therapist than their monthly rent. But whether it’s in or out of network, mental healthcare is particularly expensive.
That’s not to mention travel for care. While a majority of those seeking therapy outside the region looked for telehealth, others routinely traveled to LGBTQ+ friendly practitioners, adding an extra cost of both money and time to their search for adequate care.
Ranson, who has had experience serving rural Inyo, Mono, Kern and El Dorado Counties said that insurance coverage is one of the biggest challenges they face.
“The culprit of these exceedingly long waiting lists is the way insurance works,” said Ranson.
Which providers are deemed in-network often depends on geographic boundaries that don’t reflect where rural residents live and work. For example, someone who lives in Truckee and works in Reno might find they can only see therapists in the Nevada valley and not on the California side.
Other times, insurance might cover primary care at a hospital, but the mental health providers are considered out of network.
Providers also say they want to serve rural communities, but because some insurers pay lower rates, it can be difficult to make ends meet.
While they offer care for people on Medicaid, they’re anxiously looking at the horizon of changes slated to take effect in January—when H.R. 1 will require people to report work or school hours to continue to stay covered. Due to higher rates of poverty and disability, the LGBTQ+ community is disproportionately covered by Medicaid.
Every barrier to care can have a bigger impact on marginalized groups, like the LGBTQ+ community. “Every hoop you put in the way makes it more likely that someone will fall through the cracks, and it’s more expensive in the long run,” said Vigilante.
Eastern Sierra Counseling pushed insurance companies to come to the table to provide better care. While Eastern Sierra Counseling partners with hospitals like Tahoe Forest Health System to provide Medicaid care for youth, widespread access is impossible without addressing the cost.
Acceptability
Rural areas historically have faced challenges with stigmatization and negative perception of mental healthcare. That stigma can also extend to different identities. While LGBTQ+ people have always existed, even in rural areas, their acceptance has been met with resistance. A study from 2025 suggests that lower social support is a risk factor for LGBTQ+ youth.
Crane, who often worked with LGBTQ+ teenagers in rural areas, said, “They were very hidden and there was a lot of fear. Many patients refused attendance to events that were labeled as trans or LGBT for fear of being outed.”
People interviewed by the Tribune described being harassed both online and in real life, sometimes leading to threats to harm, injure or kill them, or to reveal their LGBTQ+ identity to their workplaces with the hope that it would make them lose their jobs. Among LGBTQ+ youth, classmates would threaten to out them to their guardians or harass them if they saw they had participated in LGBTQ+ clubs or activities they derogatorily perceived as gay.
On the other hand, people have expressed that while Tahoe and Truckee are rural, they feel safer there than they might in other mountain towns. Victoria Estevez, a resident of Truckee who praised the care she received from Tahoe Forest Health System, said, “I pay a fee for safety. I feel support from this community and I would not move to another mountain town.”
Mental health’s history has also been oppressive to LGBTQ+ people. The legacy of diagnosing gay and/or trans people as mentally ill is one that mental health practitioners contend with today—homosexuality was removed as a diagnosis in 1973, while gender dysphoria still lingers.
But up-to-date standards of practice have advocated for coming out as a benefit to mental health and guides the care of transgender and gender diverse individuals through peer-reviewed research. And several of the providers the Tribune spoke to said they believed gender dysphoria, the feeling that one’s assigned sex at birth doesn’t align with their gender expression, should not be considered a mental illness.
Providers also spoke about the challenges of balancing advice to patients to live openly with the realities of transphobia and homophobia. Ranson said that the persistence of fear can push people back into the closet, but that there were real concerns around discrimination, harassment and even violence.
Hoang said the stigma of there being less out and open people in rural areas likely made it harder for people to talk about their experiences, let alone share their worries and fears with a mental health provider. Other respondents also shared that they worried they would be judged or treated poorly if they came out to a provider.
That lack of trust makes it easy for patients to decide to forego care entirely.
While Truckee and South Lake Tahoe both have active pride groups and events, the oppressive forces can extend past what simple social groups can do.
Kye Miller, a family lawyer who works with the LGBTQ+ community and mental healthcare in Reno, said that rural environments can create barriers to care. As an advocate for gender-affirming name changes as a part of improving mental health, he sees the issues that can arise there.
“In rural Yerington, the place that clients have to go for name changes is called the Donald J. Trump Justice Complex,” said Miller. “Clients will forego doing something good for their mental health because they have to file it in a place where they feel it will likely get rejected.”
Those attitudes also impact how people receive care. Respondents and care providers had several stories where their care was denied due to homophobia or transphobia. In one case, a patient was unable to get their hormones because a pharmacist denied filling their prescription.
Homophobia and transphobia have proven negative impacts on mental health. And when those attitudes extend to every aspect of living in a small, rural town, it’s no wonder why they reverberate into every part of the LGBTQ+ community and their lives.
Hostile policies affect LGBTQ+ access to care
Rising homophobia and transphobia isn’t limited to rural areas. The federal government has leveraged hostile policies against LGBTQ+ communities, impacting funding, care and those who provide it along with their patients.
The Trump administration built a major part of its platform on transphobia, putting out executive orders to halt gender-affirming care and dismantling policies that protected sexual orientation and gender identity from discrimination.
That included removing coverage for gender affirming care from the Affordable Care Act, putting out stop work orders on research for LGBTQ+ health and active efforts to criminalize those who provided care, especially to youth.
Carrie Henning-Smith, co-director of the University of Minnesota’s Rural Health Research Center, who conducted research on LGBTQ+ rural health found these developments troubling.
“Removing sexual orientation or gender identity from data collection efforts and removing protections in policy puts individuals at risk of harm without legal protections, while also making it more difficult to see where those harms are happening. Without adequate data, it’s difficult to know the full extent of health equity issues,” said Henning-Smith.
Such intimidation from the federal government worried many respondents to the Tribune, who struggled with the idea of seeking healthcare if it would be made unaffordable or immediately taken away from them. While California and Nevada both have protections for LGBTQ+ people, they expressed fears that their providers would be limited.
“We are making it so these populations, especially the younger portions, have a higher rate of suicide,” said Ranson.
Providers feel the fear too. Ranson and Vigilante said that in the wake of hostile policies, some of their therapists were concerned about being targeted if they advertised that they were LGBTQ+ friendly or helped with gender affirming care.
They also worried that providing diagnoses of gender dysphoria could cause their patients to be targeted. The Trump administration has already directed military officials to separate members who have been diagnosed with gender dysphoria and several bills have been introduced with the aim to identify those diagnoses in the general public.
Estevez, who receives care at Tahoe Forest Health System said, “In times like these, seeing a high percentage of staff and administration at the hospital with rainbow pins means something. It signals that their support isn’t fake.” So while it can feel risky to show vocal support, even a small action goes a long way when there are such negative attitudes towards LGBTQ+ people.
Health providers are in a unique position to advocate for protecting LGBTQ+ care. Dallas Ducar, chief strategy officer at Fenway Health, said, “Clinicians carry a credibility that lobbyists and advocates don’t, and their testimony takes abstract policy debates and puts it in the reality of care, because they are there to witness what happens in the margins.”
Dr. Karen Thiele, a family medicine clinician in Reno, said, “Being an ally is standing in the same line of fire as your communities. When you can speak for your patients, that’s a critical part of protecting their healthcare, and we have to use that.”
But doing so currently risks the professions of the very healthcare providers that can serve the LGBTQ+ community. Thiele said she has seen clinicians leave the field in response to hostile federal policies, especially in the realm of pediatric medicine. “I don’t feel a tenth of the daily pressure that my patients do, but I understand the stress they feel.”
Thiele says that they are striving for shield laws for physicians, which could protect providers’ licenses against out-of-state investigations, prosecutions and civil liability. In Nevada, they previously pushed for shield laws in 2023 and 2025, and failed both times. But Thiele and others hope to advocate for it again in the next legislative session.
“There are systemic barriers for rural LGBTQ+ health,” said Thiele. “To push for change, it can’t just be one voice. It needs to come from many, unified voices with institutional support. If you say that you serve a community, it needs to be everyone. Every patient. Every time.”
Rural LGBTQ+ residents need educated providers and specialists to care for them. You can read more about those challenges and potential solutions in part one and part two of this series.
