Mari Moriarty and Justin Elizabeth Sayre were engaged to be married in June. But when Donald Trump was elected president, everything changed. Now, instead of having wedding parties in Vermont and New York, they’ll be living overseas, first in Amsterdam and then, if Sayre’s artist visa comes through, London. They took care of the marriage part just nine days after the election, rushing to New York City Hall and gathering whatever friends were available to celebrate with them on short, panicked notice.

“It threw almost all of our plans up in the air,” says Moriarty, a 30-year-old theater professional, about Trump’s win. That’s because she, a transgender woman, and Sayre, a nonbinary TV and theater writer, believe that staying in the U.S. would mean living in enemy territory, putting their health and freedom at risk.

On Sunday, while speaking at a rally in Phoenix, Trump vowed to end transgender rights. “With the stroke of my pen on day one, we’re going to stop the transgender lunacy,” he said. He added, “Under the Trump administration, it will be the official policy of the United States government that there are only two genders, male and female. Doesn’t sound too complicated, does it?”

Trump and his incoming administration have made no secret of their intention to restrict and dismantle transgender rights, particularly as they relate to accessing healthcare in the form of gender-affirming care—a range of services that can “affirm gender or treat gender dysphoria,” which is the psychological distress resulting from an incongruence between one’s sex assigned at birth and one’s gender identity.

Such services can include one or a mix of the following: mental health counseling; hormone replacement therapy (HRT); puberty blockers for minors (just banned indefinitely in the U.K.); and gender-affirming surgeries (rare for minors), which can range from facial feminization surgery and voice surgery to feminizing vaginoplasty or masculinizing chest or “top” surgery (a double mastectomy).

Despite being controversial, gender-affirming care is considered a medically necessary, evidence-based system of care that’s supported by every major U.S. medical association—largely because such interventions have been associated with lower odds of depression, anxiety, and suicidality.

Mari Moriarty and Justin Sayre at their hasty but happy City Hall wedding in November. Trump’s win, they say, “threw almost all of our plans up in the air.”

Still, 26 states have passed bans on minors receiving gender-affirming care. Some states have considered banning such care for transgender adults up to age 26, and several states prohibit public funds from being used to provide transgender health care to individuals of any age, meaning those who receive healthcare through Medicaid, work in the public sector, or are incarcerated, will be left with no options for care.

To get a sense of how transgender people are planning for life under Trump, Fortune spoke with several across the country: an 18-year-old Texan transgender woman who is resolved to stay and fight; a young transgender man in Rhode Island who is stockpiling his testosterone while preparing for various scenarios; and Moriarty and Sayre, who feel, with heavy hearts, that they’ve got no choice but to leave.

A rising panic

Approximately 1.3 million adults and 300,000 youths identify as transgender in the U.S., and among them and their loved ones, it’s clear that a level of panic is ensuing.

LGBTQ youth calls to mental health crisis lines spiked by 700% right after election day. And in the first study to assess post-election transgender mental health—by University of Utah psychology researcher Lisa Diamond and the National LGBTQI+ Cancer Network—anxiety was shown to have increased 45%, depression by 19%, and feelings of dread by 30% among trans Americans from the month before the election until the week afterward.

“November 5th was not just a political event—it was a public health event for LGBTQ+ individuals, especially trans individuals,” said Diamond in a press release.

Carolyn Jones is program manager at the Trans Youth Emergency Project in North Carolina, which provides care information and support to families in response to the gender-affirming care bans. “The reality of the situation on the ground is in a lot of ways the same as it was a month ago—which is really bad,” she tells Fortune. “The fear that this presidency is striking into people,” she adds, has been extreme.

Adding to that was when, earlier this month, the Supreme Court heard arguments in the first case to challenge the constitutionality of one of the state bans, in Tennessee. It’s stoked fears that a decision upholding the state’s restrictions could pave the way not only for more state bans, but a federal one, too. “We’re preparing for the worst,” says Jones.

So, too, are many transgender individuals.

Rose: ‘I have fought very hard to be who I am’

Rose, 18, is a high school senior in Houston. She tells Fortune she was in third grade when she finally learned—through an older transgender cousin—that there was a name for what she knew she was. “I was like, oh my god, you can do that. Wow,” she recalls.

She came out in sixth grade, which got her promptly kicked out of her private Christian school—and led to the firing of her mom, who worked at the school as a therapist. “They told me, ‘God does not love people like you,’” says Rose. After some false starts in a couple of other schools due to bullying, Rose has found a safe place, both physically and mentally, in a private high school.

Teen girl in short dress sits on curb in front of colorful mural — Rose, 18, is a mentor to many younger transgender Texan teens. “I’m in the position where I can help people,” she says.

About six months after coming out, she met with a doctor about gender-affirming care, eventually going on puberty blockers and then HRT—something she was lucky enough to continue even after Texas passed its 2023 ban on such treatment for minors. That, she explains, was due to receiving a “charity flight” to New York, where she met with a doctor who prescribed her enough estrogen to last until she turned 18.

Now, as an adult, she can receive her care in Houston. But since election day, she admits, her mental state has been shaky.

“I used to be like a very gloomy kid, right? And then in the past, I’d say, two years, finally being in an environment where I’m safe at home and safe at school, I’ve really become very, very bubbly, very outgoing,” she says. “But since November,”—when the election represented her first time voting—“I’ve kind of been in a slump, and I can’t seem to find my footing.”

It’s because Rose is carrying not only her own fears about the future, but those of about 45 other transgender youth—younger Texas teens who have adopted her as a mentor through the local LGBTQ community center, where she is president of the youth group. And it’s through her role there that she vows to continue to be a visible, outspoken example for others, despite how rough it can be.

“It’s very dire,” she says, and difficult to “project like I’ve got it together” in front of the other kids—some of whom have been forced off of HRT, but many of whom never got the chance to try it because of the expense.

The politicization of transgender rights weighs heavily on Rose. “My life and the lives of the people that I care about have been used as tools and a political game—and I’m not a political point to make in your speech. I am a teenager who goes to school who gets homework done. Like, I have a life, and my life is in danger because people refuse to have empathy.”

It all feels “dehumanizing,” she adds, but only makes her more resolved to fight.

“I think that wanting to leave [the country] is a very common sentiment—and it’s completely understandable, as well,” she says. “I think the reason for me standing my ground is I have fought very hard to be who I am…I’ve fought for my basic life, so I’m not ready to leave it.”

Further, she believes that being “lucky” enough to have come out so early in life makes her less “worn down by the pressure” than older transgender people—and that it’s therefore her responsibility to speak out and do the work here at home.

“I’m in the position where I can help people, so I think it’s wrong to not do that,” says Rose, who hopes to head to college next year. “I can’t always be there for everybody, but sometimes it feels like if I’m not, I don’t know if anyone else will. So I have to be.”

Sam: ‘You become your own doctor and your own pharmacist’

Since the election, Sam (whose name has been changed to protect his safety), a transgender man and full-time activist on the East Coast, has been doing his weekly injections of testosterone just a little bit differently than usual: He’s been rationing it, giving himself a bit less than the prescribed dose, so he can make it last in the event that he’s cut off.

It’s just one of a dizzying array of preparations he is making for the near future—when, he fears, transgender people may not only be cut off from gender-affirming care, but medical care in general, as physicians could be concerned about repercussions.

“Instead of doctors saying, ‘Okay, I’m going to be your provider, but I cannot provide you hormones any longer,’ they are using these new laws as a blanket excuse to be like, ‘sorry, I can’t take care of you. Care is not covered, so goodbye,’” he tells Fortune, based on real-life situations he’s already witnessed as an activist. (Many expect these cases to be litigated, as the Affordable Care Act contains non-discrimination protections, meaning medical treatment must be given regardless of gender or sexual orientation.)

Fearful physicians denying care could in turn drive people to turn to other ways of procuring hormone therapy, including non-U.S. sources and veterinary sources, both common but risky responses, safety-wise, to issues of access. “You become your own doctor and your own pharmacist. And that’s, of course, not a great situation,” Sam says.

He’s also been trying to get a swirl of official identification cards in order—including changing the gender marker on his birth certificate, something recently allowed in his birth state. That’s because many of the newly proposed state laws would prevent trans people from doing things like accessing public restrooms or using domestic violence shelters unless they do so according to their sex assigned at birth.

Further, he aims to update his driver’s license, passport, and Global Entry card—all of which have gender marker “X,” meaning a gender identity that is unspecified or different from M or F. And while being given the X option, under the Biden administration, was considered a victory for gender-divergent people, some, like Sam, are starting to worry it will be used against them. Especially when it comes to accessing necessary medical care.

“I’m taking the steps to minimize my risk of being caught up in a large data-set dragnet,” he says, where having his information stored in a database could present a snag to using his IDs.

But leaving the country altogether, Sam says, is also not off the table.

“This is certainly the first time in my life when I have realized I absolutely need a fully-baked exit plan in my pocket—including one that potentially adds the option of an undocumented border crossing,” he says. To that end, he’s been downloading maps of the more “porous” ends of the U.S. borders, where he’d get dropped off with nothing but a backpack.

He’d also consider doing long stays in more trans-friendly countries—Portugal, Sweden, and the Netherlands, for example—and moving around like a nomad, “for my mental health,” he says. “You can’t be living in the dumpster as it’s set on fire, right? So occasionally I’d go somewhere else, and maybe come back when the flames settle down.”

Moriarty and Sayre: ‘We just went into a panic’

Moriarty and Sayre spent election night in Vermont, tuning out political news. But when they eventually heard news of Trump’s win, says Sayre, “We just went into a panic.”

The couple started making all of their plans—contacting a real estate agent to rent out their place in Brooklyn, consulting with a lawyer over how Sayre could get an artist’s visa in Europe, figuring out how to bring their cat with them to Amsterdam—immediately. Still, Sayre admits, leaving all that you know and love is a tough pill to swallow.

“It’s like, well, don’t you want to stay and fight? I’m always going to use my voice to fight,” they say. “But I don’t know that I can be on the frontlines of it all the time, because I really don’t go to a great place [mentally]. And that’s not sustainable.”

Moriarty, who has decided not to start hormone therapy until she’s abroad so her treatment isn’t interrupted here, says she has been experiencing more street harassment than ever. “I’ve felt the temperature rising, even in New York, for years now,” she says, referring to being jeered, followed, laughed at, and having her photo taken without consent. It’s all prompted fears for her safety—and that, combined with anxiety over how both of their rights will be scaled back, has led to their decision.

“I just feel like there’s no one looking out for us. Nobody,” Moriarty says. “No one’s going to come to save us.”

She explains that the conversation she keeps having in her head is “less about fighting and more about surviving and taking care of each other, and that is where the priority will be,” she says. “I think we’re trying to put our oxygen masks on first.”

Fleeing the country and rationing testosterone: Transgender Americans’ new reality under a Trump presidency