Leann Coulter would have a feeling of dread whenever she had to go to the dentist or doctor during her gender transition.
She described the experience as a fight. Medical staff frequently misgendered Coulter, or even deadnamed her (used her name assigned at birth) despite requests for the opposite.
But that feeling changed when she was referred to a medical center specializing in trans patients in Southern California for hormone treatment.
“It’s a different feeling actually dealing with a doctor who doesn’t look at you as someone who’s transgender,” Coulter, 39, told USA TODAY. “They look at you as a normal patient. I don’t have to fight for anything; I can just ask for it.”
Triumph Trans Services in Cathedral City, California, opened last November and provides multidisciplinary health care services for transgender and nonbinary patients. The center is part of Borrego Health’s 26 clinics across Southern California, which has seen its trans patients grow from 200 to 1,200 in the past four years, said Toni D’orsay, director of transgender services at Borrego.
Amid Trans Awareness Week, several staff members at Triumph spoke to USA TODAY about what equitable health care looks like for trans patients: Providers who remember patients’ correct name and pronouns, use trans-inclusive language, and acknowledge the marginalization they’ve likely faced in a health care setting.
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It’s reassuring and validating for patients to see someone who looks like them at the clinic, said Mita Beach, who is genderqueer and works as a transgender navigator specialist. Beach’s role is to help support patients with appointments, care and things like navigating insurance claims.
All four of the navigators at Triumph, as well as other members of the staff, are transgender. Beach said they and other navigators seek to help patients find joy and excitement during the transition process, which can be stressful and anxiety-inducing.
“I think that’s the running thread: ‘Thank you for seeing me. Thank you for hearing me for the first time,'” Beach said.
But outside of some pockets like this one in California, many trans Americans don’t live near or have access to this kind of equitable care.
“The reality now is that a lot of patients come to us because they’re still not having a good experience with other providers or they’re getting misgendered,” said Mateo Williamson, 30, a navigator at Triumph.
The 2015 U.S. Transgender Survey by the National Center for Transgender Equality found that one-third of trans people surveyed who saw a health care provider had at least one negative experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity.
The survey of more than 27,000 people is the largest survey ever on lives and experiences of transgender people in the country, but more recent surveying has been delayed for at least a year because of the coronavirus pandemic, The 19th News reported.
According to the survey, 23% of respondents did not see a doctor during the prior year when they needed to because of fear of being mistreated as a transgender person. A 2017 study in the Transgender Health Journal also suggested a significant association between delaying health care because of fear of discrimination and declining general and mental health among transgender adults.
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An estimated 1.4 million Americans – about 0.6% of U.S. adults – identify as transgender, according to a 2016 report from the University of California Los Angeles School of Law’s Williams Institute, which uses data from the Centers for Disease Control and Prevention.
But despite the size of the population, many providers are not capable of providing equitable health care for trans patients because of a lack of cultural competency training in medical education, said Paula M. Neira, 58, who is on the board of GLMA: Health Professionals Advancing LGBTQ Equality. The organization is aimed at ensuring health equity for LGBTQ and sexual and gender minority patients, as well as equality for LGBTQ health professionals.
After the Affordable Care Act passed in 2010, many trans Americans gained access to gender-affirming health care for the first time, Neira said, but the number of doctors available to provide those services was limited.
“The number of clinically competent surgeons that do the work isn’t increasing at the same level as the increase in demand,” said Neira, a registered nurse. “So then you wind up with long wait times and a mismatch between how many people want the service and providers.”
There’s also a lack of data on the number and location of centers such as Triumph. D’orsay said she has a list of 40health centers around the country that she follows, but national resource lists are often out of date or incomplete.
“We’ve only recently begun to really be able to identify each other within the medical community, those of us who are doing this kind of work,” D’orsay said.
With a gap between the number of providers and those who seek services, many trans patients end up in a position like Coulter: visiting doctors who don’t provide inclusive care for them as trans people.
Marcel Omar, 28, sought care about two years ago through Borrego after experiencing transphobia in visits with an endocrinologist. His experience working directly with a navigator who also went through the transition process led him to join Triumph and offer that guidance to other patients.
Now a navigator, Omar’s goal is to ensure the patients he works with don’t have the same trauma.
“I’d never want to make someone feel like they were that small, like I felt when I walked inside a clinic every day,” Omar said. “I felt at my lowest point, like I was ready to give up, and I never want to make a patient feel like that.”
Cultural competency – or lack thereof – for medical professionals working with trans patients begins at the medical school level. A 2011 study of 176 U.S. and Canadian medical schools found a median of only five hours was spent on LGBTQ-specific content, and one-third of schools reported no time spent at all.
Neira told USA TODAY that without proper education, providers aren’t trained in howto help patients feel comfortable and accepted and are ultimately not able to give trans patients equitable care.
“Transgender health issues have never really been a part of entry level training in any health discipline,” Neira said. “But there are more and more people who are trying to find ways to include it in the curriculum and who recognize that there’s the shortfall, but that change is not going to happen overnight.”
Garrett Garborcauskas, 28, a third-year medical student at Quinnipiac University in Connecticut, told USA TODAY that providing care that’s inclusive, affirming and patient-centered isn’t just good for trans patients but also for anyone navigating the medical system.
“This really isn’t just a trans-specific thing. This is really a human-specific thing,” he said. “In the process of making it better for trans people, we make it better for everybody.”
Garborcauskas said he wished he had health care providers who could empathize with his experience as a trans person as he navigated the transition process. It’s “liberating” to serve as that person for his patients, he told USA TODAY.
He recently shared on Twitter an interaction with a nonbinary teenage patient who burst into tears when Garborcauskas introduced himself with he/they pronouns.
“They said that meeting me literally saved their life,” Garborcauskas wrote. “That seeing a trans person as a medical student gave them hope for their own future.”
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For some patients, visiting Triumph is the first time they’ve had a chance to interact with someone who looks like them, creating a sense of community by expanding on shared experiences, Williamson said.
“Every time we do our work, it’s putting our faces and our identities at the forefront of what our patients see,” Beach said. “When they … talk to people who look like them and sound like them and have lived experiences like them, it drops down some of their shields, and they feel more natural and more in a safer place.”
For Coulter, she hopes that more trans patients will have access to the ease of care and affirmative community she has experienced at Triumph.
“It’s something that needs to be carried across the health care field in general,” Coulter said. “They’re setting a good example. I just wish the rest of the medical field would kind of follow in their footsteps.”