The State of Trans Health Care
Gender affirming care in Austin is improving. But by how much? And how far must it still go?
By the time she'd turned 35, Beth Westbrook had made her mark on Austin's queer community. A well-known activist and artist, Westbrook fought to empower the transgender community at a time when LGBTQ rights were still unsupported by the general population. This was just after Y2K; less than five years had passed since Ellen DeGeneres lost her job for coming out on prime-time television. Laverne Cox wouldn't star in Orange Is the New Black for another decade.
In 2002, with Paula Buls, Lisa Scheps, and several other community organizers, Westbrook co-founded the Austin Transgender Ordinance Initiative. (Today, it's the Transgender Education Network of Texas.) It formed in part to lobby for the addition of gender identity to the language of Austin's nondiscrimination ordinance, something that the city adopted within two years.
But Westbrook's work extended beyond lobbying lawmakers and organizing. She used her writing to address transphobia and misogyny. She led education workshops on trans, queer, and women's rights, and was one of the state's first two transgender folks to be offered a role in Eve Ensler's Vagina Monologues.
In May 2004, after a week of severe abdominal pain, Westbrook checked in to a South Austin emergency room. Though the on-call doctor briefly considered her to have an appendix issue, he ultimately diagnosed her with a virus and sent her home with a prescription for Darvocet. The doctor said "all she needed was sleep and orange juice," remembered Buls, a clinical therapist. "But, from what I remember, everything changed after she put on the hospital gown and [the doctor] realized she was trans."
In the days that followed, Westbrook's pain only intensified. She went back to the hospital, and underwent an emergency appendectomy. Westbrook died a month later, on June 30, from complications of a ruptured appendix.
An avid blogger, Westbrook left a trail of intimate thoughts on her LiveJournal. Friends still remember something she wrote on May 21: "I can't believe that irresponsible doctor at the first hospital almost got me killed cause he was too lazy to order the standard test." She had heard someone at the ER refer to her as a "transperson," and wondered if "they were just trying to get me out of their holy little hospital" when the doctor said she had a virus.
But Lois Rodriguez, her friend, remembers doctors calling Westbrook something different. Rodriguez had received a phone call while Westbrook was still at the hospital: "It seemed the sole purpose of the call was to share what she heard," Rodriguez told the Chronicle. "She said, 'I'm lying here and the doctors were on the other side of the curtain referring to me as an "it."'
"I was livid. I genuinely believe the doctors treated her like trash. Like she didn't matter and wasn't worth the thoughtful consideration of doing their job as well as they would've done for anyone else."
Thirteen years after Westbrook's death, local medical providers remain uneducated when it comes to treating transgender patients. In Texas, according to a Transgender Survey Report issued by the National Center for Transgender Equality, 30% of trans folks who saw a doctor in 2015 reported having at least one negative experience "related to being transgender," including refusal of treatment; verbal, physical, or sexual assault; or being tasked with educating a provider about trans-related care.
For most cisgender Americans – that is, someone whose gender identity aligns with their sex assigned at birth – the idea that they would need to teach standard care to their practitioner is relatively unfathomable. But it's not that simple for transgender and gender nonconforming patients. Many gender-diverse folks abstain from seeking medical help as a result; 2015 statistics indicate more than 20% of trans Texans avoid doctors out of fear of mistreatment.
Such figures illuminate what the trans and queer communities have known for ages: Transgender and gender nonconforming folks face far greater challenges and prejudices than their cisgender counterparts. Much of that comes down to training. In Central Texas, medical and mental health care providers often receive little to no instruction on trans-affirming treatment. In 2013, UT researchers conducted a study asking 113 state nursing programs about whether their curricula covered trans and LGBTQ health. Only 21 programs responded; 15 said they had some sort of LGBTQ lesson (lasting an average of fewer than two hours), and of those, only 10 specifically covered transgender health.
Because medical schools don't properly educate their students on transgender issues, providers are often underinformed with their trans patients. But there do exist ways to obtain an education outside of the classroom. The American Medical Association addresses trans health care needs, as does the medical advisory board for UC-San Francisco's Center of Excellence for Transgender Health Care. The World Professional Association for Transgender Health helps develop best practices and supportive, trans-affirming policies, and hosts several conferences.
"Providers worry about being competent," said Claire Bow, an attorney with the Transgender Education Network of Texas. "There's some validity to that, but unfortunately most providers decide it's easier to simply refuse us treatment than it is to educate themselves.
"When someone walks into my office and says, 'I need to sue someone for assaulting me …' – well, if I've never tried an assault case before, I'm going to read the law on assault. I might read legal and law review articles, and I develop working knowledge to represent my client. That's what I think doctors ought to do for their patients. Instead of saying 'I don't know,' 'I'm too busy' – educate yourself."
The Gatekeeping of Care
To understand the lack of local options, it helps to make sense of what "transgender health care" can entail. Aside from general wellness (like blood pressure, annual checkups, and mental health), trans folks often seek some type of transition-related service. Though gender affirming goals are different for everyone, the most common method is hormone replacement therapy. Accessing HRT requires folks to first see a therapist, who decides whether it's in their patient's best interest to move forward with the treatment – often over a period of weeks or months. For those without access to the trans community, this first step can prove a terrifying, expensive barrier.
Once a patient is considered ready, the therapist drafts a letter recommending gender affirming treatment, either HRT or gender affirming surgery (or both). Folks must then find a doctor or endocrinologist who's willing to offer treatment. If surgery is desired, patients must furnish two letters: one from the therapist and another from a general practitoner saying that they can see a surgeon.
"Even after legally transitioning … I would still be expected to get a letter from a mental health professional if I wanted to go up a cup size," explained Bow. "Cis-ters just need to sign the consent form. It sometimes feels like I'm expected to prove I'm a real person to everyone in the world, one person at a time."
Locally, Seton Medical Center, University Medical Center Brackenridge, and St. David's all carry trans-inclusive policies, but none offer a gender affirming program. In fact, until last June, when a renowned phalloplasty surgeon behind Brownstein & Crane moved to Austin from San Francisco, it was nearly impossible to find a surgeon willing to provide and trained in gender affirming surgery. And even that feat proved a challenge. Curtis Crane moved to Austin early in 2014. It took him more than a year to receive local credentials through Westlake Hospital.
Aside from transitioning needs, the transgender community also faces a much higher risk of contracting HIV. According to the National Center for Transgender Equality, trans folks are nearly five times as likely to live with HIV (1.4%) as the rest of the country's population (0.3%). 2015 rates remained highest among transwomen (3.4%) – and specifically transwomen of color. NCTE reports nearly one in five black transwomen currently live with HIV. Latina (4.4%) and Native American transwomen (4.6%) also reported higher rates of contraction. According to the Centers for Disease Control and Prevention, the trans community likely faces higher transmission rates due to incarceration, homelessness, lack of familial support, limited health care access, and negative health care encounters.
Finding affirming health care is even more difficult for trans people of color. According to Jae Lin, the health and wellness advocate at allgo, the statewide organization for queer people of color, queer and trans people of color are often left out of health care altogether. "We're not the patients. We're not the providers. We're not even included in conversations about our health," said Lin. Due to the stigma of "transness," Lin says, providers are quick to make assumptions about trans and GNC patients. But Lin and allgo Executive Director Priscilla Hale note that black and brown folks face equally ignorant health care presumptions. The intersection of those identities further wedges the divide between patient and provider.
"Doctors assume what you do and don't know," Hale added. "They make uninformed decisions on gender identity and how that translates to the patient's sexual relationships. Western medicine has a systemic way of providing care that dissects our bodies, and they do the same to our identities. QTPOC can't walk into a medical space and be whole."
Thanks to health equity funds from the city for community-based health awareness programs, allgo leads health and wellness community discussions "by, for, and about" QTPOC. In March, they organized a community health fair to introduce queer and trans people of color to different providers, and holistic approaches to medical care.
Because queer trans people of color exist at so many different identity intersections, Lin says it's hard to have a good experience, in and outside the medical field. "Even my best experiences, where I don't get misgendered and my correct pronouns are used and my partners are respected, then I'll still get some racist microaggression. Or, on the other end, if I'm with people of color, maybe no one will say anything racist to me, but then I'll get misgendered or comments about my relationships." Making a space for QTPOC folks to be whole is what allgo strives to create. Through their wellness workshops, Lin says they're "encouraging each other and finding ways to make access easier, healing easier, and also centering our stories and our experiences."
A "Scary" Experience
Desmion Dizney can speak to a lack of provider competency firsthand. Last April, he checked in to Cross Creek Hospital, a new psychiatric hospital in Northeast Austin, for inpatient treatment due to medication distress from bipolar disorder. He said the staff was considerate and receptive during his intake, and assured him of their trans-inclusive policy. But that tone changed when he was taken to his room.
Within hours, hospital staff refused to continue Dizney's HRT, telling him it could interfere with any treatment for his mental health. After he threw what he describes as a "fit," the director of nursing spoke up, telling her colleagues that taking a trans patient off his hormone treatment would in and of itself have a negative effect on his mental health. But over the course of the next two days, the staff's treatment of him failed to improve. While nurses and the on-call doctor were respectful and used the correct pronouns, he reports, the same can't be said of hospital techs. Dizney said he was repeatedly misgendered by staff. On two occasions, he said, techs used trans and homophobic slurs to refer to him.
"One actually called me 'that,'" he said. "Right before questioning me about my genitals and asking 'Have you had the surgery?'" Yet, the most egregious offense came one night when Dizney got up to use the restroom. Overcome by an epileptic seizure, he collapsed on the floor, where he remained for several hours. When a nurse finally found him, "they told me I was delusional. The nurse accused me of making [the seizure] up and blamed my mental illness." Dizney said he checked himself out of the facility after that. Cross Creek Hospital did not respond to requests for comment.
"This place was scary and left me completely exhausted," said Dizney. "The problem is there's no sensitivity training for hospital staff. I've been really private about my [mental health], but I think it's really important for trans people to start talking about it."
Where Do We Go From Here?
If several state politicians have their way, refusing trans patients will not only get easier – it will become outright legal. In January, Republican Sens. Charles Perry, Brian Birdwell, and Bryan Hughes co-filed Senate Bill 651, a "religious freedom" law that would allow professionals in more than 65 licensed occupations to refuse service to trans and queer patrons without legal repercussions – including doctors, therapists, and emergency medical technicians. Until recently, religious liberty laws have been framed in the context of an anti-gay baker refusing to make a cake for a gay wedding under the guise of "sincerely held" religious beliefs. SB 651 makes refusal a matter of life and death.
To date, SB 651 is one of the most extreme religious liberty laws proposed throughout the country, though it's made few headlines thanks to the more infamous – and equally discriminatory – SB 6, known as the Texas Privacy Act (or, more colloquially, the "bathroom bill"), which would force trans and GNC folks to use any public restroom or locker room that aligns with the gender on their birth certificate. Both bills have real-life consequences, and not just for the adults who will suffer should they get passed into law. Texas' bathroom battle is already negatively impacting the mental and physical health of trans and gender nonbinary youth. Kathryn Gonzales, operations and programs director for Out Youth, a local nonprofit serving Central Texas' LGBTQ youth and their parents, wrote that several local children have suffered recurrent UTIs, while another has irreparable renal/bladder damage because they don't feel safe using the restroom at school."
If there is a silver lining, it's that SBs 6 and 651 have inspired mass public outcry and spurred community leaders to roll out new strategies at a faster rate. Early last year, a group of organizers from local nonprofits, medical practices, and support groups (including Gonzales) banded together to address the dearth of trans-affirming, modern providers in Central Texas. Together, they formed the Central Texas Transgender Health Coalition (CTTHC). The coalition has already started work on an educational conference for local health care providers, and begun organizing a health fair for the trans and GNC community.
Though the coalition was already planning the two events prior to the Legislature's current session, the bills have inspired members to move more quickly. Gonzales says the bills have "strengthened our commitment to advocacy. In the context of a health care setting, dignity and respect have critical implications. Providers and support staff must be held to standards of inclusivity, equity, and non-judgment in patient interactions."
CTTHC also plans to address the needs of transgender youth, specifically those 17 and under. Because minors generally cannot make their own medical decisions, trans children are reliant on their parents. If guardians are unaccepting, gender variant youth likely can't transition until they're 18. Even when parents are supportive, accessing gender affirming medical treatment and locating a doctor willing to prescribe hormone blockers or HRT is not easy. Gonzales and Katy Koonce, a local therapist who, in 1998, founded Central Texas' first therapist-led transgender support group, both said that locating and accessing affirming health care can be much more difficult for youth than it is for adults.
Joe McAdams, the executive director of the Kind Clinic, a sexual health clinic that helps residents access HIV preventive PrEP ("Season of Risk," May 22, 2015), also acknowledged the Legislature's current efforts to roll back protections for the LGBTQ community as a motivating factor. He said that, due to the "current political stigma thrown at the trans community by Texas politicians, we knew we could come out in front." In March, Kind opened the new Gender Care Clinic, the first trans- and GNC-focused clinic in Travis County. On March 23, coordinator Arthur Landin told the Chronicle the free clinic was already booked through Sept. 21.
Unlike other large American cities, Austin had never had an LGBTQ-specific medical center. New York City and San Francisco are home to multiple clinics. Some work entirely with trans and GNC patients; some, such as Dimensions in San Francisco, focus only on queer youth. Many, including Houston's Legacy and Washington, D.C.'s Whitman-Walker, stemmed from the AIDS epidemic in the Eighties, and have been operating full-time ever since. As the first such clinic in Central Texas, all eyes fall on Gender Care.
Dr. Cynthia Brinson, the clinic's medical director and a longtime researcher of HIV, said Kind opened Gender Care to address patient needs first and foremost. "All kinds of people need medical care and aren't getting it because they're afraid to approach a doctor for their primary needs," she said. "If [trans patients] are afraid of being ostracized or shunned by a doctor for asking for hormones, they're definitely not going to feel comfortable addressing secondary needs: sickness, high blood pressure, general wellness. As a doctor, you have to meet people with who and where they are in their life."
The clinic plans to address HRT needs for Central Texas' trans and GNC adults, plus other general wellness concerns, and access to PrEP. Gender Care is also in the process of building a referral program to connect patients to trans-affirming therapists. Landin told the Chronicle the clinic has also received numerous requests from parents wanting to bring their children to the clinic. Though Gender Care currently accepts patients 16 years and older, it does not currently offer 16- and 17-year-old patients access to HRT because they've yet to employ a pediatrician or endocrinologist. Landin said they're "looking into it."
And, in an attempt to push away from the paternal "gatekeeping" of medicine, Gender Care has decided to implement informed consent instead of requiring letters from therapists. When used correctly, informed consent lets folks have more direct control over their health care. But removing the gatekeeper shouldn't mean disregarding therapy (hence the clinic's interest in therapist referrals). As Bow explained, "knowing that I was transgender was not the same as knowing what to do about it. Dealing with gender dysphoria, suicidal ideation was frequent, and sometimes intense. I would've been poorly served by throwing myself into transition without support."
Koonce, a practicing therapist for 20 years, also noted there's a gray area regarding informed consent: "I worry about the 'quick fix' culture. If you can get in touch with your shitty stuff, then transitioning will feel so much better."
Kind opened in May 2015. Its board had long intended to open a clinic to specifically address trans-affirming health care, but it wasn't until recently that they had the bandwidth and funds to do so. Gender Care is currently open every other Thursday evening. Its staff hopes the clinic will begin expanding hours once it (and Kind) relocates soon to a new office at 1101 W. 40th.
No One Size Fits All Fix
After seven months of self-care, Dizney said he sometimes regrets his decision to not pursue a lawsuit against Cross Creek. He believes many of these issues stem from a lack of communication between trans folks, medical providers, and hospital staff. Which is why he's still frustrated that the mental health hospital never followed up on his offer to work with their staff for a trans 101. "When you get misgendered there's a disconnect between brain and body," Dizney said about why he offered his services. "I don't respond, and so there's usually a more abrasive follow-up to get my attention. It's embarrassing and uncomfortable." He worries most for gender variant youth. "Kids don't control where they go for health care," he said. "We need doctors to respond immediately and correctly when kids come out to them. I was lucky enough to be able to check myself out of that hospital – a kid can't."
Bow notes a need to extend trans-affirming care to LGBTQ seniors. "I don't want to end up in a nursing home with them deciding they don't want to give me my hormones," she said. A generation of queer folks have faced homophobia and transphobia in nursing homes. The gamut of mandatory change is required across the board and in all aspects of medical and mental care.
Austin has seen a slow but steady increase in accessible and affirming trans and GNC health care. "It has gotten better," said Bow, in regard to providers. "Now there are people to put on a list. Before there was no list." Gonzales believes the Transgender Health Coalition will begin to address the disparities in Austin by educating professionals to open their minds and extend their practices to transgender and gender nonbinary patients. Dr. Crane said such a need was his deciding factor in moving to Texas. The state "is behind, in terms of transgender acceptance," he said. "I hope moving here and opening a practice with a strong presence would maybe help the state's legislators see that the trans community is courageous and deserves recognition and rights."
Editor’s note: The Kind Clinic’s new Gender Care program is not a separate clinic, but part of Kind’s expanded services regarding sexual health. When we say “Gender Care Clinic” in the story above, we’re referring to the specific hours and gender affirming care offered during the program’s allotted time slots. For more, see this “Letter to the Editor.”