FAYETTEVILLE, ARKANSAS — Only 15 minutes after the doors opened, an Arkansas health center’s waiting room was already half full with people waiting for hormone replacement therapy. Patients, mostly draped in grey and black and wearing cargo shorts and sneakers, all began smiling and snickering when they spotted a spider quickly making its way from the door to the receptionist’s window. Patients worked together to carefully lure it under a cup and let it outside.
The Planned Parenthood Fayetteville Health Center, which expanded care for trans patients in 2017, fosters a sense of community for LGBTQ patients. The wall is decorated with a transgender pride symbol and the words “Different is beautiful so be yourself.” The entire clinic is decorated with LGBTQ pride flags and symbols and posters. Dr. Ho made many of the signs in the office herself. She said it didn’t take long for trans patients to find out that the health center was offering them additional services.
“We definitely have had a significant uptick in [transgender] patients and to my knowledge, we haven’t done any advertising,” Dr. Ho said. “All of this has been word of mouth. We have a pretty healthy population of transgender patients at this time and one of the things trans patients have to do is support each other. I know that they have [online] forums where if someone had a good experience, they recommend us.”
It’s important for trans people to not only access services such as hormone therapy, but also primary care and reproductive care that is inclusive to trans patients. It’s tough for transgender patients to access inclusive health care, particularly in states such as Arkansas, Oklahoma, Kansas, and Missouri, where Planned Parenthood Great Plains (PPGP) expanded care for trans people in 2016. Planned Parenthood Great Plains provides transgender care at its Little Rock, Fayetteville, Tulsa, Oklahoma City, Wichita, Gladstone, and Kansas City locations.
According to one 2016 study, Oklahoma and Arkansas are among the worst states for trans health care because they have the highest odds of health care refusal in the country. A 2015 National Center for Transgender Equality (NCTE) study found that a quarter of trans people nationwide decided to delay care due to the possibility of discrimination and a 2010 study from NCTE found that 19 percent of trans people had been denied care.
Providing trans-competent care in conservative states
Trans people continue to fight for insurers to cover transition-related care. Health care providers, if they aren’t refusing care, are often hostile, refuse to use the correct pronouns, or abuse trans patients.
Dr. Janet Cathey, who grew up in Arkansas, recently became director of transgender health services at Planned Parenthood Great Plains. She has been serving trans patients and focusing on improving health care for trans patients since the late 1980s, when trans patients didn’t have social media to find her and other trans inclusive doctors. Cathey sees her work as much bigger than providing services that specifically help trans patients. She believes health care centers have to be spaces that connect trans people to a range of services they require, such as providing resources on name changes for important documents and identification and finding decent mental health care.
“We want to make Arkansas, where transgender care goes, into this little blue area in a sea of red where people can feel safe,” Cathey said. “Primary care [in Arkansas] is really lacking. There are people who do say ‘I just don’t see your kind.’ There really are. It’s also because they say ‘I don’t know anything about it. I don’t know how to take care of them’ and and that’s why I go out and speak is to say ‘Look, I’m here I’m at Planned Parenthood.'”
Cathey described trans competent care.
“I’ll get people started on their hormone management and you can just manage it after that and so they don’t have to drive three hours for a 15-minute check up. We know that your legal name has to be on your insurance but that Samantha wants to be called Sebastian and how to put names in medical records,” she said. “These things seem like little trivial things but they’re really not. It’s trans competent care.”
She said one of the things she wants providers to know is that they shouldn’t assume they know what trans patients need from them.
“Everyone has a different end point in their transition,” Cathey said. “And a lot of the time that end point changes, where they come in and want to have all of this done and say ‘How soon can I have surgery?’ Then they get on their hormones and they feel right and they feel like they’re supposed to be and they get enough physical change that when they look in the mirror they see who they are. And surgery becomes not as big of a deal. So that’s one thing you need to tell people, that not everybody wants or has surgery.”
“They get enough physical change that when they look in the mirror they see who they are.”
Dr. Ho said she started at the center in 2017 and brought her knowledge of gender care from her private practice to the center.
“My goal from the beginning was to make sure I’m taking care of patients who have problems with access, so I want to serve underserved populations, women who need terminations, transgender patients, HIV patients,” Ho said. “Those are all patients I care about and really enjoy taking care of so I was glad that they let me do [gender care] in addition to letting me bring primary care to this clinic.”
How trans patients struggle to find inclusive care
Evelyn, a trans woman, has been a patient of Dr. Ho’s since she moved to Northwest Arkansas. She and her husband, Bob, moved to the area from San Francisco in 2015. ThinkProgress agreed not to share full names of patients at the center. Evelyn said she loved her doctor in California and was concerned about moving to Arkansas and whether she would find the right provider. But Evelyn said Dr. Ho is one of the best doctors she has ever had. She comes in for hormone replacement therapy, primary care, and routine checkups. Evelyn, who is self-employed, said she chose private insurance that covers her gender care needs.
“Even among the trans population, I’m post-operative so it’s a smaller more specialized subset and about finding that care, finding someone who is knowledgeable about doing a gynecological exam. Here I’ve gotten excellent care and it’s as good as I got from my doctor in San Francisco,” she said. “Dr. Ho is thorough and knowledgeable. Part of it is I do like coming here because I like supporting Planned Parenthood’s mission of supporting women’s health care and family health care but even on top of that, the quality of care I receive here is really excellent.”
Evelyn said that she went to a local doctor someone recommended to her and although it was a good appointment, it wasn’t as welcoming and knowledgeable as this clinic.
“Even coming into front lobby with the signs and everything else, you know immediately it’s a welcoming environment. It’s a nonjudgmental clinic regardless of your sexuality or your gender or anything else,” she added.
Her husband Bob, who is bi, said he has also been happy with the care he’s received. He said it was “definitely a search” trying to find the right health care provider for himself and Evelyn.
Paula Sophia Schonauer, a trans woman who lives in Oklahoma City, in what she calls an “eclectic and LGBTQ-friendly part of town,” says it’s still a struggle to access health care, she told ThinkProgress.
“We are dependent upon the benevolence and knowledge of sympathetic physicians,” Schonauer said. “The University of Oklahoma Medical Center is making strides to be more informed about the needs of transgender patients, but they are far from providing affirming care. From what friends in the community have described, finding a physician and nursing staff who understand our needs is like rolling the dice.”
“I had no recourse to make a complaint, and nobody would listen to me when I tried.”
She said her insurance will not cover many transition-related treatments and that many Oklahoma physicians require letters from mental health care providers to access treatment such as hormone replacement therapy. Schonauer said her current physician has been professional and admits when he doesn’t know something, which she considers a positive trait. She said he either works with her to solve the issue or refers her to someone more knowledgeable. But that hasn’t always been the case.
Schonauer said that not longer after her surgery, a doctor insisted she needed a pap smear.
“She explained that she wanted to make sure I was ‘healing properly’ when I reminded her that I did not have a cervix. She checked me, a painful experience, and then billed me for a prostrate exam,” she said. “My insurance would not cover a prostrate exam, since I was now being treated as a female. I had no recourse to make a complaint, and nobody would listen to me when I tried.”
Schonauer said she hasn’t been to a Planned Parenthood clinic for treatment, but she said the local clinic has been very supportive of transgender clients.
“They have been an oasis for many people who cannot afford comprehensive insurance or affirming care. Though the Planned Parenthood of Central Oklahoma has more than one clinic, the clinic in the central part of the city is the most affirming,” she said.
Dr. Cathey said that she believes health care providers will become more competent and affirming once insurers change their tune and cover more transition-related treatment, which she calls life-saving.
Under Trump, the outlook for transgender health care is grim
There have been a number of signs that a rollback of LGBTQ rights has already begun on the federal level, including for trans people’s access to nondiscriminatory health care. Last month, the Office for Civil Rights at the Department of Health and Human Services changed or removed information on its website about sex discrimination. There is no mention of sex discrimination on the basis of gender identity, that relate to requirements for health services for transgender people. And the Justice Department filed a notice this year in pending litigation that mentions a rule affecting transgender people’s access to health care, because it said those parts of the rule were unlawful.
In addition, HHS recently created a new division within the Office for Civil Rights called the Division of Conscience and Religious Freedom and the Justice Department created a religious liberty task force, both of which LGBTQ rights advocates suspect will limit trans people’s health care access.
On the state and local level, trans people already struggle to find access to health care. In states served by PPGP, LGBTQ-focused and inclusive health centers are rare, said Tamya Cox, regional director of public policy and organizing at PPGP. Cox said there are only two organizations providing treatment for trans patients in Oklahoma City, including the Planned Parenthood health center.
Cox said there are very few options in Oklahoma City for trans people to find health care and private doctors who serve trans patients aren’t “common knowledge.”
“They don’t have more options and that’s in the urban areas,” she said. “We know that in rural communities, health care in general is not accessible, so transgender care follows that pattern.”
Oklahoma is one of the states that asks trans people to provide documentation they have gone through sex reassignment surgery to change their gender marker or get a court order. Oklahoma providers ask for a mental health care provider to sign off on gender-appropriate health care. In Arkansas, you have to submit a petition to the court to get a name change. Health care providers at Planned Parenthood know what to do when a patient’s legal name is different, and they don’t ask for a letter from a therapist, she explained.
Schonauer said that she fears discriminatory federal policies will enable the state legislature to introduce and pass discriminatory bills that make it more difficult for trans Oklahomans to receive the affirming health care they need. She’s worried that will allow therapists who push harmful “reparative therapy” on the LGBTQ community to thrive.
“Oklahoma is a state that continues to enable and support reparative therapists,” she said.
She added that conservatives on the religious right might “want to prohibit any treatment of people with transgender identities except in the form of psychiatric treatment.”
Dr. Cathey said she’s worried that after her many years of working to improve health care for trans people, advocates will lose ground. Anthony Kennedy’s retirement from the U.S. Supreme Court has worried LGBTQ rights advocates.
“I’ve been doing this for 30 years and I’m like ‘Please, don’t make what I’ve done for 30 years all of a sudden meaningless.’ You don’t want to see your life’s work totally erased and that’s how a lot of people feel — are we going to back to pre-Stonewall days? It’s more important than people realize,” Cathey said.