Robert Eads was visiting friends in the late 1990s when he woke up in a pool of blood. His terrified hosts quickly began calling hospitals, clinics, and private physicians, explaining that Robert was a partially-transitioned female-to-male transsexual and demanding an immediate appointment.
The request was repeatedly rebuffed. By the time Eads found physicians willing to diagnose and treat him at an Augusta, Georgia teaching hospital — a three-hour drive from his home in rural Taccoa, Georgia — his ovarian cancer was so advanced that nothing could be done to save his life. He died in 1999, at age 53.
His friends were outraged but knew that Eads’ experience was not anomalous. While transsexual identity is rare — the American Psychological Association estimates that two to three percent of men periodically cross dress but that only one in 10,000 biological males and one in 30,000 biological females feel the need to transition to a different gender — their health needs are largely unmet.
Indeed, members of the transmasculine community understand that the line separating them from Eads is frighteningly narrow. Most, like him, have undergone radical mastectomies to better present as male. Furthermore, like him, most have neither the money nor the inclination to have their female genitalia removed. This means that they need to see a physician for routine, annual Pap smears, STD testing and gynecological exams.
As a tribute to Eads, a group of friends decided to mark his passing by surveying Georgia’s medical personnel to ascertain who was willing to treat transexuals. Within short order, the Feminist Women’s Health Center in Atlanta rose to the challenge. Starting in 2000, they began examining transmen attending the annual Southern Comfort Conference, an international confab that has brought transpeople and their partners together for a weekend of workshops, partying and camaraderie since 1990.
By offering low cost gynecological exams during Southern Comfort, organizers felt that they were not just paying tribute to Eads, but were encouraging participants to take better care of themselves. In the eight years since the program began, it has grown from a once-a-year offering to a year-round program called the Trans Health Initiative of the Feminist Women’s Health Center. Since opening in June 2008, more than 200 transmen have been served by the initiative.
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Patients are enticed not only by the Trans Health Initiative’s compassionate and non-judgmental approach to medical care, but also by the program’s sliding fee scale which enables them to access a host of discounted services, from a Human Papilloma screening for $69 to extensive lab work starting at $26. Those with health insurance can sometimes have their lab work paid for — if the tests are not transition related. Nonetheless, clinic staff report that many patients opt to pay for treatment out of pocket, fearing that their privacy will somehow be breached if their insurance company is contacted.
The decision to extend health care to the transgender community was a not a difficult one for Feminist Women’s Health Center staff. Since opening in 1977, the clinic has been in the vanguard, offering abortions to 24 weeks and serving survivors of domestic abuse, gang violence, incest, rape and other types of assault.
“The Feminist Women’s Health Center has a long history of providing services to folks who seem to fall through the cracks,” says Executive Director Nancy Boothe. “There are people out there who are denied respectful, quality-driven health care because they refuse to walk around in a body that doesn’t fit well with who they are. Specifically, transmen with female sex organs have been shamed away from even the most routine, preventative, gynecological health care.”
A perusal of transsexual websites and blogs bears this out. Transmen and women describe being derided as freaks, and write of being called fiends and sickos by medical professionals. Several report being asked to leave medical facilities despite high fevers, acute respiratory distress, or other symptoms because their presence would disturb other patients. Regardless of whether their illnesses correlate with their transgender identity, they speak of rampant discrimination as the rule, and compassionate care as the exception.
Hearing such stories affirmed the FWHC’s commitment to treating transsexuals. “When the organizers of Southern Comfort came to us and said, ‘Listen, we’d like to make gynecological care and pap smears available,’ we set out to create services,” Executive Director Boothe says. “But first, we had people come and talk to us about trans health so that we could sensitize and educate ourselves.”
Boothe reports that staff immediately saw the provision of services to transgender patients as part of their mission — to promote reproductive justice and aid marginalized communities. “When we learned about guys getting illegal drugs on the street or online, avoiding established health protocols, we realized that people will get the right bodies any way they can. Right away we knew it was a safety issue and agreed to provide space for care,” she says.
Jac Camp runs the FWHC’s Trans Health Initiative and admits that the idea of seeing transmen at a women’s health center initially raised the hackles of some Atlanta-area feminists. “They were confused over how wanting to present as male could be feminist,” he begins. “But I think the most feminist thing you can do is give people control over their own bodies, empowering them to make the decisions that are right for them. The mandate of feminist health care is to support people in times of need, whether they’re facing a crisis pregnancy or a gender transition.”
A self-identified transman, Camp describes the Initiative’s growth and charts its incremental expansion. The first Robert Eads Clinic, he says, drew just seven Southern Comfort conferees; the next year 12 came, and as the idea caught on, more and more transmen filed in for blood work, prescriptions, HIV and STI screenings, and gynecological exams. “Transpeople hesitate to get health care when they perceive they’re not welcome,” he says. “Once people learned that a transman was involved in the project, people understood that they were being encouraged to come in.” At this point, he continues, transsexuals from Alabama, Florida, Georgia, Mississippi and Virginia flock to the clinic throughout the year. “Some patients drive as much as seven hours each way,” he says, “which tells you that things are pretty bleak in the parts of the country where they live.”
This dearth of services underscores Camp’s enthusiasm for the Trans Health Initiative. “Patients tell us we’re the only medical facility in five states where staff are friendly and where they can get testosterone prescriptions [to enhance masculinization] without having to explain themselves. In addition, I think our work literally saves lives.” Since early detection of cervical, endometrial and ovarian cancer increases survival rates, Camp sees preventative care as essential. “Teaching people to care for their bodies, even when they don’t identify with particular body parts, is key,” he says.
The initiative is a team effort. According to Camp, “Nurse practitioners handle the hands-on care as it relates to physical exams, injections or injection teachings, while the MD provides case management and orders for labs, tests and any medications that they authorize, including hormones. I act as coordinator, facilitating all appointments, counseling clients about the process, assisting in records management and assisting the nurse practitioners with lab work.” Referrals for services not offered by the initiative, such as long-term therapy, are provided as needed.
A comprehensive medical history is taken for every person seen by the initiative, alerting them to potential red-flags in their history that make hormone usage risky, but ultimately, the decision to use these drugs rests with the patient.
“At least half the people I’ve talked to have gotten hormones from an illegal source,” Camp continues. “No one wants to go on the street or get hormones off the Internet but they do what they have to. Generally, a legal prescription for testosterone runs $60-$125 for a supply lasting five or six months. When they get it here, initiative staff monitor reactions, and start them with a low dose to introduce it to the body.” Patients are also counseled about testosterone’s possible side effects, from cardio-vascular issues, including elevated cholesterol levels, to liver problems.
“We practice fully informed consent,” Camp explains. “We let the person know everything they need to know as a transperson and are as transparent as we can be about options. We also tell people that there hasn’t been much research on testosterone usage yet, so there’s a lot we don’t know.”
In addition to seeing patients, the initiative works to educate the wider community about the health issues facing transpeople. Toward that end, personnel address medical students at Emory University, a group they describe as receptive.
“It’s obvious that there is a lack of understanding of the transgender patient within the medical community,” Camp says. “For one, the lack of research on caring for transgender patients has impacted the curriculum in learning institutions, leaving providers with little knowledge about the health needs of the transgender community after completing their education. Most providers probably feel unequipped to care for trans clients and therefore are not comfortable doing so. I have also heard providers express the belief that caring for transgender patients is best left to endocrinologists or specialists because of the complexity of hormone regimens. This may be true in some cases, but certainly not all.”
Jonathan Caronia, a physician who graduated from the New York College of Osteopathic Medicine in 2006, agrees that medical students would benefit from training about transsexuality.
“There was not a single didactic lecture ever given on transsexual health issues in medical school,” he begins. “At the hospital we have grand rounds in which someone presents a lecture to the whole department, going over the latest research, medications and information on a particular illness or health concern. Transsexual health has never been mentioned.”
This means, he concludes, that interns, residents and physicians are unprepared to treat transgender patients when they seek services. “I was never educated in the stages of transition or what is done at each stage. Most of my knowledge comes from Lifetime TV specials,” he laughs.
Even more appalling, he says that when clinicians discuss their treament of transsexual patients, other medical personnel typically respond with giggles and smirks.
This comes as no surprise to Lola Fleckenstein, Robert Eads’ partner during the last several years of his life, now a Feminist Women’s Health Center board member. “Being trans is tricky in every regard but presenting in a body people aren’t used to is particularly tough,” she says. “What we’ve found at the initiative is that just having a place where transpeople can be seen and treated with respect, regardless of their health needs, is all that matters. Being taken care of by people who show patients common courtesy is even more important than providing low-cost services.”
Fleckenstein, Camp and Boothe are pleased about the initiative and what it has done so far, but they are not resting on their laurels. Within the next year they hope to expand their services, treating transwomen in the Southeast alongside transmen and heterosexual patients.
Cross posted from On The Issues