States around the country are moving to restrict the rights of LGBTQ people, including in sports, education and health care. But many transgender people have already felt poorly served by mainstream medicine, even in relatively liberal states.
Some providers in western Massachusetts have begun to focus on that population, including one new clinic that serves trans patients almost exclusively.
Many in the LGBTQ community say it’s about time.
Nuri Sherif told their doctors for years they didn’t want kids. The providers usually dismissed it as the fleeting belief of a young person.
“It was like, ‘Just wait, honey,’ kind of thing. Like, ‘You'll change your mind,’” Sherif said. “I'm like, ‘No, I'm pretty sure I won't.’”
But when Sherif had their first appointment at the clinic Transhealth, via zoom, the provider, a trans man, didn’t question that decision at all. He even went a step further.
“He was the one that was like, ‘Do you ever think you would pursue a hysterectomy?’” Sherif recalled.
Sherif, who is 29 and trans nonbinary, was assigned female at birth. They already take testosterone and plan to have top surgery, which includes breast removal. Sherif figured it took a provider with a real understanding of gender issues — willing to listen to what Sherif wanted — to suggest removing their uterus.
“[The Transhealth doctor] was the first one to be like, ‘Yeah, for sure. You want that organ out of your body, do you think?’” Sherif said. “And that was cool.”
That sort of sensitivity is why Transhealth opened in Northampton a year ago, in May 2021, as a clinic for transgender patients. It was created, and initially funded, by western Massachusetts philanthropist Perry Cohen, an LGBTQ-focused entrepreneur. Cohen nowchairs the Transhealth board.
One of Cohen’s first hires was CEO Dallas Ducar, who helped survey the local community about its health care needs.
“A lot of folks said they had to teach their provider how to provide gender-affirming care,” Ducar said. “And they should be the ones teaching you.”
In 2016, Ducar herself transitioned while working as a psychiatric nurse. As she runs the clinic business, she said she draws on some of her own challenges getting health care, including constantly having to correct the gender on her medical record or to justify the care she was seeking.
“The data shows that if you are trans, you are more likely to be discriminated [against] in health care settings. And if you're a trans person of color, you're much more likely to be discriminated than not,” Ducar said. “And we know that if you get discriminated, you are much less likely to show up to that health care visit again or to really engage in your health care at all.”
Now that Ducar represents Transhealth in various contexts, she said she’s had to go public with her personal story. Occasionally, after national press coverage, she’ll receive hate mail from people in other parts of the country, which has led the clinic to take extra security precautions.
“We try to ensure doors are locked, that we have an exit plan, that we have good relationships with local law enforcement,” she said. “Just to really ensure that we're as safe as we possibly can be.”
Beyond safety, she said, the clinic’s priority is to offer nonjudgmental care. The rooms include rainbow flags and other art, soft lighting and no tile flooring.
“We really wanted to make this a space that didn't feel sterile. It didn't feel like an exam room necessarily,” Ducar said. “There's so much trauma that's been perpetuated in medical systems. We wanted to make this feel different.”
That’s why they also offer non-clinical services, including a clothing swap among people transitioning, and a community space for theater practice.
Once a week, after the clinical staff goes home, a theater troupe leads acting exercises and different forms of performance and expression for LGBTQ youth.
Theater co-director Shai Kuper, himself a Transhealth patient, said having free space to do theater practice serves as a kind of mental health care. In addition, he said, “We see it more as a way to have our community validated and affirmed.”
But having the idealism to start a new health center is one thing. Making it work in the U.S. health care economy is another. Ducar said, at first, they couldn’t predict the demand.
“We could have hired providers and no one could have showed up,” she said. “So instead the opposite happened and we got flooded with requests immediately.”
She said it’s been hard to hire enough providers, so waiting lists for new appointments are long.
“How can so many people still need care and how can so many people be arriving with such complex needs, too, and just not have been taken care of throughout their life?” Ducar said.
As a primary care clinic, Transhealth treats all their patients’ needs, mental and physical. But gender-affirming care, including hormonal treatment, is often front and center. That was the appeal for Z Belfer-Shevett.
In college, Belfer-Shevett, who is trans non-binary, decided to seek hormone therapy.
When they mentioned it to their regular doctor, “she went straight into all the potential side effects and the logistics about it,” Belfer-Shevett said. “And I just ended up feeling very uncomfortable and, like, I was in a little over my head and she didn't really know how to react to what I was saying. I just was very unsure that I was getting good care.”
Belfer-Shevett, who’s 23, did get a prescription from the doctor for hormone therapy, “and then didn't start it because I felt too weird.”
With the pill bottle in their cabinet, they saw an article about Transhealth in the newspaper and then waited four months for a Zoom appointment. They felt like the doctor, a trans woman, knew much more about gender-affirming care — down to the insurance coverage.
"[She said], 'On here, page 14, section C, this is the actual relevant piece of information that you need to look at. This is exactly what they cover,'" Belfer-Shevett said. "Like she just had it, she knew exactly where to look."
Belfer-Shevett got the same hormones their previous doctor prescribed, but this time they took them.
Transhealth is not the only medical practice in the region to focus on trans care. At Oxbow Primary Care, part of Cooley Dickinson Hospital, about half the patients are LGBTQ.
“I am continually humbled by how complicated people's gender journeys and identities are,” said Oxbow’s medical director, Dr. Miranda Balkin.
Balkin said part of treating trans people is not always considering gender first. Balkin referred to what’s called "trans broken arm syndrome" – when a trans patient will have a basic complaint, like a broken arm, and a provider will immediately assume the problem is gender-related.
For instance, Balkin remembered one of her patients going to a specialist for an eye disease and being told it was caused by the hormones they were taking. Balkin told her patient that was ridiculous.
“‘There is no physiologic pathway by which your testosterone could be causing this eye problem; this doesn't make any sense,’” Balkin told her patient. “‘You continue taking your testosterone, which you need for your gender dysphoria, because you're going to feel terrible if you go off it like they want you to.’”
Balkan said providers also need to keep in mind the organs that a trans person may still have as a result of their assigned sex at birth.
“People with a cervix need pap smears. People with a prostate need PSA checks,” she said.
Like Transhealth, Balkin said the Oxbow clinic is trying to hire more providers to meet the demand. At the moment, they are booking new patient visits for 2023.
“I don't think there is enough care available yet. So I think there's certainly room for both of us,” she said.
Transhealth said it has surpassed 1,000 patients in its first year.
Ducar said the center's current focus, in addition to hiring, is on financial independence once the seed money is gone. They are considering starting their own pharmacy, or creating a research division on trans care so they can get government grants.
In the meantime, she’s had to accept the limitations of what a medical clinic can do for the transgender community.
“We cannot stop someone from experiencing discrimination in all aspects of their life. We cannot stop someone from not experiencing gender dysphoria,” she said. “We can try our best and proceed with the knowledge that we're not going to solve everything overnight.”
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