Health care hard to come by for transgender people outside urban areas

Sandra Hinojosa standing outside of the California Rural Legal Assistance office in Salinas. Hinojosa, a transwoman, is a longtime member of Conexiones, an LGBT leadership group operated by CRLA in Salinas. Photo: Kate Moser/California Health Report

Nick McDaniel lives within a couple of miles of the sites of some of his worst memories.

Growing up in the farming community of Salinas, McDaniel, a transgender man, survived sexual assault and years of severe depression, multiple attempts at suicide, and many months spent in county psychiatric wards.

Life may have improved in places like Monterey County for transgender people, McDaniel said, but there’s still a long way to go – from fighting discrimination in jobs and housing, to making inroads in health care.

In seeking medical care, transgender Californians routinely face a number of challenges, particularly in more rural regions, where they often live their lives under the radar.

“I do think in Monterey County, like in most areas, the needs of transgender people are not well-recognized,” said Jennifer Hastings, a family practice physician who started a Transgender Health Care Program at the Westside Planned Parenthood in Santa Cruz in 2005.

People come a long way to see Hastings. Through word of mouth, many in the transgender community in Monterey and surrounding counties hear about her and find their way to Santa Cruz. Those who don’t have a car or the means to travel are often out of luck.

In many ways, Hastings said, transgender people are the least understood group in a society that sees gender in a strictly binary way. But she sounds a hopeful note that – while there’s a lot of work to be done – the medical profession is making progress in treating transgender people.

“My sense is that we will have more training in medical schools,” she said. “It will get better.”

Transgender people face discrimination from the medical profession. It’s even worse for transgender Latinos, according to a 2011 study. The National Transgender Discrimination Survey found that 23 percent of Latino transgender people reported being refused medical care because of bias, and 36 percent said they had put off going to the doctor when they were sick because they were afraid of discrimination.

“The stress of visiting a health care provider who is not aware of transgender issues can keep transgender people from seeking any heathcare needs for fear of being outed, or mistreated at health facilities, or simply not having enough information to educate the heath care provider on what they need as a transgender person,” said Axil Cricchio, a social science professor at California State University – Monterey Bay and a transman, in an email.

There is an acute need for better access to health care for transgender people. Respondents to the discrimination study reported more than four times the national average for HIV infection. Nearly half reported that they had attempted suicide.

Transgender people in Monterey County who want to see a doctor who is specifically trained to work with transgender patients must travel outside the county – whether to Santa Cruz, San Francisco, or San Luis Obispo. People who want a prescription for hormones and who don’t have a car or a ride out of the county, then, may turn to the black market.

“A problem we have in this county is ignorance and an unwillingness to learn by health care providers,” said Stephen Braveman, a gender specialist and sex therapist in Monterey.

One young doctor in Salinas, with Hastings’ help, is hoping to chip away at that problem.

Jennerfer Tiscareno, a second-year resident at Natividad Hospital in Salinas, plans to start a weekly clinic for transgender patients as part of her community medicine rotation.

She realized there was a need for such a clinic during her intern year, when she saw or heard about multiple patients who had come into the emergency room with stab wounds. They were all transgender women who worked as prostitutes and were attacked by clients, she said.

One of the main areas where Tiscareno sees a need is training for hospital staff. Some nurses, for example, were unsure of whether to call transgender women by their birth names, or by the names they have adopted as women.

“I always said there’s no question, call them by their name of which they would like to be called,” she said. “As a physician, maybe you have that impact of saying this is what you need to do. You don’t need to be specialized to deal with transgender medicine. It’s really just comfortability.”

Roselyn Macias, a transgender woman in Salinas, can relate to the problem of hospital staff being untrained – she’s been treated poorly by front desk staff in the past. Now she is considering getting a degree as a medical assistant; more transgender people should be trained to enter health care fields, she said.

“That helps transgender people – they’re not going to be afraid” to go to the doctor themselves, she added, if they see more people like themselves providing care at clinics and hospitals.

Braveman said some Monterey County hospitals refuse to place transgender patients in rooms that match their gender identities. Some providers in the county don’t understand the basics of transgender care and refuse to learn, Braveman said; some are rude to transgender people who come in, some refuse to give them care, and every now and then a provider will find it so bizarre that someone is transgender, he said, that they will call the police.

McDaniel, now a therapist, recalled seeing a specialist for a sinus condition; when the doctor inquired about his previous surgeries, and McDaniel told him about his gender reassignment surgery, the doctor made a point of crossing off “male” on McDaniel’s chart and writing in “female.”

He now travels to Santa Cruz to see Hastings for his medical care. “I got tired of going in and having to teach medical professionals,” he said.

Aside from genital surgery – which not all transgender people seek out – there is nothing particularly special that transgender people need from doctors. Hormone therapy replacement – which not all transgender people seek out – is common among all genders. All other health needs simply relate to the human body, Cricchio said, regardless of a person’s gender identity.

And not all doctors in Monterey County, of course, are dropping the ball on care for transgender patients. “What I’ve seen are doctors are pretty well-trained,” said Sandra Hinojosa, a transgender woman and leader, along with Macias, in an LGBT support group in Salinas run by California Rural Legal Assistance.

“Whoever you are – whether transgender or not – they give you good care,” she said in Spanish through an interpreter.

The only difference she experiences when she goes to the doctor, she said, is that medical staff, not knowing initially that she is transgender, will ask her if she’s had any children, and when her last period was. When she tells them she’s transgender, she said, they reassure her: “Relax, you’re not going to have a problem here. You’re OK.”

There are larger systemic problems – health insurance companies, for example, because the system is set up so that tests are linked with gender, routinely deny coverage for preventative care screenings such as prostate exams for transgender women or pap smears for transgender men.

Paying for health care is also a problem. The Latino transgender population faces a debilitating 18 percent unemployment rate, according to the 2011 discrimination study.

Macias said she’s had health insurance in brief spurts while working picking raspberries in the fields around Salinas and Watsonville. Without health insurance, hormones cost her $100 a month. She’s paid $20 a month for them when she’s had health insurance through work.

And it’s tough finding employment; Macias is trying to stay upbeat about her job search, but it’s frustrating. She always gets an interview if she applies online, but after the interview, employers typically say they’ll let her know. She repeatedly gets told that she’s overqualified, but she said she’ll take any job.

Lacking health insurance because of its expense, many transgender people – like many people in general – get their primary care at emergency rooms or clinics only when they absolutely need it. Getting to Santa Cruz, to San Francisco or south to San Luis Obispo for care from doctors who are trained to work with transgender patients is only a dream for many people in Monterey County.

“Traveling these distances are simply not an option for those who do not have the means for such travel, nor the money to finance their own health care,” Cricchio said.

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