Two patients, strangers to one another, chitchat comfortably about their pets in the waiting room of Lyon Martin Health Services in San Francisco. Another patient says that her appointment at Lyon Martin is the highlight of her day as she makes her way back to the exam room.
Lyon Martin is a unique place, in part because of the patients they serve and the atmosphere of comfort and openness they cultivate. They serve primarily lesbian and bisexual women, as well as transgender people, providing a medical home where their clients access primary care, gynecological care, chronic disease management, hormone therapy for gender transition, and HIV screening and treatment. The clinic also offers behavioral health specialists, individual and group therapy, as well as staff social workers helping patrons with everything from housing to employment. There’s even a program devoted to devoted to transgender telehealth, where Lyon Martin staff can share expertise via online video with transgender patients and providers far away from San Francisco.
At the heart of all of these services is their distinctive care-giving philosophy. Executive director Dr. Dawn Harbatkin has hung up her white lab coat pretty much permanently, and not because she stopped practicing medicine when she took over her leadership role in 2012. Harbatkin still personally treats about 200 of the clinic’s 2,000 or so patients. She shuns her lab coat as an embodiment of the clinic’s approach.
“We’re trying not to distance ourselves from our patients; we’re trying to be partners,” Harbatkin says. In fact, no one on her medical team dons the coat. Of course the staff has to come to work looking professional — “no ripped jeans” — but in a way that will make patients feel at ease, not like they have to “bow to the temple of knowledge.” Harbatkin says, “Anything that helps level that playing field and helps us all play together is better.”
It might seem trivial to pay so much attention to the dress code at Lyon Martin, but Harbatkin is adamant that creating a safe and comfortable environment is essential — particularly when it comes to treating a population with a history of discrimination in the medical setting.
More than half of lesbian, gay and bisexual respondents and 70 percent of transgender respondents had experienced at least one form of discrimination from health care professionals, according to a 2010 survey. Respondents indicated that doctors refused to touch them or used excessive precautions, used harsh or abusive language, were physically rough or abusive, blamed them for their health status, and refused them needed care. The survey, conducted by the LGBT and HIV civil rights organization Lambda Legal, also found respondents had a high degree of fear around accessing care. For instance, 49 percent of LGB respondents and over 89 percent of transgender respondents believed there were not enough medical providers properly trained to care for them.
Marj Plumb, Lyon Martin’s current board chair and former executive director from 1989 to 1993, says that the discrimination — both actual and perceived — has consequences on people’s ability to stay healthy.
“We’re not talking about, ‘Is the beach lesbian-friendly?’ You’re going into a health care environment, something that is already filled with a certain amount of tension and dread,” Plumb says.
Plumb, who also has a Ph.D. in public health, says that for many patients at Lyon Martin, attending a clinic where heterosexuality is not assumed can help alleviate some stress.
“When you go into a facility where you’re going to become vulnerable at some point — you’re going to need health care, you’re going into surgery, you’re getting some test that’s going to scare the bejeezus out of you — to have that extra burden of ‘do they see me?’ has an impact.” For patients at Lyon Martin, she says, “You know you are seen.”
A group of medical providers and activists founded Lyon Martin in 1979 as a clinic that would specifically serve lesbians. As a safety net clinic, the mission was to provide care that was not only nonjudgmental but also affordable — and it wasn’t long before women who weren’t gay began to seek services. Today, the majority of Lyon Martin’s patients are lesbian, bisexual or transgender and the vast majority are uninsured (70 percent) and low-income (89 percent have incomes below 200 percent of the federal poverty line.)
Lyon Martin does not currently treat men who are cis-gender — those who continue to identify with the gender they were assigned at birth.
“One of the questions for our future is, do we start seeing men and what does that mean for us?” Harbatkin says. “With continuing to respect our history and our patients — who really want this to be a safe space, who have been brutalized by men in their lives and want a space that’s separate from that — how do we create both things?
“I think it’s going to be the creative tension that we’re going to have to figure out. Really exciting.”
But recently for Lyon Martin, it looked like there would be no future.
In January of 2011, Lyon Martin was suffering financial hardships so dire that its own board of directors voted to shut down the clinic. Between the tanking economy, the organization’s mismanaged accounting and its significant debts, chances for recovery seemed slim. The clinic was responsible for a $600,000 bridge loan from the California Primary Care Association and had not paid that year’s payroll taxes to either the state and federal government.
At that point, Harbatkin was serving as a physician and the organization’s medical director. She couldn’t fathom dropping the clinic’s nearly 3,000 patients.
“[The board members] couldn’t see a way out at that point…I understand why they were panicked, but we’re not a coffee shop; you can’t hang a sign on the door that says ‘closed today,’” Harbatkin says. “That part was really hard, as a physician, to accept.”
Patients also refused to accept the clinic’s closure. The day after the board announced its plan to close Lyon Martin, patients began to rally. “The outrage from the community was extraordinary. The community really felt like Lyon Marin was their health home. It was theirs and it wasn’t the board’s to take away,” Harbatkin says. “That if Lyon Martin closed, they were not going to get health care anywhere. They felt a personal desperation that rivaled the panic of the board.”
Community members were able to raise over $600,000, primarily from grassroots style, “pass the hat” kinds of fundraising events, says Harbatkin. Lyon Martin was able to provide continuous services to existing patients with the donations, but for the first half of 2011, it had to stop accepting new patients and transfer out some 200 patients who were covered by Healthy San Francisco, the city’s public health program.
Though it’s been more than two years since Lyon Martin began taking new patients again, Harbatkin says they’ve struggled to get back to their previous numbers. Currently Lyon Martin has the capacity to take on another 1,000 or so patients, and with plans for hiring more providers, Harbatkin hopes to eventually grow to a total of 5,000 to 6,000 patients by next summer.
The Affordable Care Act might be both a boon and a challenge to Lyon Martin’s future — a boon in the form of better reimbursements from insurance companies, and a challenge in the form of potential competition with other providers.
With hundreds of thousands in California expected to gain insurance coverage for the first time, Harbatkin says it’s even more important for Lyon Martin to feel like a place of choice.
“For a long time, community health centers have been that place of last resort; where you go when you don’t have any where else to go,” Harbatkin says. “We have worked really hard to not be that place. We want to be a place that people choose to go because it’s the best place to be.”
While some patients may turn to more mainstream providers, Plumb says that a one-size-fits-all approach doesn’t always work in medicine.
“I don’t think it’s a failing of our society that sometimes we still need separate services,” Plumb says. “Some folks think the goal should be a health care system that is pluralist; that serves everybody equally. But the problem is, that not everyone is servable equally because we all have our own lives and experiences in the world.”
To not acknowledge the differences, Plumb says, “I think that’s missing a huge part of who are as human beings.” Or in other words, “the demand will not go away.”
For a patient named Roberta, staying with Lyon Martin is a “no brainer.” For about a year and a half, Roberta has been using her Medi-Cal coverage to get primary care from Lyon Martin, where Harbatkin is her doctor and helps her manage diabetes, high blood pressure, and hormone replacement therapy.
Roberta, who is a transgender woman, used to educate her medical providers about her health needs. “In the past, I have been leery of previous medical providers’ knowledge; in a lot of instances, I was training them,” she says.
But at Lyon Martin, Roberta feels she can let her guard down. “I totally trust them over the past 18 months. I appreciate that they are better educated than I am about my health.”
Roberta, who is 61, says she has personally seen the consequences of ignorance when it comes to transgender health care. When she was in her 20s, “no one knew what hormone replacement therapy would be doing to anyone’s body,” Roberta says. “Girls back then wanted to max out as quickly as they could.”*
“Back then, girls didn’t have the kind of health coverage that they have now. Even now, I would say at least half the girls have no clue what hormone replacement therapy is going to do to them,” she says. “It’s not fair that you don’t know everything you need to know.”
From childhood, Dawn Harbatkin’s parents pressured her to become either a lawyer or a doctor. She enrolled in Columbia Medical School on her own terms: “The way that made it palatable for me to go to medical school was that I was going as an activist.”
“I was going to change this old boy’s network,” she recalls. “That was the whole purpose in going.”
Still, medical school wasn’t easy. Harbatkin was the only openly lesbian student of her graduating class, and says that the majority of dropouts were either women or people of color.
“The amount of racism and sexism and homophobia that was expressed by the teachers and then reinforced in the class was really challenging,” Harbatkin says. She even considered dropping out herself, until a friend protested, “‘You’re gonna let them take another lesbian out of the system. Great job.’”
“That was really powerful for me, and is what got me through medical school.” After that, she felt, “I survived for a reason and I have to give back.”
After finishing her residency in the Bronx, Harbatkin began working for a clinic serving LGBT people in New York City — against the warnings of her colleagues. “My friends at the time said, ‘You should not do this; you’re getting pigeon-holed into queer health care. You’re fresh out on your career, you need to do something broader so you have more options going forward.”
Harbatkin has continued to specialize in LGBT health care ever since. She agrees, in that sense, she has been pigeon-holed, but she points out that her field has grown tremendously since she started in medicine. “And I think it’s fabulous.”
*This story has been updated to correct the following error: the story initially stated that Roberta knew someone who had died from estrogen overdose.