When Phillippa Bisou decided to begin transitioning from male to female, she started searching for a knowledgeable doctor who could prescribe her hormones.
Though she lived in Santa Barbara, a city with hundreds of physicians, she couldn’t find one who specialized in treating transgender patients. She ended up driving close to two hours north to San Luis Obispo to see a doctor.
Not long after, that doctor moved to Australia, and Bisou, who is in her 50s, would again be without a physician if not for a clinic that opened in 2015 in neighboring Ventura County.
The clinic is the first health center in the region specifically for people who are lesbian, gay, bisexual or transgender. In a time when mainstream culture has made strides in recognizing LGBT rights, access to culturally sensitive health care remains out of reach for many who identify outside traditional gender or sexual norms.
There are only a handful of LGBT health clinics in California, and residents who live outside the Los Angeles or San Francisco metropolitan areas often face hurdles to care.
“In areas like the Central Valley or Inland Empire, or certain parts of Ventura County, there is a lack of culturally competent health care,” said Jason Howe, communications director at Equality California, a statewide LGBT health advocacy organization. “People don’t understand the unique health needs of LGBT people, who are a lot less likely to have (health care) access or be insured in the first place.”
An alternative to black-market hormones
In part due to decades of being ostracized by mainstream culture and the medical community, LGBT people face health disparities. The population has higher rates of HIV, smoking, obesity and some mental health issues, said Robbie Rodriguez, Equality California program director. The fact that many LGBT residents have low incomes and are people of color can also contribute to disparities, he said.
“What happens is if a patient goes in and the provider doesn’t treat them in culturally sensitive way or they don’t feel welcome?” Rodriguez asked. “We either shut down and don’t disclose honest information, or we just leave and don’t come back. Unfortunately that can only exacerbate health disparities.”
Patients who don’t want to risk being misunderstood or mistreated at a traditional doctor’s office often must chose between going without care or paying-out-of-pocket to travel to an LGBT clinic.
Some transgender patients without access to a clinic resort to ordering hormones on the Internet, a dangerous proposition. Hormone therapy should be closely monitored by a physician because side effects can include blood clots, stroke and high blood pressure, said Jake Donaldson, a family medicine doctor at the Ventura County clinic.
Donaldson said he has treated a handful of transgender patients who were ordering their hormones on the black market before the clinic opened.
One woman was hospitalized with a blood clot after taking hormones she ordered online, Donaldson said. When she came into the clinic, she had been off the medication, which was also problematic, because the hormones were part of her to her transition process.
“We found a way that was safe to restart estrogen, going slowly, and it’s incredible the effect that has had on her sense of wellbeing,” Donaldson said.
Driven by alarming HIV rates
Donaldson also prescribes pre-exposure prophylaxis, a medication that significantly reduces the chance of being infected with HIV, to patients who are at risk.
LGBT patients without access to a culturally sensitive doctor are also less likely to take PrEP, as it is known, even when it could save their lives, Rodriguez said.
“If you’re not welcomed and you don’t feel safe, you’re probably not going to be recommended or advised to take an HIV test or pre-exposure prophylaxis,” he said.
The Ventura County clinic was started in part due to increasing HIV and AIDS rates among the transgender and gay population in the area, said Shannon Enochs, clinic manager and nurse.
“Our health statistics were showing that there was a need, and we needed to do something about it,” she said. “Once we got started with it, we realized it was much bigger than we imagined.”
In 2014, the latest year statistics are available, the county saw a more than 20 percent increase in the number of HIV cases compared to the previous year. About 77 percent of those who were newly diagnosed were men and teen boys younger than 34. The majority of cases — 83 percent — were in men who had sex with men.
The clinic has seen over 100 patients in its year and a half of operating, three quarters of whom are transgender. Part of the Ventura County Health Care Agency, the clinic is housed in an existing medical practice in Santa Paula and operates every Monday and every other Sunday. The majority of patients at the clinic have the state’s low-income health insurance, known as Medi-Cal, Donaldson said.
The clinic has the option of a private waiting room and entrance for patients who are concerned about being “outed” by visiting the office. To help patients feel welcomed, all staff members wear rainbow stickers on their badges or rainbow pins on their scrubs, and the bathrooms signs specify that they are for “any person regardless of gender identity or expression.”
A marriage and family therapist also works at the clinic, treating patients with mental health issues, such as depression.
“About 41 percent of transgender adolescents and young people attempt suicide every year — it’s horrible,” Enochs said. “I was like, ‘We have to do something about this.’”
The counselor also sees patients for visits that insurance companies require before they can undergo gender reassignment surgery.
While the clinic is making an impact locally, there remain hundreds of LGBT people in the state who don’t have access of culturally sensitive health care, Rodriguez said.
His organization has spent the past two years training more than 1,100 health providers primarily in the Central Valley and Inland Empire on how to provide appropriate care to LGBT patients.
Simple changes, such as displaying a rainbow sticker or having an LGBT publication in the waiting room, can signal to patients that they are welcome, Rodriguez said. Many physicians also need to think about revising their intake forms to include space for a preferred name in addition to a legal name, as well as multiple options to select for gender and relationship status.
“If a provider is culturally competent, it can really save lives,” he said.
Bisou, who has a podcast about being transgender called Your True Gender Radio, knows this firsthand. It took her several months of working with Donaldson to find the right level of hormones.
“But the feedback from the clinic was really helpful,” she said. “It was a more personal approach and it really helped me be clear about my intentions.”