Transgender people struggle to find health care. Charlotte doctors want to change that.
Before he met his current doctor, Eli Carleson dreaded doctor’s visits.
Carleson is in the 11th grade at Northwest School of the Arts and identifies as transgender. Despite having already transitioned socially — his friends and family no longer use the name he was given at birth, and he identifies as a man — past doctors repeatedly reduced him to his anatomy, referring to him as a young woman.
“If somebody doesn’t get the correct pronouns, it feels crushing. If you are finally comfortable enough to come out and start opening up, it feels like getting shot down,” he said.
The barriers to health care for transgender people are numerous, including social stigma, discrimination, and excessive costs. Not only is there a lack of providers sufficiently knowledgeable about transgender health care, but the environments in which trans people seek medical support are ill-equipped to care for them.
Some Charlotte doctors and health leaders are trying to change that.
Ten years ago, a study showed that the median time dedicated to teaching LGBTQ-related content in U.S. and Canadian medical schools was five hours. While more medical schools have added LGBTQ-related content to their curricula since, some medical students still feel they are receiving inadequate training on this patient subset.
“Like many, many doctors, I wasn’t taught about (LGBTQ care), and it was like this big black box of knowledge that I don’t have,” said Dr. Rhett Brown, a family physician at Novant Health in Charlotte.
Brown has been treating trans patients for over 10 years. In 2009, he took a year to educate himself on transgender care.
“It’s basic hormone therapy — as a family physician, I prescribe birth control and use estrogen all the time. We use testosterone all the time under other conditions. So there weren’t any medicines that I wasn’t familiar with or wasn’t comfortable with. It was just using them in a different way,” Brown said.
Brown has seen more than a thousand trans individuals come through his clinic over the past 10 years.
For Carleson, it was a huge relief to find Dr. Brown, who affirms his male identity while also discussing his health holistically, making him feel safe in the doctor’s office.
“I really like him,” Carleson said. “My pediatrician is for younger kids and wasn’t sure how to work with a transgender kid. Dr. Brown has been really affirming and is very, very helpful… We do normal health check-up stuff too. But he’s really good at answering questions I have... Having somebody there, who’s like ‘I get this,’ and can help you figure things out, it’s really validating.”
Streamlining the search
Finding a competent doctor can take months of research for a transgender person. Novant Health recently added LGBTQ care options to its online search tool, physician finder, allowing patients to search for specific providers with expertise in such care.
While such tools can make it easier for trans people to find quality providers, some say that’s not enough.
“There is still no centralized institute of care for trans people, no one-stop-shop, at least for adults,” said Kelly Leech, Health care Outreach Initiative Manager at PFLAG Charlotte, an organization that provides support for LGBTQ youth and their families.
There is, however, a consolidated center for transgender care for young people in Charlotte. Atrium’s Levine Children’s Center for Gender Health, which opened in April 2019, is the first in the region specifically geared towards LGBTQ patients aged 11-25.
The Center for Gender Health provides medical consultations for patients, including children, and their families at all stages of their journeys to gender confirmation.
The goal of treatment varies based on the patient’s age and needs. For pre-pubescent trans patients, the care is centered around verbal affirmations and validation, supported by trained mental health specialists.
As trans patients begin puberty, physical treatments such as puberty blockers and testosterone and estrogen become available if the patient and their family are ready. Surgeries, such as top surgery, otherwise known as masculinizing chest surgery, in which breast tissue is removed and the chest is contoured to appear more masculine, are often only available to patients over 18, explained Dr. Shamieka Dixon, the director of adolescent medicine at the center.
Disparities persist
One in three transgender people has to teach their doctor about trans-specific needs in order to receive appropriate care, according to a 2020 study by the Center for American Progress. Nearly 3 in 10 transgender individuals report postponing or avoiding medical treatment due to discrimination.
Transgender women of color face heightened barriers to care as the result of multilayered minority stressors, including racial and gender identity discrimination.
Before going to a doctor, a trans individual has to ensure a number of vital questions have been answered:
“Has this professional dealt with trans patients before? Are they recommended by other trans patients? Do they have credentials and recommendations? What is their experience like?” said Devin Green, an 18-year-old transgender man from Charlotte.
In most cases, the onus is on the patient to avoid inadequate and potentially dangerous health care spaces.
“It’s constant advocating,” said Liam Johns, a transgender man from Charlotte who is in the middle of his second pregnancy.
Educating the wider hospital workforce
Many studies have shown that social gender affirmation, in which a person receives social recognition and support for their gender identity and expression, is a key component in health care access for transgender people. In its absence, transgender adults experience stigma, prejudice, and discrimination, according to a 2019 study.
“You can have every bell and whistle on your website that says that you are trans-friendly. But if you walk up to the front desk of an institution and get misgendered and dead-named, it’s not an affirming place,” said PFLAG’s Leech.
For a trans person, visiting the hospital can be traumatizing. A few years ago one of Brown’s trans patients was verbally abused inside a trauma unit after being involved in an automobile accident. When the nurse undressed the patient to check for injuries, she announced to the whole room that they were dealing with “a freak,” Brown said.
“He spent a week being called his female name, being called a girl ,and when I saw him back in follow up, we were back at ground zero. He said, ‘I’m a freak, I’m never gonna be good enough,’ and I thought, we have got to do better,” said Brown.
Since then, Brown has traveled across the state to teach providers about affirming health care for trans people. In 2011, he co-founded the Charlotte Transgender Healthcare Group, over 70 health care providers focused on removing health care disparities for the transgender community.
The Charlotte metro area, along with Asheville, Charleston, and the Triangle, is near the top of a short list of Southeastern metro areas with increasing numbers of trans-friendly health care providers. Of the 25 N.C. health care facilities ranked as equality leaders by the Human Rights Campaign, over half are Novant Health facilities.
Providers taking part in surgical procedures on trans patients in Novant undergo sensitivity training before seeing patients, most of which is coordinated by Wendy Renedo, a transcultural health manager, nurse and chief educator. She has spent the past three years supporting trans individuals going through gender-affirming surgery from the moment they walk through the door.
“These patients needed more than a well-educated nurse, they needed an advocate or liaison,” Renedo said.
For Melissa, a 26-year-old trans woman who underwent facial feminization surgery last year through Novant, Renedo’s support throughout her surgical experience made her feel safe and cared for. She chose not to share her last name to protect her privacy.
Facial feminization surgery changes masculine facial features into feminine features. Patients, for example, have their hairline moved to create a smaller forehead, or have their lips and cheekbones augmented. The surgery is an important component in the transitioning process for some trans people and reduces their risk of exposure to violence and discrimination.
“It put me at ease to know there was an ally there that wasn’t my family. It was a very positive experience for me,” Melissa said.
Novant’s LGBTQ Community Advisory Council, a group of LGBTQ community representatives and advocates co-led by Brown, helps frame Novant’s goals for improving LGBTQ care and addressing health disparities. Both Atrium and Novant have LGBTQ business resource groups, in which staff members who are part of the LGBTQ community meet to discuss their professional needs and opportunities for development.
“We can’t do this alone and work in a vacuum. We have to work with the people who know best,” said Tanya Blackmon, Executive Vice President and Chief Diversity and Inclusion Officer at Novant.
Modernizing medical records
Intake forms can be stressful for transgender people. The same 2019 study found that trans people often have to interpret whether a facility is asking for information about their gender identity or their sex because the forms use the terms sex and gender interchangeably.
Further complications arise when trans people have to provide their legal name, current name, and pronouns on intake forms, the study reported.
Liam Johns faces issues with electronic health records constantly. When he called his obstetrician’s office in mid-July, the secretary told him he had called the wrong place, because his records said he was a man.
“Yes, I understand. I am a man! I am a pregnant transgender man,” Liam recalls telling the secretary.
When Johns became pregnant for the first time in 2019, the obstetrician told him they had to change him to female in their system, but his pharmacy still had him registered as male. It became impossible for him to get any prescriptions approved by his insurance. He struggled to get his asthma medication refills because his medical records and medical insurance documents showed different genders. For his second pregnancy, he was allowed to stay as male in his medical records, which made things much easier.
A report from the National LGBT Health Education Center said collecting sexual orientation and gender identity (SOGI) data in electronic health records can help address these issues. SOGI data can also help health care systems learn about which populations are being served, and measure the quality of care provided to LGBTQ people.
Both Atrium Health and Novant are in the process of improving their SOGI data collection with the hopes of better understanding barriers to LGBTQ care.
Charlotte health care systems have a ways to go in achieving equity for transgender people. Nonetheless, Brown is hopeful that things are changing.
“It has been wonderful to see the acceptance and the growth there has been,” he said. “A rising tide raises all boats.”
This story was originally published July 16, 2021 at 11:01 AM.