By Rose Hoban

Even as North Carolina continues to argue about the fallout of House Bill 2, a bill that writes transgender people out of North Carolina’s statewide anti-discrimination policy, health care providers gathered in Asheville this past weekend to learn how to better care for those in the transgender community.

About 120 physicians, nurses, mental health providers, parents and family members gathered, along with people along the spectrum of gender transition, at the Mountain Area Health Education Center for a two-day workshop. In addition to providers from North Carolina, the symposium also drew providers from Alabama, Michigan and Nebraska.

“Most of the clinical education happens in the absence of transgender people,” said Allister Styan, during a Transgender 101 talk that kicked off the weekend on Saturday morning. “That’s not the case here. This is a collaborative effort to care in this moment for people who are actually in the same space as you.”

He told the group what was important to them, as health care providers, was to shed assumptions about the transgender patients in front of them.

Styan made the point that there “are as many different ways to be transgender as there are transgender people and [an] individualized way to approach someone is the best way to go forward.”

“This is about getting to know an individual,” Styan said.

Barriers to care

A lot has changed since the first Southeast Transgender Health Symposium at MAHEC in 2012, said Jennifer Abbott, a physician with Western North Carolina Community Health Services who organized that conference as well as this one.

For one thing, that was just after the World Professional Association of Transgender Health (WPATH) updated guidelines for the standard of care for transgender patients to be used by physical, surgical and mental health providers.

“It was sea change,” she said.

She explained that before publication, there were strict guidelines about what someone who wanted to transition to a different gender had to do to get hormone therapy.

“The [new] guidelines became very patient-centered, which is kind of what, as a family physician, I felt they needed to be all along,” Abbott said. “It didn’t feel good to be a gatekeeper.”

Nonetheless, Abbott and other speakers said there are still plenty of hoops to jump through for someone who wants to make the transition, or even get competent health care.

“How many trans people does it take to change a lightbulb?” joked Holiday Simmons, a black transgender Cherokee man and social worker.

“It only takes one… but only after four visits to a mental health provider, three phone calls to a primary care physician and two visits to an endocrinologist,” he said to laughter.

He said barriers can start at the front desk of a health care provider’s office, where staff might embarrass a patient by using the wrong name, causing that person to leave. Simmons outlined issues with insurers that might not be willing to cover care delivered to someone whose name is now different than the one on the policy, clinic intake forms with “male” and “female” as the only gender options, and many other seemingly small problems faced by transgender patients that become barriers to care.

And he had some advice for providers in the room, who, by and large, were welcoming to the transgender community.

“Train other people, it’ll save your workload and to have a cadre of clinicians in your area will save that one person who’s currently seeing everyone from burning out,” Simmons advised. “For example, my primary care provider is that person in my area. People come from all over Georgia to see him, and I know he’s maxed out.”

Teaching the basics

The new standards of care include guidelines for primary care providers.

Abbott cited some considerations providers should make with a person who wants to receive hormone therapy. She pointed to guidelines for dosing and timing recently published by the University of California at San Francisco.

“I really like having something we can trust to hang our hat on,” she said.

Abbott acknowledged that the question of hormone dosing intimidates many providers.

“Someone comes in and says ‘I’m really interested in hormone therapy to start my transition, can you help me do that?’ You can do that,” she said.

“Of all the things I do in medicine, it’s not that complicated,” Abbott said.

However, providers in settings such as urgent care centers may encounter out of town patients who come in and ask for a prescription update.

“We’re primary care providers, that’s what we do every day, all the time, so it’s really no different,” she said.

Abbott talked about documentation and coding, essential for physicians to track and get paid for services rendered. But sometimes that can be a challenge, especially in getting coverage of Pap smears for transgender men or prostate cancer testing for transgender women.

“I sometimes write letters to insurance companies,” she said.

Abbott also sought to reassure practitioners working with young people who are starting puberty. She discussed both hormones and medications that block the hormones that produce the deepening voices, increased breast size and other secondary sex characteristics kids display as they start to mature.

In her years of practice with the transgender community, Abbott says she’d only met a handful of people who regretted making the transition and told the crowd that some of the results of hormone therapy can be reversed, while others are irreversible. But that’s why she and her colleagues go through a thorough informed consent process with patients.

“I’ve learned a lot,” said Asheville gynecologist Grace Evins, who said she started seeing transgender patients about three years ago. “Hormones were one thing I wanted to learn more about the ins and outs of that, the terminology that’s used, the self perspective forums… that’s all stuff I was looking for.”

“It’s always a benefit to increase your skills and get alternate information about best practices as we’re working with this population,” said Charlotte psychologist Jennifer Ratajczak, who is part of the Charlotte Transgender Health Co-op.

“I work with a lot of youth,” she said. “It’s really validating to hear lots of success stories to help them, meet them where they are, get everyone on the same page, so they can have healthy children so we can prevent a lot of the high suicide rate in this population.”

Her colleague Holly Savoy, also from Charlotte, said this kind of continuing education is essential.

“There’s a difference between someone who is trans-friendly versus trans-competent,” Savoy said. “Trans-friendly is someone who’s welcoming and open and receptive to being more informed as a provider into their practice… whereas I’ll say a trans-competent provider is someone who’s taken the time to do the work to attend a conference such as this, to do the reading, to stay abreast of things.”

The two noted there are also upcoming opportunities for providers. The Area Health Education Center in Charlotte will be doing a one-day symposium on LGBTQ health in October.

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