On a recent weekday afternoon, Ruby Corado let herself into the drop-in center at the homeless shelter she founded for LGBTQ youth to make the rounds with new clients.
In the basement of Casa Ruby in Washington, D.C., transgender men and women in their late teens and 20s, mostly brown or black, shared snacks, watched TV, chatted or played games on their phones. Many of them, said Corado, are part of the 31 percent.
That's 31 percent of transgender Americans who lack regular access to health care. The finding comes from a new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of public health.
"I'm not surprised, because 31 percent — it's a lot," Corado said quietly. Her own experiences with homelessness, rape, assault have left her all too familiar with the vulnerabilities faced by many transgender people.
Corado pointed to one crucial word in the study that deserves extra emphasis. "What does regular health care mean?" she asked, then answered the question herself: "Preventable."
Preventable problems, including HIV infection and some cancers, kill many people in this community. It's harder for transgender people to find health care coverage, because it's harder for them to find jobs. Social stigmas aside, consider the difficulty of getting hired if your gender does not appear to match the one on your legal ID. According to the 2015 U.S. Transgender Study, transgender people face an unemployment rate three times as high as the national average — 15 percent versus 5 percent.
Then there's what might happen when seeking medical attention. In the NPR poll, 22 percent of transgender people said they'd avoided doctors or health care for fear of being discriminated against.
"Your trans status is on display and on parade for people to make fun of you," Corado said, reflecting on insensitive medical professionals who have asked her such questions as, "What are you?"
"Right now, it's very hard for a lot of people to even find a primary care provider who's willing to work with them," said Kellan Baker, a doctoral candidate at Johns Hopkins University who studies how health policies affect gay, lesbian, queer and transgender Americans. He said even if you regularly see a physician, a number of insurance companies will not cover care related to gender transition, such as hormones or surgery.
"Which, as you can imagine, is a huge barrier for transgender people in terms of mental health," he said. "So you're looking at yourself in the mirror, you're not able to get health insurance coverage [and] you can't get health care that you need to make sure that how you look aligns with who you are."
Surgery on reproductive organs is expensive, so many people leave them alone. That means a trans man with a uterus — or a trans woman with a prostate — might have to endure embarrassing, awkward questions from health care providers when getting regular care, such as an annual physical.
Baker had no trouble providing examples."What do you mean you need a cervical Pap test for a man or a prostate exam for a woman?" he asked. "How do we compute that? You shouldn't have that part, so we don't know what to do with you."
Those were the kinds of questions Yee Won Chong had to face when he was diagnosed with stage 2 breast cancer. He had undergone what's known as top surgery, where breast tissue is removed and the chest is reconstructed to a more masculine appearance. However, he later developed cancer in the remaining breast tissue. His doctor didn't know how to code him into the medical records system.
"I'm her first transgender patient," Chong explained. But he was lucky. His oncologist, Dr. Tammy De La Melana, committed herself and her office team to the best possible care for Chong. And in a coincidence that Chong described as freaky, his roommate, who is also transmasculine, discovered he had ovarian cancer. They're working now on a documentary about their experiences, called Trans Dudes with Lady Cancer.
It's worth noting that Southern Comfort, an earlier documentary about a transgender man with ovarian cancer, won the Grand Jury Prize at the Sundance Film Festival in 2001. Back then, transgender people were even more likely to slip through the cracks of the health care system, but insurance companies and many medical professionals still treat them as though their bodies don't make any sense.
All that said, there is a place for transgender people looking for high-quality and low-cost health care to go: Planned Parenthood.
Planned Parenthood trains its staff to be sensitive to transgender people. Many of its health centers offer trans people a wide array of services, including primary care, annual exams and STD screenings. Currently, Planned Parenthood offers hormone replacement therapy at health centers in 17 states, and its national headquarters reports an 80 percent increase in centers offering hormones to transgender patients from 2013 to 2015.
At the Virginia League for Planned Parenthood in Richmond, Va., a number of services for transgender people are available.
Afton Bradley, the center's program manager for transgender health, ran through some questions he thinks about when providing care to trans patients. "Does our front desk know how to be affirming?" he asked. "Is our electronic health record affirming? Does it ask about pronouns and gender ID in addition to whatever legal sex is on their insurance or ID?"
Bradley said this Planned Parenthood can handle trans-specific problems. What happens when a trans woman injects herself with building-grade silicone to get feminine curves? Or a trans man buys black market testosterone, or injures himself by binding his chest with duct tape?
Ryan Brazell, a trans man who gets his care here, remembered his first visit. "I went out to my car and was like, 'I felt really weird,' " he said. "And it took me a few days to figure out why. It was the first time I had a health care experience I was happy with. And I didn't know what that felt like until I had that experience at Planned Parenthood."
That experience is wholly unfamiliar to many clients at the Casa Ruby LGBTQ shelter. "I've seen a lot of people die," said its founder, Corado. "I've been to a lot of hospitals to recognize bodies that were dead from HIV or violence, or shot and stabbed and wounded."
Dozens of trans people have been violently killed just this year across the country. Another tragic public health issue: Almost 20 percent of black transgender women are HIV-positive, compared with only 3 percent in the general population.
"It is very likely, if you are a transgender woman of color, that you will die from HIV," Corado said, underscoring again the number of deaths suffered by transgender women of color that are potentially preventable. "That you will die from AIDS. That you die stabbed or killed. You'll die from some kind of cancer, or suicide."
The U.S. Transgender Survey found that 40 percent of transgender people have attempted suicide in their lifetimes. But that too, is potentially preventable, said Bradley at the Virginia League for Planned Parenthood.
"What we see is a dramatic reduction in those attempts when people have access to affirmative care," he said. Affirmative care means treating trans people like people, Bradley says, adding that it's not that hard.
Our ongoing series "You, Me and Them: Experiencing Discrimination in America" is based in part on a poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. We have previously released results for African-Americans, Latinos, Native Americans and whites so far. In coming weeks, we will release results for Asian-Americans and women.
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