THE SAN FRANCISCO BAY AREA is regarded as a haven for LGBTQ communities in the state and across the country. Yet, health care that specifically addresses the concerns of those communities remains elusive to many.
Ninety-seven percent of 800 Bay respondents who identify as LGBTQ in a recent survey by a sexual minority advocacy group reported negative experiences within mainstream health care settings, including shaming, judgment and inadequate care from providers who lacked awareness about LGBTQ health needs.
The problem is particularly acute in the trans community, where access to health care is met with stigma, discrimination and lack of knowledge from providers.
Transgender people face discrimination and barriers to care in every aspect of their lives, and the health care system is no exception. We need to do more to ensure that transgender people have access to the quality care they deserve.
Cecilia Chung, Transgender law center
The study by San Francisco-based Horizons Foundation found that nearly one-quarter of transgender respondents did not seek health care they needed due to fear of being mistreated as a transgender person, and 33 percent did not go to a health care provider when needed because they could not afford it.
“The findings of this study are alarming, but they are not surprising,” said Cecilia Chung, CEO of the Transgender Law Center. “Transgender people face discrimination and barriers to care in every aspect of their lives, and the health care system is no exception. We need to do more to ensure that transgender people have access to the quality care they deserve.”
Long journeys, limited clinics
For the past decade, Timothy Nguyen dedicated his career as a health care provider to serving the Bay Area’s LGBTQ community. He noticed a trend with most of his patients – an unusual one. They drive miles from all over the Bay Area to seek care at the only LGBTQ center in Oakland.
“Many of my patients come all the way from Richmond, Castro Valley, Sacramento to seek health care,” Nguyen said. “Due to the distance, people come only when there is a problem.”
The San Francisco Bay Area has a large transgender population, with an estimated 25,000 transgender adults living in the region. However, the Trans Resource Guide by the University of California San Francisco (USCF) School of Medicine, shows there are only six primary and transition-related medical care clinics for transgender people in the Bay Area.
“Due to the distance, people come only when there is a problem.”
Timothy Nguyen, physician’s assistant
Nguyen observed the high demand for care coupled with limited resources worsened health outcomes of not only trans persons but especially Black Indigenous Persons of Color (BIPOC) sexual minority groups in the Bay Area who frequently meet long wait times in finding specific doctors and treatments for their sexual or gender identity needs.
The consequences of those delays can be high, not only for the specific patient but for others.
“Whether it’s chlamydia (or) gonorrhea we know that there’s a high rate of asymptomatic cases,” he said. “But also, about 25 percent of syphilis infections are latent – making late detection a trigger for an epidemic.”
Losing trust
The Horizons report uncovered a disturbing discrepancy between the experiences of people who identify with their gender at birth — “cisgender” — and those of transgender, genderqueer and non-binary individuals. The nonbinary reported being more frequently met with insensitivity from health care providers regarding their gender identity and expression — an experience Flora Bradford, a trans woman in Oakland, relates with.
In March 2023, Bradford tried getting a referral to an endocrinologist with expertise in estrogen therapy in trans people. Like Bradford, trans women need estrogen because it is a hormone typically associated with feminization. According to the World Professional Association for Transgender Health, estrogen therapy is a safe and effective way for transgender women to align their physical characteristics with their gender identity.
After waiting three months for a referral from her primary care provider at Sutter Albany, Bradford was referred to a provider at Sutter Health. The prolonged waiting period meant an underdose of estrogen which affected her therapy.
“That experience and so many other interactions with the health care system led me not to trust it.”
Flora Bradford, a trans woman
“My blood tests were coming back with very low estrogen levels, like not acceptable,” said the 41-year-old. “I really needed the estrogen injections to get to a therapeutic level of estrogen, a level that the experts deemed correct for me.”
After months of waiting, Bradford recounted the additional frustration of meeting an endocrinologist at Sutter who admitted to having no expertise in dealing with trans women. Bradford said she was denied the care she needed.
“I had waited two and a half months for nothing,” Bradford said. “That experience and so many other interactions with the health care system led me not to trust it.”
In response, Sutter issued a statement that read in part “Sutter Health offers a comprehensive gender care program in which we provide affirming, integrated care to our transgender and gender-diverse patients. There is always room for improvement, and that’s why we continue to enhance our services through ongoing training, sharing of best practices and hiring of excellent clinicians and support staff.”
Bradford’s care provider may not have been intentionally discriminatory. Still, they may have been lacking in trans medical knowledge due to the failure of many medical schools to improve curricula pertaining to LGBTQ care.
‘It’s not rocket science’
A 2011 study found that students received a median of 5 hours of training on LGBT+-related topics, and one-third of 176 medical schools did not provide any training at all.
Dr. Dustin Nowaskie, president and founder of OutCare Health, a nonprofit LGBTQ health-equity organization, in reference to the study argued in a paper that medical schools must provide at least 35 hours of training on LGBTQ health.
Nowaskie, whose paper examined the cultural competency of 940 medical students, said training should start with learning about the terminology commonly used by LGBTQ people, then expanding to culturally sensitive care such as health conditions that occur at higher rates among LGBTQ people, including sexually transmitted infections.
“Training more care providers, investing more into LGBT health care, expanding access to trans people can go a long way.”
Timothy Nguyen, physician’s assistant
“These skills should absolutely be required,” said Nowaskie. “Special emphasis should be given to transgender-related patient care topics.”
California has the highest percentage of LGBTQ adults in the country, with 9.1 percent of adults identifying as lesbian, gay, bisexual, or transgender. This is considerably higher than the national figure of 7.9 percent. And yet, there are no publicly available data on the LGBTQ patient-doctor ratio in the state, let alone the Bay Area, except for the clinic numbers cited by the Trans Resource Guide by the University of California San Francisco (USCF) School of Medicine.
Physician Associate Nguyen said funded LGBTQ centers like Oakland’s Glenn Burke Wellness Clinic — a project of the Oakland LGBTQ Community Center offering LGBTQ+ centered and affirming medical services — are racing against time to change the narrative of LGBT medical care in the Bay Area. Faced with inadequate funding amid a high demand for their services, Nguyen wants more state funding for LGBT-affirming medical clinics in the Bay Area.
“Training more care providers, investing more into LGBT health care, expanding access to trans people can go a long way,” he said. “It’s not rocket science.”
Intersecting struggles
The shortage of LGBTQ health services is being compounded by the nationwide attacks on the right to abortion.
Noting two attacks on Bay Area Planned Parenthood clinics, one a shooting in San Jose on May 24, 2022, and the other a firebombing in Oakland on June 12, 2022, both motivated by anti-abortion sentiment, trans woman Veronica Culpepper spoke out about the impact of anti-abortion politics on trans health.
Culpepper said Planned Parenthood has been a “huge asset” to the transgender community, providing hormone therapy and other essential health care services. However, she said that the recent attacks on Planned Parenthood by anti-abortion activists have had a “formal impact” on trans health.
“We need to make sure that everyone has access to the health care they need, regardless of their gender identity or sexual orientation.”
Veronica Culpepper, trans woman
“For many of us, Planned Parenthood was a place where people could get hormone treatment,” Culpepper said. “Having agency over your own body is a right that is impacted not just for women when clinics like Planned Parenthood are attacked, but also for trans women and I assume transmasculine.”
Culpepper pointed out that the anti-abortion movement is often motivated by a desire to control women’s bodies. However, she said that these same efforts also hurt transgender people. The 62-year-old high school teacher wants support for Planned Parenthood and other organizations that provide essential health care services to transgender people.
“We need to make sure that everyone has access to the health care they need, regardless of their gender identity or sexual orientation,” Culpepper said. “We need to fight against the attacks on Planned Parenthood and other organizations that provide essential health care services.”