Tommilynn
Travis spent years driving an 18-wheeler across the United States, but
the trip she remembers most is the one she took after the job ended. Two
years ago she set out along
Highway 62 from the oilfields of rural New Mexico, where she’d recently
begun working, to the Texas panhandle town of Lubbock, 110 miles
northwest. Travis was at a crossroads in her life. Newly divorced,
estranged from her kids, and nearing 40, she had decided
to transition from male to female.
As
for most people in her situation, starting the transition wasn’t easy.
Nobody in Hobbs, New Mexico, the small city near the state line where
she was living, had any experience
treating gender dysphoria, the severe condition of depression and
anxiety that ensues when people feel their body doesn’t match their sex.
“They weren’t trained; they weren’t taught; they had no clue,” Travis
says today, wearing a crucifix tattoo inked like
a necklace down her chest. The doctors she saw were baffled.
The
Transgender Resource Center of New Mexico, in Albuquerque, was five
hours away. An appointment would take all day. After making dozens of
phone calls, she set out for an infertility
clinic in conservative West Texas. When she walked in with a
recommendation from her therapist and asked to be put on female
hormones, the doctor didn’t bat an eye. “Surprisingly, at that clinic I
didn’t have many issues,” Travis remembers, speaking in a soft
Southern twang, a relic of her Memphis, Tennessee, upbringing as a
Southern Baptist. “They were so used to dealing with people in crisis
situations all of the time—couples that couldn’t have babies or
whatever. They were extremely supportive.”
The
major downside was the expense: Few insurance carriers covered the
treatment, despite the American Medical Association declaring in 2008
that gender dysphoria is a “serious
medical condition” that “for some people without access to appropriate
medical care and treatment” can lead to “suicidality and death.”
(Photo: St. John's Well Child and Family Center/Flickr) |
“It saved my life, hormone therapy. It did," Travis says. “It was all out of pocket back then; it was terribly expensive."
Still,
Travis had it relatively easy at the beginning of her transition. While
acceptance of transgender people seems to be accelerating in the U.S.,
with celebrities such as Caitlyn
Jenner and Laverne Cox getting unprecedented levels of attention, many
trans people continue to face harassment and discrimination in the
health delivery system, and are frequently denied access to vital
treatments because health care providers refuse to shoulder
the costs. Though Travis now lives in California, one of 16 states that
have banned health care discrimination based on gender identity and
sexual orientation, she has nonetheless faced insurance-related delays
and outright denials for transition-related health
care.
But
Travis now knows that such denials can be illegal, and is at the
forefront of a movement to get all trans people access to health care,
and to force health insurance companies
to pay for hormone therapy and gender reassignment surgery. Activists
say this is the next big civil rights battleground for transgender
Americans. The Affordable Care Act banned discrimination in health care
on the basis of sex, but some say the law wasn’t
explicit enough when it comes to trans people and their health care
needs. “There was no statement about what is and isn’t prohibited,” says
Harper Jean Tobin, the director of policy at the National Center for
Transgender Equality in Washington, D.C. Health
care plans that exclude any services related to gender-transition, from
counseling to medical procedures, survive—“even though,” Tobin says,
“many observers have thought that they would probably violate” the
sex-discrimination ban.
Tommilynn Travis. (Photo: Lauren Wade) |
Being
trans is an identity that comes with a bill: Hormone therapy to treat
gender dysphoria costs money, and the male-to-female sex reassignment
procedure can range in cost from
$7,000 to $24,000, according to the Transgender Law Center;
female-to-male surgery can cost upwards of $100,000. As a patient
volunteer on the Transgender Health Advisory Board of St. John’s Well
Child & Family Center, an L.A.-based nonprofit community
organization
providing health care and services at eight centers and five schools,
Travis works to educate insurers about their obligations under the law
and pushes them to pay for care for people like her. When her own
insurance company delayed approval of a prescription
for progesterone, Travis filed a grievance. When her claim for gender
reassignment surgery was denied, she fought back until she got it
approved. “It was like pulling teeth,” she says. “It was ignorance of
the law—the fact that we need this to function normally."
St. John’s recently prepared a
report
on the status of transgender health care in the U.S., the culmination
of years of research, community surveys,
and input from the advisory board. Its primary conclusion? "Many of the
health plans are systematically denying access to care even though it's
a mandate under the Affordable Care Act," says St. John’s CEO Jim
Mangia.
In
September, the Obama administration proposed a new rule that would
clearly outline that discrimination on the basis of gender identity is
against the law of the United States.
The proposed rule, in the words of the Dept. of Health and Human
Services, “extends nondiscrimination protections to individuals enrolled
in coverage through the Health Insurance Marketplaces and certain other
health coverage plans…[and] explains consumers’
rights under the law and provides clarity to covered entities about
their obligations.”
All
the hours Travis has spent “calling, fussing, trying to figure out
who’s in charge, who’s holding things back—it’s going to pay off for all
these other people who were too scared
to say anything,” she says. She’s no longer alone in the fight for
transgender health care, as she sometimes felt in New Mexico. Now she’s
surrounded by a community of transgender men and women with urgent
medical needs. “Rather than just be an advocate for
myself,” she says, she now has “these 400, 500 other girls” to fight
for. “It’s not just me. That’s the way I always try to look at it—as not
just helping me but helping everybody where I can.”
Efforts
she and others at St. John’s have put in are now paying off for her, as
well. Travis is waiting on a phone call from her insurance company to
let her know her surgery has
been scheduled—at its expense. "It was a matter of getting L.A. Care to
get off their butts and start processing stuff," she says. And she
would know: The phone calls helped her land at the top of an L.A. Care
waiting list for gender reassignment surgery.
"It makes me feel good to know that all the hours I put in calling,
fussing, trying to figure out who's in charge, who's holding things
back—it's going to pay off for all these other peole who were too scared
to say anything."
(Photos: St. John's Well Child and Family Center/Flickr) |
The
light on Diana Feliz Oliva’s office telephone flashes red with new
voicemails, signifying to her one thing: patients needing her attention.
As the Transgender Health Program
coordinator at St. John’s, Oliva schedules all first-time appointments
for transgender patients. "I cannot go home and sleep at night until
this light is clear," she says.
For
a number of people in California, a phone call to Oliva, a transgender
woman with feathered black hair and bangs, is the first step in starting
the transition. It can mean the
difference between life and death: Forty-one percent of trans people
attempt suicide, according to a
survey by the National Center for Transgender Equality, compared with 1.6 percent of the general population.
Outside
the window of Oliva’s office, sunlight glares down on the fenced-in
brown lawns and the iron bars on the windows of single-story homes
across the street. About two miles
away from the health center, black transgender woman Deshawnda “Ta-Ta”
Sanchez was murdered late last year. It's not the kind of neighborhood
where you might expect to find one of the most radically progressive
health programs in the country, specializing
in serving a low-income transgender population. It’s one of just five
federally qualified health centers nationwide to offer a transgender
health care program—and according to Mangia, it’s the only one to
provide services to people who are undocumented, many
of them non–English speakers.
Since
St. John's launched the program in January 2013, it has ballooned from
serving nine patients to assisting nearly 500. At a time of growing
awareness and acceptance of the
trans community, it’s a precedent-setting attempt to address an old
problem. In a 2011 survey conducted
by the National Center for Transgender Equality, 19 percent of
transgender or gender-nonconforming people reported being denied medical
care owing to their gender identity, and 28 percent of respondents
reported verbal harassment during a doctor's visit. That's
among those who managed to see a doctor—many transgender people can't
afford medical care. About half of respondents in the survey said they
had delayed even basic medical care because of the cost. It doesn't help
that transgender people experience unemployment
at a rate about double that of the general population.
Access
to hormones—which many St. John’s patients were previously buying on
the black market, like illicit drugs—is just one aspect of the St.
John's program, alongside psychological
counseling, HIV testing, referrals for gender reassignment surgery, and
assistance enrolling in insurance. By providing legal and unemployment
resources, the program seeks to address problems in the community that
can't be diagnosed by doctors or fixed with
Band-Aids.
When
meeting patients for the first time, Oliva likes to remind those who
she says might need that extra touch, “Remember me? I'm Diana. We talked
on the phone, and I scheduled
your appointment,” she says she tells them. “A lot of them will cry,
and I'll hug them for a moment, and they're like, 'Wow, this is the
first time I'm able to live my authentic, sincere life.' So there's a
lot of emotion." After the event ends, she heads
back up to her office, where the red light on her telephone flashes
back at her. She isn't sure how much longer she can single-handedly
field calls from new patients, but she's not ready to share the
responsibility with her co-workers yet. "Remember me? I'm
Diana. We talked on the phone and I scheduled your appointment," she
likes to tell new patients who "might need that extra touch" when she
meets them in person.
"A
lot of them will cry and I'll hug them for a moment and they're like,
'Wow, this is the first time I'm able to live my authentic, sincere
life.' So there's a lot of emotion."
Mangia
hopes the Transgender Health Program can be a model for health centers
around the country and help change an industry that largely
misunderstands the needs of the transgender
population. "Caitlyn Jenner aside, it's still a relatively new
situation people are just learning about, and it's just kind of moved
into the mainstream in a way that it never had been," he says. "It's not
a comfortable subject to talk about in the health
care community."
The
center’s Transgender Health Advisory Board Travis serves on identifies
the industry’s blind spots in providing health care to a transgender
population. Many of the concerns
raised during its monthly meetings concern St. John's own waiting room.
The bathrooms, which are not gender-neutral, remain a constant
complaint from trans patients who find choosing a binary public restroom
anxiety-inducing. Mangia says it's first on his
list of building renovations. Another problem the board identified
early is that the electronic medical record system did not allow
staffers to enter patients by their preferred name, which led to lots of
anger in the waiting room. It took months, but Mangia
worked with the software vendor to create a fix.
St.
John's has sought to achieve what Mangia calls "cultural competency” by
employing from within the transgender community it serves. A grant from
the California Endowment, a private
health foundation that supports community-based organizations
throughout the state, enabled it to hire Oliva and people like her. A
prior grant from the Transgender Law Center allowed the clinic to train
existing employees on the needs of transgender patients.
Like
many of the patients she refers to case managers for help finding work,
Oliva struggled with unemployment for two years before finding a job at
St. John’s. Though she has a
master’s degree in social work from Columbia University, the recession
led to budget cuts for programs like the one she worked for in her
native Fresno, California, helping inmates at the Valley State Prison
for Women. She moved to Los Angeles and started
at St. John's 10 weeks ago.
"I'm
spiritual, so I was always praying for a job. I kept praying and
praying," she says. When she got the job and met her new patients, she
was struck with a realization. “This
is God's will," she says she thought, "and I'm just glad to be a part
of his master plan and make a ripple of positive change in our patients'
lives."
Diana Oliva. (Photo: Lauren Wade) |
On
a warm Thursday in August, Travis and fellow members of the Transgender
Health Advisory Board, along with a crowd of staffers, politicians, and
activists, gather in a conference
room on the first floor of St. John’s to celebrate the release of the
center’s report on health care for transgender people in the U.S.
Over
a catered lunch of El Pollo Loco grilled chicken and tortillas,
staffers rattle off some of the report’s painful statistics: Transgender
people experience homelessness at double
the rate of the general population, for example. A man at the front
translates to Spanish for people wearing headsets.
The
presenters pause to say the names of the transgender women who have
been murdered in the United States since January. The number was 16 at
the time of the event; at press time,
the statistic is estimated to be at least 19, although it can be tough
to track the deaths of transgender people because police reports do not
always identify them as such. Though the mood is grave, the room feels
inclusive and welcoming.
It’s
the kind of supportive environment that four years ago, Travis didn’t
know existed. Shortly after her ex-wife moved the family to New Mexico
from Dallas, she left Travis for
somebody else. “She told me, ‘You’re not man enough for me.’ And it
really struck a nerve,” Travis recalls. “My whole world fell apart
because of that. I was like, ‘OK, I did everything I was supposed to,
everything I was taught. It didn’t work.’ I thought
I was broken.”
She
didn’t want to live anymore. The morning after she attempted suicide,
she says, “I made the decision I gotta live. I need to be me. I can’t
give up. I’m too stubborn.”
She
started taking hormones in July 2013, after making that first 110-mile
trek to Texas. At the time, she had been working in the oil fields,
transporting freshwater out of drilling
rigs and into disposal sites. "I'd been hauling fuel and crude oil,
asphalt, whatever. It was very heavy manual labor, and it was very
dirty—it was very nasty," she recalls. "When they had oil spills and
whatever, they would call us to come help clean up.
It was gross. Absolutely gross."
When
she told her boss she was going to start transitioning, he shrugged.
"He's like, 'As long as you can do your job, I don't care.' " The boss’
wife, the company's only female
employee at the time, was happy to have another woman on the team. Her
coworkers began to gossip when her transition became noticeable, but
they never gave her grief. Travis relished the new attention from the
other laborers she came across in the field. One
day, she recalls, "I backed up to a site to unload—we were filling up a
pit for a drilling rig—and I get out of the truck, and there were four
guys filling up the hoses for me." By that time, she had grown her hair
out and had started wearing a bright-pink
hard hat. "I was like, 'Chivalry is not dead!'"
One patient was denied hormones, and then when she wanted to access other services, they said, 'Sorry, you're not on hormones.'- Jim Mangia, CEO, St. John's Well Child & Family Center
When
the company folded, Travis headed west to California, where she
imagined she wouldn’t have to jump through any more hoops for health
care. In March, she arrived in a coastal
suburb of Los Angeles to live with her mother, who had found herself
alone after her husband died. Travis' mother had two sons and always
wanted a daughter; after a year of denial, she has finally come to
accept that now she has one. The commute to St. John's
is a short drive compared with Travis’ old truck-driving runs, and
she’s found purpose helping people overcome the obstacles the health
care system still places in front of trans patients like those detailed
in Mangia’s report.
Among
the policy changes Mangia and his staff propose are removing the
authorization process required for hormone therapy and making it a
"lifetime-approved medication," like insulin.
They would also like to see timely access to gender-affirming surgeries
like the one Travis has been waiting months to schedule.
"One
patient was denied hormones, and then when she wanted to access other
services, they said, 'Sorry, you're not on hormones,' " Mangia says.
Providers such as HealthNet, which
insures nearly 6 million people nationwide, put transgender patients in
a catch-22, he says. Other patients have been denied hormone therapy by
insurance providers because they haven't been under the care of an
endocrinologist for 12 months—which is not a
medical requirement for accessing hormones. HealthNet spokesperson Brad
Kieffer ,in an emailed response to questions, said, "We are committed
to being responsive and ensuring timely access to care for all of our
members, and we are open to hearing how we can
improve our service."
After
being hit with denial letters, many St. John's patients switched from
HealthNet to L.A. Care, the country's largest publicly operated health
plan. Trans customers of L.A.
Care also report delays and denials; Clayton Chau, L.A. Care’s medical
director of behavioral health, says this is often the result of quirks
in the system, not discrimination. For example, a request for estrogen
from a customer identified in its system as
male could be flagged as fraudulent. It took a phone call from
Mangia—who served on L.A. Care's board of governors for four years—to
bring about change. "Hey, do you know that transgender services are
getting uniformly denied? Hormone therapies?” he remembers
asking L.A. Care directors. They had no idea, he says. "Literally the
following week there was a conference call," Mangia says, snapping his
fingers, and the process for approving transgender health care began to
improve.
“I
said, ‘Wait a minute, this is crazy. These are needed services,'” says
Chau. He then relayed the message to physician groups L.A. Care
contracts with. “We realized that when
the primary care physician submits the request to the physician group,
the physician group didn’t know what to do about it, so it just sat
there and sat there and sat there.” Chau assigned case managers to
intervene and help fast track the process.
It’s
been about six months since Travis moved to California—and it took
nearly that amount of time for L.A. Care to approve her prescription for
progesterone, she says. But since
she’s been taking the steroid hormone, her mental outlook has improved
drastically. She has started going out with friends again, something she
shunned for a long time after starting the transition, and has begun
warming up to the idea of dating for the first
time since her marriage fell apart. When she first started the
transition, she thought, “It’s hard enough to be an older guy trying to
find love, much less an older transgender woman. I just closed off. I
got so jaded, I just quit looking.” But taking progesterone,
she says, has gotten her to the point where she no longer feels “ugly
inside.”
Along
with the mental changes, her physical transformation is under way.
She’s been working for months to lose weight so she can reach her ideal
BMI, which is often used to determine
a patient’s candidacy for gender reassignment surgery. Since beginning
her transition, she’s dropped 60 pounds—just 20 short of her goal
weight. Recovery from the surgery, which can keep a person out of work
for up to two months, will be small stuff compared
with what Travis and others have had to overcome.
“Mama
has always told me that I was the person trying to take care of
everybody else. I used to put myself last. Now I make sure to include
myself in the mix,” Travis
says. “I do not like seeing people thinking they have to be the victim.
You have to empower yourself, sugar.”