R is for Respecting Differences

The world of transgender people - those who think of themselves as born into the wrong gender and who sometimes seek to change their appearance through cross-dressing, hormone therapy or surgery - is almost by definition a conflicted one.

And considering that transgender people often don't seek medical care precisely because they are misunderstood, the confusion can become self-perpetuating. Lori Kohler, medical director of the San Francisco General Hospital Family Health Center, and a specialist in medical care for transgender people, has set about to bridge this gap between the medical community and this unseen world of patients - and to do so with compassion and a touch of humor.

"I think that gender is such a basic part of who we all are that it is quite frightening to people when they start challenging it, changing things around and suggesting that it is a mutable aspect of human experience." Moreover, Kohler understands not only the problems that transgender people face - the alienation, the assumption that their condition is pathological, the black-market "therapies" - but also the difficulties non-transgender people have in relating to them. "I have to spend a lot of time with people speaking about gender before I can even get to transgender." In doing so, this graduate of San Francisco General's family practice residency program gets people to think about themselves and how they too may not exactly fit the definition of what is stereotypically "male" or "female." Her hope is to crack open rigid boundaries and show them that what transgender people are doing is similar - being creative about what it means to be male or female.

That creativity is not always appreciated or understood by the medical profession. Transgender people are "a disenfranchised and underserved group of people in medicine," says Kohler. Many have been exploited by physi-cians in the past. Mistreatment includes not doing follow-up care and monitoring to outright exploitation by overcharging, exchanging services for sex, and selling undisclosed preparations. Many transgender people have avoided the medical field altogether by self-medicating, purchasing hormones on the street or in Mexico, taking unknown doses of unknown hormones, and/or combining them with unknown substances.

Additionally, many transgender patients suffer from depression and alienation - mental health issues that are specifically related to being transgender, Kohler says. "That by no means implies that there is more mental illness among transgender people - it's related to the dysphoria that goes along with having a mismatch between your body and your internal sense of self." The risks of violence, once they are exposed as transgender, are also high. Still, Kohler believes that the biggest health risk of all remains the reluctance of transgender people to seek out health care because they are afraid to be vulnerable to their medical providers.

A Community Ignored

The plight of transgender patients came to Kohler's attention in 1994 when she worked at San Francisco's Tom Wadell clinic, which was just starting a transgender-specific program. "I learned that there is this whole population of transgender women and men that is basically ignored by the medical community," she says. "We have no training in understanding what their medical needs are, much less their social needs. And this is a group of people who are very reluctant to seek medical care, so really we need to do a lot of outreach and be open to serving them. I think they are pretty easily alienated from medical care just because of our own ignorance."

Kohler is dedicated to alleviating the communication difficulties between transgender people and health care providers, and does so in a number of ways, including working with community organizations, consulting with physicians across the country, advising the California State Prison system on the treatment of their transgender inmates, and by teaching as many physicians-in-training and medical providers as she can to "at least open their minds to the concept of transgender," she says. "And to teach them some of the medicine that there is that they need to know, which is basically very simple." Physicians with transgender patients need to know a bit about hormone therapy, but she says they "primarily they need to know how to listen to a patient to understand if they would be appropriate for therapy." She emphasizes that the most important thing a doctor can do is allow patients to self-identify in whatever way they want.

A Community Served

It's really just teaching practitioners how to give good, safe medical care, Kohler says. She is putting this goal into practice at SFGH's family health center, which provides medical care to a multi-ethnic, medically underserved population in general. Through her clinic, which is part of the Community Health Network of the San Francisco Department of Public Health, she has trained the majority of the providers in the network on dealing with transgender issues. She says it is very satisfying to see how comfortable the staff has become with the transgender patients, because it's not something intuitive. One has to learn to use right pronouns, follow them through all their transitions, and even give them beauty tips, which is not typical medical practice. "But it's an important part of this work," she says, "to encourage transgender people that they are looking good, because that part has been so difficult for them."

"I think that in a lot of ways, they describe themselves as being incomplete because their bodies are so very foreign," she says. Often after she talks to her patients and offers them general medical care - and perhaps hormones, if that is what they are after - it is just a tremendous relief for them to know that they have been recognized and respected for who they are and that there is hope for them to change their appearance, for them to become who they really believe they are, she says. She is proud to say that she often loses patients - they get better jobs, get health insurance, and basically improve their lives dramatically and do not need to come to the free clinic anymore. Once they start to make progress to a more complete life, they are much happier people. "It's probably some of the most satisfying work you can do, because you actually really help people in incredibly profound ways, with simple medical interventions that actually work and produce palpable results," she says.

"My main goal is to encourage primary care providers, especially family physicians, to be accessible to transgender patients. It's OK to be ignorant, as long as you are open-minded and listen to what the patients have to say. There is very little medical literature on any of this. There are no good resources, no good references. You have to learn from your patients - they're the ones having the experience."

by Mitzi Baker