Trans Health Care

T.J. Briggs was sitting in an endocrinologist’s office waiting for a checkup and an initial prescription of testosterone. During the exam, Briggs was undressed and soon humiliated.

“He stood on the other side of the room from me as soon as he knew I was trans,” Briggs said of the doctor, “and he asked me gross questions like, ‘Have you had the surgery?’ I felt so awful. I am sitting there in a hospital gown with this dude who won’t even come near me.”

Briggs cried after leaving the endocrinologist’s office. It took trips to three different doctors to get prescriptions for hormones. Briggs said having to go to multiple doctors is “pretty common.”

Disclosing to health professionals is a double-edged sword. To receive the necessary, sometimes life saving, hormones needed for transitioning, transgender individuals must disclose the genders of their birth.

“Disclosing to health professionals when you have to do it is scary,” Briggs said. “You never know if they are going to be discriminatory.”


Dr. Vishal Patel and his daughter at Carilion Hospital.

Dr. Vishal Patel, who heads Carilion Hospital's Gender Clinic, says what happened to Briggs is legal. In fact, 19 percent of physicians refuse to treat patients when they come out as transgender, he said.

Doctors can say they are rejecting a patient because they believe they cannot provide adequate care.

“I would want to know why they dismissed that patient, and why they would treat that patient differently. What would they do if that was one of their family members or [their] child?” he said.

Dolly Davis, a transgender advocate in Roanoke, had a similar story. Davis had a sinus infection, and called her primary care practice for a prescription.

She said the doctors told her they were not qualified to prescribe anything during her transition, and that her “medical needs were so sophisticated” she had to go elsewhere.

“Any doctor can prescribe you hormones,” Briggs said. “It doesn’t matter what your gender is.”

Briggs said some doctors get “gate-keep-y” about giving hormones to transgender patients. Doctors will run through the gamut of side effects of hormones, and will ask, “if it’s a phase.”

“And if you switch doctors you might have to prove yourself over again to get a refill,” Briggs said.

Briggs, who asks to be referred to with plural identity pronouns, moved from Arizona to Virginia in the fall of 2015 to start law school. Briggs receives medical treatment through the university’s student health center. Briggs said at first, the school directed them to Carilion’s Gender Clinic in Roanoke. But driving the 100 mile round-trip for medical access was out of the question for Briggs, who would have had to miss classes to go to the doctor.

“I do have a fear of what if I have to go to the ER and they have to take my clothes off and they decide, ‘Oh, I’m not going to treat this person,’” Briggs said. “They can do that whether they are allowed to or not.”

The fear of rejection is one reason Dr. Robert Slackman, an endocrinologist in Roanoke, created Carilion’s Gender Clinic in the fall of 2013. Before Slackman retired in 2015, the hospital sent out a memo asking for someone to take over. Dr. Vishal Patel, a doctor of internal medicine, jumped at the opportunity.

“There’s a need for patients to go to a place where they can feel safe and talk about their needs,” Patel said.

He said his job begins as soon as a patient schedules an appointment.

“If a patient calls and they don’t feel welcome, they will not come for their first visit,” he said.

Patel says transgender patients looking to conform with their gender identity usually come to the Gender Clinic for hormonal treatments.

For trans men, people who were assigned female at birth but who identify as men, hormonal treatment takes the form of testosterone.

For trans women, people who were assigned male at birth but who identify as women, Patel usually prescribes estrogen and a testosterone blocker.

But hormone treatment is not cheap, and can cost $100 to $200 every other week. Patel said most of his patients struggle financially.

And then there are the costs of surgery.

“Top” surgery occurs when trans men have their breasts removed and reconstructed to resemble a more traditionally masculine form. Trans women undergo top surgery when breasts are constructed. It generally costs around $5,000.

Some patients decide to have “bottom” surgery, in which a trans patient’s genitalia are reconstructed to match their gender identity. Depending on the type of procedure, bottom surgery can cost anywhere from $18,000 to $20,000.

But Briggs said some operations, especially bottom surgery, require multiple procedures and lengthy healing time.

“So not only do you have to pay for that, but you also have to take time off work, and have someone there to help you,” Briggs said.

Brantley Meddings, a transgender man, said undergoing top surgery is not only about a desire to look a certain way.

Meddings “binds” his breasts, an uncomfortable process in which a tight piece of clothing suppresses the breasts.

“I have a lot of top dysphoria,"Meddings said, “I have to wear a binder. I want [my breasts] gone. Sometimes it’s really hard for me to look at them.”

Most insurance companies do not cover gender confirmation surgery, and many do not cover hormone therapy. Patel says insurance companies don’t consider those services a “medical necessity.”

“A person is born with [gender dysphoria], and it’s like any other condition a person may be born with, like a heart defect,” he said. “It’s not by choice.”


The Trans Psyche

T.J. Briggs was working at a call center when they first came out as trans. When speaking to customers on the phone, Briggs, who asks to be referred to with plural pronouns, said they would get “mocked and belittled” for their voice.

The experience caused panic attacks and made them lose sense of time. “I would get to school and be like ‘I don’t know how I got here.’ I knew how I got there. I drove myself. But I didn’t remember the act of doing it.”

Briggs tried to get out of talking on the phone. They asked their boss for any other position in the company. The company told Briggs that they “just have to let it roll of their back.”

“Ultimately I was faced with check into a hospital, or quit,” Briggs said. “And I quit.”

Briggs described that period in their life as “eight months of hell.” They said that even today, they have a hard time making calls, although they rarely get misidentified by gender on the phone.

The stress Briggs felt could be attributed to minority stress, an experience that comes from being part of a marginalized group. Lucie, a clinical intern and transgender woman who asked to be identified by first name only, said that LGBT people are likely to experience minority stresses as a part of their lives whether they realize it or not.

“It’s where we feel that sense of fear,” she said. “Or the fear of I don’t want to speak up. Whenever in the face of micro-aggressions and societal gaslighting, it’s just easier to smile. And that itself, that’s where I feel it.”

Gaslighting is a tactic in which a person, in order to gain more power, makes a victim question his or her reality.

But transgender people experience more than just the stresses from being a member of a marginalized group. Gender dysphoria, suicidal ideation, depression, and anxiety occur at higher rates in the transgender population than in the U.S. population at large, according to PsychologyToday.com.

Lucie said gender dysphoria, distress over gender of birth, is common among trans folk. But not all trans people have gender dysphoria. She described it as a “state of being.”

Gender dysphoria is not included in the Diagnostic and Statistic Manual-5, the standard classification of mental disorders used by mental health professionals.

Anton Black, 43, says he suffers from gender dysphoria. He described it as “never being happy” and always feeling “less than, or trapped.”

“The only time I don’t have it is usually in the drag show because I am fully bearded and I have a binder on,” he said. “It’s a constant struggle.”

Part of Black’s dysphoria stems from his breasts, which he likened to a tumor.

“I hate the jiggle,” Black said. “It’s a constant reminder that I am not who I want to be. I feel wrong. I feel trapped in the wrong body.”

Serenity, a self-described “chick with a dick,” said she used to turn to drugs and alcohol to cope with her depression. According to the 2015 U.S. Transgender Survey, transgender people are nearly three times more likely to use illicit drugs.


Serenity at The Park.

“There was this inner struggle,” she said. “I want to be [a woman], but I’m not supposed to. We’re from a farming community in Indiana where people like me are supposed to be a man.”

A lifelong actor, Briggs reached a breaking point and could no longer take it when teachers and others said they needed to “act like a lady” and dress accordingly.

“I don’t want to act 24/7,” Briggs said. “Nobody does. Nobody should have to.”

Briggs didn’t want to commit suicide, but wanted to die.

Suicidal ideation is not uncommon among transgender people. According to the 2015 U.S. Transgender Survey, 40 percent of nearly 27,700 respondents said they have attempted suicide in their lifetime—nearly nine times the attempted suicide rate in the United States.

Black and his family have been on suicide watches for their trans brothers and sisters before. He said around major holidays, when families gather, some transgender people get depressed.

“If it takes me to talk you down from wanting to kill yourself because your family has hurt you so badly, then we will talk for three to four hours,” Black said. “We will do whatever it takes.”