Pride is traditionally a celebration centered on shared, in-person experiences, so it’s bittersweet that the 50th anniversary of the first Pride march is happening when we’re being advised to practice social distancing. While this year’s festivities will look different, the spirit of Pride remains stronger than ever.
Even as we celebrate and recognize the hard-won progress for the LGTBQ+ community, we want to acknowledge that the work for greater equality is far from over. Institutional discrimination among LGTBQ+ people and other marginalized communities still exists across many aspects of life, and that’s particularly common in health care. A 2017 survey found that nearly a quarter of transgender people have avoided doctors or health care out of concern they would be discriminated against (22%), and 31% say they have no regular doctor or form of health care.
To better understand the health care experiences of transgender and nonbinary people, Pill Club reached out to a medical practitioner who works directly with this community: Dr. Izzy Lowell, founder of QMed. A telemedicine health care provider, QMed works with trans and nonbinary patients in the southeastern part of the country, which includes Georgia, Alabama, Tennessee, North Carolina, South Caroline, and Mississippi. By sharing QMed’s mission and work, we hope to provide a window into the limitations and opportunities for transgender health care.
Where did the inspiration for QMed come from?
I used to work at Emory University’s family medicine department, where I started a gender clinic. Over time, more people heard about the clinic—in fact, many people were driving from out of state just to get affirming care and hormone therapy! I was dismayed by the lack of access for so many trans and nonbinary people in this country, especially in the south. I started QMed to fill this major gap in care.
In working with your patient population, what are some of the barriers that have historically kept transgender people from getting the medical care that they deserve?
The biggest barrier is outright discrimination from health care providers and insurance companies (it’s actually still legal in the U.S. for insurance companies to specifically exclude coverage for transgender care). Many patients have had terrible experiences seeing a doctor or going to the hospital, so understandably, they don’t want to do it again unless it’s absolutely necessary. Other barriers (also due to discrimination in many cases) include: lack of insurance, unemployment, poverty, lack of transportation to a clinic that may be hours away in a different state, and distrust in the medical system (with good reason in most cases!).
What systemic issues exist that lead to sexual and reproductive healthcare falling through the cracks for trans people?
Many healthcare providers haven’t had any training about transgender care and the specific needs of the transgender and nonbinary population, including sexual and reproductive health. I think some healthcare providers get totally spun out about a patient’s potentially “confusing” gender when it doesn’t fit clearly into what they learned in biology class. It’s actually quite simple: what sexual acts are you doing, and with whom are you doing them? All we’re trying to do is make sure patients are safe and protected from harm. We educate patients about the risks of pregnancy, sexually transmitted diseases, and future fertility options. We prescribe birth control for anyone who needs it and connect patients to affirming resources for HIV care, PrEP, sperm banking, egg preservation, and other reproductive health needs.
Some of our readers might not be familiar with the health experience of trans men. Can you clarify why this population could be at-risk for women’s health problems, if their health care were to go unchecked?
I think it’s easier to think about what “parts” a person has, as opposed to connecting that to a gender. If a person has a cervix, they need to take proper care of it, which includes getting pap smears. Cervical cancer is highly treatable if caught early, but it’s taken the lives of far too many trans men. Similarly, if they have a uterus and ovaries, there’s a chance they could become pregnant, and they need to take precautions against that—unless pregnancy is desired. But for so many trans men and trans masculine people, it can be really hard to think about some of these body parts. Health care providers are often no better, even avoiding asking about it altogether because they may not feel comfortable either. Please advocate for yourself and find a healthcare provider who can do a pap smear in a respectful and affirming manner.
What are 3-4 practices that you’d like to see more medical providers implement to better address the needs of trans patients?
Simple! 1. Ask everyone what name and gender marker they use. That’s huge—it says a lot about the medical provider’s understanding of gender and different gender identities. 2. If possible, add questions about name and gender in electronic medical systems so that patients don’t have to come out to every new provider they see. 3. Include non-binary bathrooms. 4. Don’t use the excuse “I wasn’t taught this in medical school.” There’s so much we weren’t taught in medical school, especially if someone attended medical school decades ago! Part of being a medical professional is lifelong learning to best serve our patients.
What impact has the COVID-19 had on trans health services? How has QMed managed to adapt during this time and ensure that you’re still able to serve your patients?
COVID-19 has made it much harder for patients to continue hormone therapy at traditional medical clinics that didn’t previously have any telemedicine infrastructure in place when everything shut down. Because of this, we’ve seen an increase in patients who are looking for affirming virtual care.
Before COVID-19, over half of our care was already provided via telemedicine, so it was easy to switch to 100% virtual care. The main reason people needed an office visit in the past was because of a federal regulation requiring an in-person visit in order to get a testosterone prescription, but that’s been waived due to COVID. Now we can do everything virtually and will continue to do so for the foreseeable future.
How do you think telemedicine can be a bridge to helping trans people get better quality medical care?
Traditionally, trans care has been provided at major medical centers with comprehensive gender clinics. They often have primary care, mental health, hormone therapy, STI testing and care, and surgery in one central location. Many major U.S. cities (mostly in the north and on the coasts) have centers like this—and they provide amazing care. But it’s limited to patients who live there or who can afford frequent air travel. For people without the resources to take time off work and travel great distances, there are few, if any, options for care. Telemedicine offers a great solution for some things—mainly mental health and hormone therapy—which is great. But we still need more access to specialty care that can’t be done virtually, such as surgery. I hope that one day procedures for transgender and nonbinary people will be as routine as other surgeries around the country.
What advice would you give to trans patients who might have had an unpleasant experience with their health provider at one point or another?
It can be scary, but try to advocate for yourself and your body. If your provider doesn’t offer you appropriate care, ask for birth control and what kinds of testing is needed for your body parts, or switch providers if you can. I look forward to a time when trans and nonbinary patients no longer need to educate their medical providers!