For the last two years, Chloe Jones has periodically driven to Chase Brexton, an inclusive health clinic in Columbia, for hormone replacement therapy. The testosterone blockers and estrogen injections are part of her transition as a transgender woman. Jones, 23, didn’t necessarily plan to rely on a provider situated more than 40 minutes away from her home in Frederick. But there are few other ways to get the treatment she needs.
There are currently no physicians in Frederick County known to offer hormone replacement therapy to transgender patients. When Jones first brought it up, at 19, to her doctor at the Pediatric Center of Frederick in Mount Airy, she said she was met with a general air of confusion.
“I don’t think they really knew what to do with me,” Jones said. “They said they would have to refer me to another practice, but then I don’t think they even knew where to make a referral. So, there were really just no resources for me at that time.”
For transgender patients in Frederick County, Jones’ experience is frustratingly common. Lack of knowledge, lack of understanding, and a lack of respect for LGBTQ patients are some of the biggest complaints heard by The Frederick Center, a nonprofit serving the local LGBTQ community.
The problem is especially acute for trans patients, whose specific medical needs — including hormone replacement therapy — remain underserved nationwide. But even gay and lesbian patients have reported negative experiences with medical providers in Frederick, said Kris Fair, the board chair of The Frederick Center.
Oftentimes, those experiences involve a doctor’s lack of knowledge or awareness of basic preventive medicine like PrEP, a drug that can reduce the risk of new HIV infections by up to 92 percent. There can also be a lack of basic sensitivity. Just a couple weeks ago, Fair was seeing a specialist in Frederick and met with a nurse who repeatedly encouraged him to ask his “wife” to help him eat healthier.
“And I said, ‘Ha ha ha, it’s my husband,’” Fair said. “And he said, ‘You’re right, your wife needs to keep track of what you’re eating.’”
It’s an uncomfortable gray area that can be both difficult and intimidating for gay patients to navigate, Fair said.
“When you’re in this community, you do this thing where you’re like, ‘Did he not hear me? Or did he do that deliberately?’” In this case, Fair said the nurse finally corrected the mistake after he repeatedly referenced his husband throughout the conversation.
“So, it didn’t end up being a negative interaction,” Fair said. “But I spent 15 minutes almost shaking with concern because of that fear that strikes us all — that fear of not knowing whether you can trust that person or if you’re about to get a very stringent anti-LGBTQ reaction. And then, of course, there’s the question of why the immediate assumption is that I must have a wife.”
Last September, The Frederick Center launched the Healthcare Equality Index, an attempt to corroborate reports of biased medical treatment from the LGBTQ community. The optional survey assessed providers’ comfort and confidence in treating LGBTQ patients, as well as their knowledge of community-specific health concerns and disparities.
When the survey ended, only a small sliver of the county’s 4,677 health care providers had responded. But of those 108 respondents, the data looked encouraging. More than 80 percent reported that they felt “comfortable” or “very comfortable” treating LGBTQ patients. More than 70 percent reported that they felt “confident” or “very confident” treating them. And a majority reported they felt comfortable asking about a patient’s sexual orientation and gender identity, an important step in providing compassionate and comprehensive care.
When it came to behavior, though, the landscape suddenly changed. Of the providers who said they felt comfortable asking about sexual orientation and gender identity, only 20 percent reported that they asked about sexual orientation “often.” Nearly 30 percent never asked. Only 13 percent asked about gender identity “often,” compared with the more than 40 percent who never asked. And nearly half of all respondents reported that their practice provided neither staff training on LGBTQ health issues nor LGBTQ-specific sensitivity training.
“I’d point out that there’s a difference between tolerating LGB and trans patients and actively affirming them,” said Lee Blinder, an activist and co-founder of Trans Healthcare MD. The advocacy group, formed this year, aims to help trans patients navigate the health care system and provide information on competent, affirming providers in Maryland.
Both Blinder and their co-founder, Khan Rosenrot, said they formed the group — at least in part — over frustration at the lack of resources for transgender patients. Both have petitioned Planned Parenthood of Maryland to add hormone replacement therapy to its list of services, but neither made significant inroads. Planned Parenthood has added LGBTQ-specific care to its strategic plan for the future, but the organization does not currently offer those services at any of its clinics, said Vanessa Geffrard, the vice president of education and outreach.
They’ve also struggled to identify providers in Frederick who offer even bare-bones care for LGBTQ patients. There are currently only two providers in the entire county who can prescribe PrEP, an essential medication especially for gay and transgender patients, who experience HIV at higher rates than the general population. They haven’t identified any doctors who can provide hormone replacement therapy to transgender patients.
Janet Harding, the director of cultural awareness and inclusion for the Frederick Regional Health System, said that some patients in Frederick do receive hormone replacement therapy through physicians within Monocacy Health Partners, the system’s affiliation of private practices. But neither she or Melissa Lambdin, the spokeswoman for Frederick Memorial Hospital, would identify the specific providers who adminstrated the treatment.
According to Blinder and Rosenrot, there are also no doctors in Frederick County who can provide gender-affirming surgeries to transgender patients. It’s important to note that not every member of the trans community wants or seeks out surgical interventions as part of their transition — the decision is deeply personal and individualized. But for patients who do choose surgery to align with their gender identities, the procedures can be life-saving, said Dr. Gabriel Del Corral, a plastic surgeon with MedStar Health who specializes in gender-affirming surgeries.
“It allows them to feel comfortable in their own bodies,” Del Corral said. “We’re talking about a population where 40 percent have attempted suicide, and for some patients, the surgery can be the final step that allows them to finally flower into who they are as a person.”
Both Fair and Peter Brehm, the vice-chair of The Frederick Center, have also been disheartened by the lack of providers who seem to take an interest in basic sensitivity training. For the past three years, they’ve hosted Welcoming Frederick, a day-long seminar on affirming and supporting the LGBTQ community. The response from the medical community has been “dismal,” Brehm said.
“This past year, we had less than 10 medical providers,” he said. “That would be more than accurate to say.”
'It could just ruin their whole day'
The lack of affirming care in Frederick County has funneled patients directly to Chase Brexton. Of the clinic’s roughly 3,000 trans or gender diverse patients, about 144 come from the Frederick area, according to Dr. Elyse Pine, a pediatric endocrinologist who can prescribe and maintain hormone replacement therapy.
Both she and Deborah Dunn, a physician with Chase Brexton, treat multiple patients from Frederick County as part of their specialty in LGBTQ care. It’s a skill set that takes hundreds of hours of independent research and training, Dunn said. Even basic sensitivity training is usually addressed as part of an elective course or module in medical school. Mt. Sinai Hospital in New York City recently launched a full-year transgender surgery fellowship, Pine added, but it’s the only one of its kind in the country.
“So, it’s not surprising to me that there isn’t a comprehensive transgender health program in Frederick,” she said. “Because it’s work — you need a place that can provide mental health resources, medical care for puberty blockers and hormone replacement, and referrals for surgery. And it’s not a field that hospitals are going to make a lot of money in.”
Chase Brexton also provides hands-on sensitivity training for every member of its staff, from nurses and medical assistants to receptionists. For Dunn, that support system is crucial to ensure that LGBTQ patients feel comfortable and affirmed from the minute they step into the waiting room.
It starts with intake forms that allow patients to list their legal name and preferred name, their sexual orientation and their current gender identity, as well as their pronoun preference. That screening — administered to every patient — allows Dunn to provide more informed care to patients who identify as LGBTQ. She knows, for example, that the trans population experiences higher levels of suicidal ideation, so she’s able to do a mental health screen on patients who feels comfortable disclosing their gender identity. And she’s more confident that patients at Chase Brexton won’t avoid care out of fear of being outed in the waiting room.
“A person might come to the front desk and if their name hasn’t been changed on their insurance, you may be outing that patient to the entire exam room if you call out ‘Jennifer’ when they go by ‘John,’ Dunn said. “Or it could just ruin their whole day. If the front desk staff don’t treat that person with respect, it doesn’t matter if you have the best, most sensitive provider in the world.”
Kyle Lawton, a trans man living in Frederick, said he has experience with being misgendered or incorrectly addressed by local providers. During a recent visit to Frederick Memorial Hospital for behavioral health care, he noticed that his ID bracelet carried his legal name even after he told doctors how he preferred to be addressed.
Statewide, almost 30 percent of transgender people in Maryland report having at least one negative experience with a medical provider in the last year related to being transgender. Twenty-three percent of respondents chose not to see a doctor in the past year out of fear of being mistreated, according to the Maryland State Report from the 2015 U.S. Transgender Survey.
Since The Frederick Center publicized results from the Healthcare Equality Index, the Frederick County Health Department has announced plans to introduce in-trainings on LGBTQ comptency and sensitivity. The department is also collaborating with Frederick Memorial Hospital in hopes of starting a continuing education class for medical providers in the area.
The Frederick Regional Health System introduced an initiative last spring to collect sexual orientation and gender identity data through Monocacy Health Partners, according to an email from Harding. Around 275 staff members have already attended a class on collecting and documenting the information if a patient offers it. The health system is also working on introducing gender neutral questions and spaces where patients can offer preferred names and pronouns.
Patients like Jones, though, still have no plans to switch to local care.
“If Chase Brexton were to close, I don’t know what I’d do,” she said.