Transgender Delawareans face hurdles

With buxom curves and shapely hips, Christina Warburton resembles a pin-up mom. But, at the end of the day, Warburton will always just be dad to her kids.

Warburton, 37, can't definitively say how long she's known that she couldn't live as a man. As she struggled with her gender identity, she fell into severe depression and heroin addiction.

"I'm just as unique as anyone else in this world," the Dover resident now says, two years into hormone replacement therapy which helped mold her formerly broad shoulders into a more feminine frame.

Though she's happy now, Warburton's journey is still rife with roadblocks, as it is for many transgender women and men. Their issues have been thrust into the headlines on the heels of Bruce Jenner's announcement that he is transitioning from a man to woman.

A transgender person is someone who is born as a male or female, based on body parts, but identifies with the other gender. As Jenner conveyed in his interview with Diane Sawyer, sex is between your legs, gender is between your ears.

Warburton, for instance, says she was born a woman, not a man even though she was born with male genitalia.

It's hard to say with any authority how many transgenders live in Delaware. Based on some national population stats, Equality Delaware, a lesbian, gay, bisexual and transgender advocacy organization, estimates there are 2,800 transgender people living in Delaware. The U.S. Census Bureau and the state health department do not survey transgenders.

No matter how many, transgender people in Delaware face must deal with inconsistent and expensive insurance coverage as well as small group of local medical providers trained to handle their physical and emotional needs. The average family doctor is likely to have little expertise in the issues involving a medical transition and many Delawareans go to Philadelphia for their care.

Even so, the transgender community in Delaware is feeling more comfortable about coming forward, says Andrea Conner, president of Delaware Renaissance, a transgender support group.

Around 30 people attend the group's meetings most Saturdays. Five years ago, there were only a handful of participants. Family members and younger transgender Delawareans also attend in higher numbers, Conner said.

She and Warburton, co-workers at the Amazon fulfillment plant in Middletown, consider themselves fortunate to be up on their feet and working steady jobs, but that wasn't the case throughout their lives.

Conner was homeless for four months after she broke up with her wife during her transition from man to woman. She lived out of her car. After that experience, she knew she had to give back, to make sure that no other transitioning man or woman has to weather that storm.

For the past 12 years Conner has opened her modest trailer in Middletown to any transgender person living in Delaware or just passing through. It's known as an unofficial halfway house. People can stay as long as they need. But they have to prove that they are working to better themselves, adds Conner's roommate Amanda White, who is transgender.

The three acknowledge that it was more difficult coming out when they were younger than it is today, but they are dedicated to helping anyone regardless of whatever age they come out. Today, Warburton is the social coordinator for Delaware Renaissance and White handles outreach.

"I just want to live my life," Warburton said.

Finding ways to get help

Conner's been doing hormone therapy since about 1993; testosterone blockers daily and estrogen injections every two weeks.

"I was going to our family practitioner when I first started and he had no clue," she said. Now she has a primary care doctor in Newark, but Conner said she had to train the doc on her specific health needs herself.

That kind of cultural competency is an issue in the medical field, says Anand Kalra, health program manager for the Transgender Law Center.

There are training programs available, but there's no national requirement for doctors, nurses and other health care providers to be trained to consult on transgender related health issues.

"Overall there's a shortage of educated providers. You've got insurance, that's great, but when you get there does that person know how to properly take care of you," Kalra said.

Brett Herb, a psychotherapist with Christiana Care Health System, is one of the few Delaware therapists working with transgender Delawareans. He's been doing it for 10 years.

"There's absolutely been an increase in people coming in," Herb said. That doesn't mean more people are transgender. It only means more people are seeking help, he said.

There are no specific transgender surgeons in Delaware.

About 11 to 53 percent of people who identify as transgender report discrimination from healthcare providers, including people denied care based on their gender status, said Deborah Hall, president of the American Medical School Association.

Currently 144 transgender Delawareans, including Warburton, White and Conner, get health care through the Mazzoni Center, a health care clinic in Philadelphia that specifically offers services such as primary medical care, hormone therapy and social workers to LGBT people. But not every transgender person chooses to undergo a medical transition.

The organization also sponsors the annual transgender health care conference that looks to educate medical providers and trans people on the services available. This year, that program will be Thursday through Saturday. Sunday's print edition incorrectly states the date of the program.

At Mazzoni, staff have patients sign a consent form that spells out the risks and benefits of hormone replacement therapy, says Dane Menkin, a nurse practitioner and clinical operations manager for Mazzoni Family and Community. For transgender women taking estrogen, there's an increased risk of blood clots and potentially breast cancer. For trans men there is an increased risk of cardiovascular disease, diabetes and high cholesterol.

Another issue also comes into play: fertility. Menkin said he often discusses with young transgender women the opportunity to put their sperm in a bank in case one day in case they'd like to have children.

Though aware of the issues and complications, Conner still has no reservations about the therapy. Her family has a history of prostate cancer.

"I'm just like OK – the possibilities of cancer ... I would have that on either side no matter what I did," Conner said. "With every medication there's always 15 million side effects you have to worry about just depending on your personal genetic makeup."

Medical providers unfamiliar with transgender patients are especially hesitant to prescribe hormone treatment, Menkin said. He believes they are nervous because of a lack of knowledge, not because they don't want to help.

Insurance woes

Warburton considers herself lucky that her employer, the Amazon fulfillment site in Middletown, covers up to $25,000 of trans-related health services. But it is not enough. Gender reassignment surgery, which surgically changes a person's sex organs, can cost upwards of $20,000.

Warburton recently just started a Go Fund Me to help with some extraneous costs. Now, however, Amazon is doing away with the coverage cap, Conner said. But there are still issues with physicians actually getting reimbursed for the services.

Nationally, though, there's been progress on the insurance front. The Human Rights Coalition says more than a third of Fortune 500 companies now offer transgender-inclusive health benefits while nine states, including Washington, D.C., specifically prohibit insurers from offering plans that exclude services for transgender people.

Some Delaware companies such as J.P. Morgan and Amazon, offer transgender health benefits, but there is no state insurance regulation mandating services. Private policies can exclude coverage for trans-related health care such as facial surgery, hair replacement and genitalia reassignment.

"Equality Delaware is aware of incidences where individuals are not getting the transition-related health care that they need," says Mark Purpura, board president of Equality Delaware, which that has pushed for gay marriage in Delaware and anti-discrimination laws for transgender Delawareans.

"State and insurance companies need to address it immediately," Purpura said in an email.

Delaware's Medicaid program also does not cover such services, but the state is reviewing changes to expand that coverage, said Jill Fredel, spokeswoman for the state health department.

One reason is that medical opinion and research on this is changing, she said. Being transgender is no longer stereotyped as a mental illness. Instead, it's described "gender dysphoria," a physical condition. Certain medical procedures can help relieve that dysphoria by helping people transition to the gender that they identify with.

The surgeries can range from serious invasive reassignment to more cosmetic things. So far Conner's had hair-removal procedures on her legs and face. Being strawberry blond naturally helped, she joked.

The feds are tackling the transgender issues. Medicare prohibits an exclusion, and the U.S. Department of Health and Social Services issued guidance in mid-May that issuers cannot "limit preventive services based on an individual's sex assigned at birth, gender identity or recorded gender. Issuers should cover the preventive services that an individual's provider, not an insurance company, determines are medically appropriate."

Discrimination can be addressed on the state level if the state issues a ruling that extends coverage, explains Kalra, with the Transgender Law Center. For example, hormone therapy is standard for women in menopause, but it's also quite prevalent for transgender people to hormonally transition.

"It needs to be based on what anatomy you have and what care you need," Kalra said.

However, health insurance regarding transgender issues in general is spotty because transgender people face workplace discrimination and issues keeping their job, being promoted and paid fairly, Kalra said.

Trying to move forward

As transgender people face issues with insurance, access and acceptance, medical problems tend to get swept under the rug.

Chronic illnesses such as diabetes and high blood pressure as well as sexually transmitted diseases and depression risk going undiagnosed and untreated, adds Hall, president of the American Medical School Association.

According to a report from the U.S. Substance Abuse and Mental Health Services Administration, little data exists about depression and other mental health disorders for transgenders, but thoughts of suicide reported among transgender people can range from 38 to 65 percent. Suicide attempts range from 16 to 32 percent.

Though she no longer is married to her wife, Warburton, her ex and her two children still live together. Life is normal: the kids play, the adults make dinner and homework gets done. But there was a time when Warburton didn't have faith she'd make it one more day.

She credits her daughter, Alessa, from saving her from suicide before she began her transition.

"She just said, 'I love you, daddy,' " Warburton said.

That made her think, "What am I doing?"

Conner knew before she was 5 years old that she was a girl, not a boy. One moment vividly sticks out in her mind.

Her mom, in the midst of doing laundry in their Churchville, Maryland, home had just pulled the clothes of the line outside and laid them across the bed. Among them was her mother's slip, screaming to be worn. She pulled that slip over her powder blue coveralls and a striped T-shirt ("light blue, dark blue and white," Conner said).

Then she adjusted the straps and walked through the kitchen door to where her mom was.

She said, "Look mom, I'm a girl."

"Take that off and don't ever do that again" was her mother's response, Conner said.

Conner worked a series of odd jobs: from cutting hair at her family's barbershop to driving a truck. She got married to a woman, too, but that eventually fell apart.

"In the very beginning, I always thought I was falling back down in the same rabbit hole," Conner said.

White, who is Conner's 46-year-old roommate, had a similar childhood.

"I knew I didn't fit in with the typical vision of 'male'," she said. "I knew I didn't want to be around the boys. I just didn't have the words to call it transgender."

White eventually joined the Navy, where she stayed for 13 years. She never fully understood why she was attracted to girls, yet just wanted to be like the girls. Three or four years ago in the midst of a depression, she found an online forum that became her safe place.

"Up until four years ago I thought transgender was an extreme side of gay," she said. "It adds a certain amount of peace to understand why you are the way you are."

But she also lost some things. Her daughter and son no longer speak to her. She and her wife are splitting up. Her daughter, who is 19, is moving to Louisiana to be with White's extended family.

It's a mixed blessing, White says. She's moving away, but maybe family down South will convince her daughter to reach out.

"I do have hope," she said. "Just talk to me. That's all, just talk to me."

Jen Rini can be reached at (302) 324-2386 or jrini@delawareonline.com. Follow @JenRini on Twitter.

If You Go: Philadelphia Trans-Health Conference

WHAT: Annual transgender health care conference that looks to educate medical providers and trans people on the services available

WHERE: Pennsylvania Convention Center, 129 N. Broad St., Philadelphia

REGISTER HERE: www.trans-health.org/REGISTER

FOR MORE INFORMATION: Go to www.trans-health.org/