Mammogram waiting rooms are sometimes different from other medical waiting areas. If you’re going to get an x-ray of your knee or any other body part, you stay fully clothed until you are called into a private exam room. But if you’re going for a mammogram and then a follow-up ultrasound (a separate procedure), you might find yourself sitting tensely in a room with other women, each attired (or should I say barely covered) with a medical gown. In the mammography waiting rooms that I’ve been to, there is low-key, soothing music playing, plenty of pink paraphernalia scattered on the tabletops, brochures about the importance of breast self-exams, and an undercurrent of worry as women wait for radiologists to read their films and tell them whether they need a follow-up ultrasound or biopsy, or whether they’re free to forget about the possibility of cancer for another year.

As I waited in this mammography limbo last week, a bearded man with a hairy chest sat across from me. He had large breasts, self-consciously protected by that too-small gown. The other women glanced at him and then at each other, recognizing the unusual circumstances. It occurred to me that this transgender man was probably much more uncomfortable than the rest of us were in this setting.

This man deserves a lot of credit for entering this highly gendered domain and not just skipping potentially awkward mammograms altogether. Many trans men have chest surgery, surgically removing their breasts and transforming their bodies to acquire a more typically male chest. But chest surgery is expensive and not accessible to all who need it. Those who retain their female anatomy are still at risk for breast cancer — hence this man at the breast imaging center.

For transgender men who have not had bottom surgery (and the majority of transmen have not), routine pap smears should not go by the wayside either, even though they are female no longer. Testosterone can cause thinning of the walls of the vagina, and that can increase the risk of sexually transmitted diseases if these men still use their vaginas for sex, which not all trans men do. Unless this man in the waiting room had his ovaries, uterus, and cervix removed, he would continue to need pelvic exams and regular cervical cancer screenings.

Sadly, trans people still face many barriers to quality healthcare, including interacting with providers who lack experience with transgender-specific medical issues and who sometime exhibit alarming degrees of transphobia in their practices. For their part, even the most sensitive hospital or office staff often struggle as they face unique questions regarding ethical care for people with gender-variant bodies and gender-variant medical histories.

According to the 2011 National Center for Transgender Equality/National Gay and Lesbian Task Force report “Injustice at Every Turn: A Report of the National Transgender Discrimination Survey,” of the 6456 transgender and gender-nonconforming people polled, 19% of respondents had been refused medical care, 28% had experienced verbal harassment in a medical setting, and 2% had been physically assaulted in a physician’s office. Fifty percent of respondents reported having had to teach their physicians how to care for them.

Why wouldn’t physicians know how to care for transgender patients? Often it’s not a question of knowing “how.” It’s a question of unfamiliarity with transgender patients at best and transphobia at worst. There are countless stories of healthcare workers just getting up and leaving the room when confronted with a gender nonconforming or a visibly trans person. One trans man reported to the Task Force: “After an accident on ice, I was left untreated in the ER for two hours when they found my breasts under my bra while I was dressed outwardly as male.” Another trans person distressingly recounted, “I have been refused emergency room treatment even when delivered to the hospital with numerous broken bones and wounds” (p. 73).

When we think “transgender healthcare,” we can no longer limit ourselves to considering just those medical services specifically related to a patient’s transition, such as hormones or surgery. We need to guarantee that trans people are treated as people, with a variety of medical needs and concerns, and that they don’t face transphobic betrayal from medical providers. There are many excellent medical centers that cater to the LGBT population, offering a broad range of assistance, social as well as medical. But this isn’t enough. The most routine screenings, like mammograms and pelvic exams, can be worrisome and annoying, but they should not and cannot be humiliating or shaming if we are to achieve excellent transgender healthcare.