By MARIA CLARK, NOLA.com | The Times-Picayune

NEW ORLEANS (AP) — It's been over a decade since Malaysia Walker's life started a new course.

At the time, Walker was living in her hometown of Jackson, Mississippi, as a gay man.

That's what she was limited to, she said, "Back then, it was either gay or straight."

She dressed masculine and grew out a mustache to try to fit in. But it didn't feel right.

"I was uncomfortable trying to live up to those standards every single day," she said. "I didn't know what it was. But I knew I felt uncomfortable."

Over time, Walker realized she was a transgender woman and began researching what that meant. Almost immediately, she found that one of the greatest barriers was accessing adequate medical care that catered to transgender patients.

"They didn't know what medical care meant for trans people and, unless you did research, you didn't know either," Walker said in an interview at the CrescentCare clinic on Elysian Fields Avenue, where she now works as a retention specialist for transgender women who have fallen out of the healthcare system.

Transgender patients face huge challenges in Southern states where the number of medical providers trained to work with this patient group is limited, advocates say. In New Orleans, CrescentCare is on a short list of three health systems that have policies in place to provide equal access to healthcare for LGBT patients, employees and visitors. Transgender patients sometimes have to travel from neighboring states and rural areas of Louisiana to get medical care at the clinic in New Orleans.

"We don't have the infrastructure in the South. We are shuffling around the nation looking for medical care," said Camilla Marchena, 26, who works at CrescentCare connecting transgender women to the clinic.

Doctors who haven't worked much with transgender patients might not be familiar with the side effects of medicines involved in hormone replacement therapy, or the complications they can have with other medications, Walker said.

Transgender patients may also avoid going to the doctor at all based on previous experiences. A year ago, The Center for American Progress, a liberal public policy research and advocacy organization, conducted a national survey that found discrimination in health care settings often discourages people who identify as LGBTQ from seeking medical care.

About 29 percent of transgender people surveyed said that a doctor or health provider refused to see them because of their actual or perceived gender identity. Another 29 percent said they had experienced unwanted physical contact from a doctor or health care provider, including fondling, sexual assault or rape.

Under the Trump administration, this patient group has faced further setbacks, advocates say. In November, the Department of Health and Human Services (DHH) issued a final rule broadening religious exemptions in health care law and giving health providers and insurers the right to deny service to patients based on religious or moral grounds.

In October, The New York Times reported the DHH was rolling back a series of decisions by the Obama administration recognizing gender by what the person chose and not the sex they were assigned at birth. The agency said in a leaked memo obtained by the Times that government agencies had to have a uniform definition of gender determined "on a biological basis that is clear, grounded in science, objective and administrable."

A lack of safe and inclusive medical care means that many transgender patients have to resort to buying their hormones online and off the black market, according to Sable Murphy, 27, a trans woman who receives care at CrescentCare.

Murphy says she is fortunate that her hormone replacement therapy (HRT) is covered by Medicaid. As soon as she was able to start with HRT, everything fell into place, she said

"The testosterone lowering, the estrogen increase, all of these things help me feel better, like a whole-rounded person," she said. "People need to see us, they need to get comfortable with us, there is no other way around it."

The gender clinic at CrescentCare opened about two years ago with a focus on providing healthcare specific to transgender patients. This includes monitoring of hormone levels and their side effects, but also providing comprehensive medical care from providers who know how to correctly address and identify their patients.

Tonya Smith, 36, also moved to New Orleans from Jackson, Miss., where she had started hormone replacement therapy. She said her doctors weren't trans sensitive and the medication they gave her wasn't working.

"They treated me pretty much like I was a science project or something," she said. "It was one of the worst experiences of my life."

Smith moved to New Orleans three years ago and during the first two years went to a different clinic in the city. It was rocky trying to find a provider she felt comfortable with, she said. One of her providers never gave her a wellness check while she was a patient at the clinic.

"He didn't want to touch my body or look at certain parts of my body," Smith said.

That was when her social worker suggested Smith look for alternatives, eventually connecting her to the gender clinic at CrescentCare.

"The resources they have here have really lifted me and just encouraged me. I'm in a good place," she said.

Each year the Human Rights Campaign publishes an index of healthcare facilities around the U.S. that have policies and practices in place to be inclusive and provide equal care for LGBT patients, visitors and employees. Only three New Orleans facilities were included in the most recent list: CrescentCare, Ochsner Health System and the VA Southeast Louisiana Healthcare System.

This was the second year in a row the VA hospital was recognized for its care of LGBT patients. The facility provides mental health services, pre- and post-surgery care for transgender patients, and offers a transgender support group coordinated by a licensed clinical worker.

Dr. Brandy Panunti, an endocrinologist at Ochsner who works with transgender patients, said last year that the health system was focused on standardizing training for all employees and establishing non-discrimination policies. This includes establishing the correct coding when a provider has to order gender-specific exams (like a pelvic exam) so a patient isn't denied insurance coverage because the exam does not match their preferred gender identity.

Some clinics still require trans patients to be in therapy and provide a letter from their therapist saying it's OK for them to transition, whether they choose to start HRT or surgical sex reassignment, Marchena said. She started her transition at CrescentCare two and a half years ago.

"Here we use informed consent, meaning you're aware of what you're doing. That's the way it should be," she said. "I don't need validation. This is not a mental health issue. I can make this decision for myself."

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Information from: The Times-Picayune, http://www.nola.com