Hours after the Obama administration’s May 13 announcement that public schools must allow transgender students to use bathrooms corresponding to their gender identity, the administration announced a second directive making it illegal for insurance companies to deny insurance coverage and services based on their gender identity.

The directive will make it easier for transgender people to have the medical services and surgeries necessary to transition – including hormone replacement therapy and sex reassignment surgery – covered by their insurance companies.

Some insurance providers in Oregon already provide coverage for transgender-related health care, including the Oregon Health Plan, which began offering transgender benefits last year.

“Oregon has always been a leader and a state that spearheads the health and wellness of transgender people,” said Jazz McGinnis, the trans services coordinator for Outside In, a homeless youth service agency.

When McGinnis, who is transgender, heard the Oregon Health Plan would cover transgender services, he was overcome with a feeling that “my state felt like my life was important.”

“That was not a message I received from a government agency before,” McGinnis said.

Acceptance of transgender people and transgender rights remains elusive in America, but nowhere can it be more apparent – and heartbreaking for a transgender person – than in the country’s health care system, where transgender people routinely face discrimination, harassment, poor medical care or none at all.

“Very often, our health care system sticks with a gender binary and very little understanding of people who experience a different gender identity than their sex assigned at birth,” said Eowyn Rieke, the associate director of medical care at Central City Concern’s Old Town Clinic.

It is all the more paradoxical given that transgender people need the health care system to transition – a step fundamental for transgender people to have an identity and sense of self that reflects who they are.

That critical intersection has prompted the National Health Care For the Homeless Council to specifically address the issue during its national convention in Portland at the end of May. Both Rieke and McGinnis will speak before health care and homeless professionals across the country.

Social services in Portland that provide health care to homeless people, such as Outside In and the Old Town Clinic, have been some of the first organizations in Portland to adopt practices that make their clinics safe and affirming for transgender people.

Transgender people are disproportionately represented in the homeless population, especially among homeless youth, where up to 40 percent of homeless youths identify as transgender or gender fluid – a mix of both traditional genders.

Rieke and others say that the basic mission of the Old Town Clinic – serving low-income people and people marginalized from society – made changing the way the clinic’s staff communicates with transgender patients, and some aspects of how care is provided, a no-brainer.

“Just like other traditionally undertreated groups, transgender people need to feel like the system is considering their existence,” Rieke said.

FURTHER READING: Transgender clients faces unique challenges within health system (commentary)

Outside In opened Portland’s first primary care clinic specifically designed to serve transgender people in 2004. Executive Director Kathy Oliver said Outside In always made serving LGBT youths a priority since they made up such a large percentage of the homeless youth population. After a few years, she noticed that “clients were focused more on gender identity than sexual orientation.”

She said she also noticed it “was a continually growing and expanding group.” Over time, the clinic, which was operated by volunteers twice a month, began attracting a bigger client base.

“Outside In was positioned in a place where we were seeing a lot of marginalized folks for care,” McGinnis said. “Low-income, uninsured people or people living in poverty (who were not homeless youths) began to come to us. No one was doing trans-inclusive care.”

The effects of not receiving adequate care can be devastating. Transgender people may not get the hormones or surgeries they need and they may avoid receiving health care altogether, letting other diseases and illnesses go untreated.

McGinnis said the problems transgender people experience in trying to access care and develop a patient provider-relationship with a primary care doctor are “institutional as well as individual.”

The discomfort, discrimination and barriers to accessing health care can start the moment a transgender patient walks into a provider’s office.

Hospitals and clinics may prohibit people from using bathrooms or changing rooms that correspond with their chosen gender.

Medical forms ask patients to check a box that labels them as male or female. There is no place for a person to say that they are transitioning or are gender fluid.

“It’s uncomfortable for some people to answer that question because their physical anatomy may not match their gender identity,” Reike said.

Medical forms and electronic health records also do not have places to enter information such as a person’s preferred pronoun or a chosen name different from their birth name.

Receptionists at a clinic or hospital’s front desk may even yell out the incorrect name, which can cause emotional pain. It can also lead to feeling physically unsafe and to more harassment, violence and prejudice because a person has “been called out as being transgendered,” Reike said.

Reike and others acknowledge that using incorrect pronouns and names can result from a simple mistake or oversight.

“I still misgender someone,” Reike said. “I say something that’s not accurate.”

Patients may go to a doctor for routine care and may be given an unnecessary pelvic exam or asked questions about their genitalia or hormones.

“I thought I had strep throat once and the doctor was asking about surgeries and hormones and how it all works,” McGinnis said. “That had nothing to do with strep throat.”

McGinnis said some interactions between a transgender person and their health care provider are tainted by “the ick factor.”

“Transgender people are seen as a curiosity, an oddity,” he said. Health care providers effectively send a message to transgender patients that “we don’t want to see you. We don’t know how to treat you. And you’re kinda weird. I don’t really know about you, and it kind of makes me uncomfortable. Can you go somewhere else?”

Training health care workers

The solution to changing the way health care is provided to transgender people starts with language – training providers to ask about people’s preferred pronouns and chosen name.

“You don’t want to mess it up,” Rieke said. “It undergirds everything.”

Adding a place for preferred pronouns in electronic health record systems is one of many examples where the health care system can be more sensitive to transgender people, Rieke said.

“We had to find a place to fit it in,” Rieke said. “It’s one small piece, and it’s so complicated to change. But it’s so important.”

The Old Town Clinic allows people to use bathrooms that match a person’s gender identity. The clinic has also trained front-desk staff, pharmacy staff and other people who may not provide care to transgender people but still interact with them in the clinic on how to appropriately communicate.

The clinic posts transgender-related trainings, workshops and other events “to normalize the existence of those things” for the clinic and Central City Concern’s staff, Rieke said. It also shows transgender people that the clinic is accepting and trans-inclusive.

Rieke also said it’s important that if clinics and health care providers are unable to provide services, they are able to provide specific information and referrals to other clinicians that do.

Last year, Outside In closed its Trans Clinic and integrated all its services into Outside In’s primary care clinic.

Over the course of a year, McGinnis and other staff at the Trans Clinic provide trainings and workshops. Outside In sent its clinic’s providers to other trainings and brought in providers from the community to act as consultants.

Ultimately, providing trans-inclusive primary care is easy, McGinnis said. Hormone replacement therapy is just a prescription medication and occasional blood tests.

“It’s not complicated,” he said. “The biggest thing in terms of training is building the confidence of providers.”

Dr. Suzanne Scopes, a naturopath and former volunteer doctor with Outside In’s Trans Clinic, agreed.

“It doesn’t take that much,” she said. “I teach doctors all the time. It takes a few hours, a few nights reading some basic information.”

As hospitals like Oregon Health & Science University begin training all their medical staff on providing trans-inclusive care and being more sensitive to communicating with transgender people, McGinnis said, trans-inclusive care is more than a doctor being able to provide comprehensive medical care to patients.

“We have patients come in and they’re suffering from extreme depression and suicidality, who are struggling with anxiety,” he said. After starting hormone replacement therapy, “they come back and these folks are no longer suicidal and have their depression lifted because they can finally be able to live in an identity and in their body.

“It’s medically necessary care that stops people from killing themselves, straight up.”