In March, the Kind Clinic in Austin, Texas, launched a pilot program offering free and accessible gender-affirming care to the city's transgender and gender nonconforming population.
At the time, the Kind Clinic was the first facility in Central Texas to offer a service that is often out of reach for transgender people, especially those living in one of the red states that use legislative means to deny them humanity. Planned Parenthood of Greater Texas followed suit a month later, offering gender-affirming hormone therapy at its North Austin Health Center, the second of its clinics in the state to do so.
The program at Planned Parenthood's North Austin site has so far been a success, said clinician Heather Brand. "Patients have told us that they love the care we are providing, that we make them feel affirmed in their gender identity and safe in our care, and that they trust us as experts in the care we are providing them," Brand told TheBody.com.
Discrimination, stigma and violence have a tremendous impact on a transgender person's physical and mental health. Statistics have shown that abuse and harassment have kept transgender people from seeking medical care. Maltreatment has also contributed to exceedingly high rates of mental illness and suicide among the transgender population.
Advocates say that gender-affirming programs like the ones provided by the Kind Clinic and Planned Parenthood are vital to trans people's wellbeing. Access to gender-affirming care allows transgender people to feel empowered, which benefits their mental and emotional health. And transgender people living with HIV who receive gender-affirming care are more likely to stay in treatment, which has massive implications for their overall wellbeing.
"We've seen that people are more likely to take care of themselves," said Dani Castro, project director at the Center of Excellence for Transgender Health at the University of California San Francisco. "It's a necessary part of general health care that needs to happen for everyone,"
Gender-Affirming Care and Mental Health
According to the National Center for Transgender Equality (NCTE)'s 2015 U.S. Transgender Survey, 39% of trans respondents reported experiencing "serious psychological distress" in the month prior to filling out the survey. Another 40% said they'd made a suicide attempt in their lifetime -- nearly nine times the rate of the general population. (Of that number, more than two-thirds had attempted suicide more than once.)
"There are astronomically higher rates of trauma among the trans population -- the stigma, discrimination and violence they face, and what ends up being multiple traumas across the lifespan," said David Guggenheim, Psy.D., chief mental health officer at Callen-Lorde Community Health Center in New York City.
For trans people living with HIV, that statistic is significantly higher. The 2014 National Transgender Discrimination Survey found that 51% of trans respondents with HIV had attempted suicide compared with 41% of the general trans population. Transgender women of color living with HIV would be most at risk: According to the NCTE survey, 19% of black, 4.6% of Native American and 4.4% of Latinx transgender women reported living with HIV. Among the general trans women population the HIV rate was 3.4%, the survey found.
Research has shown that accessible and culturally appropriate gender-affirming health care can be lifesaving for transgender people. According to a 2016 paper published in the Journal of Acquired Immune Deficiency Syndromes, gender-affirming clinical care has shown to improve transgender people's mental health and quality of life because they gain a sense of confidence and self-worth. Fenway Health, an LGBT health care, research and advocacy organization, also found that accessible and affordable hormonal therapy, breast augmentation, and gender-affirming surgery is linked to lower rates of suicidal ideation, binge drinking and substance abuse. "We see it all the time, in all sorts of patients, that it helps with their mental health," said Tim Cavanaugh, M.D., medical director of trans health at Fenway Health, providing "a general sense of well-being."
More importantly, transgender people living with HIV are more likely to begin and stay in treatment if they also have "access to gender-affirming care if they need and want that" in the same clinic, said Tonia Poteat, Ph.D., PA-C, M.P.H., assistant professor in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health. "Being able to get support and affirmation in being who you are and getting to live a longer life that you feel is more worth living because you're able to be who you are just makes common sense to me," Poteat told TheBody.com.
But, too often, transgender people come up against multiple obstacles in accessing adequate health care, whether it's HIV treatment, gender-affirming care or both. "Historically, we've had to jump through hoops because of who we are," Castro said.
Transgender and gender nonconforming people living with HIV experience disproportionately higher rates of poverty, unemployment and housing instability, and are more likely to be uninsured, experts say. According to Positively Trans' 2016 survey, "Some Kind of Strength", nationwide, trans people are four times more likely to be living in extreme poverty, and survey participants had six times the unemployment rate of the general population. Those barriers put medical care financially out of reach.
Stigma and discrimination also play a huge role in whether a trans person living with HIV will seek care and how that impacts their mental health. The NCTE survey found that one-third of trans respondents said they were mistreated at least once by a health care provider because of their gender identity. The same survey found that the fear of bigotry, abuse and harassment kept nearly a quarter of respondents from seeking medical care. This is particularly acute for trans women living with HIV.
"I have patients who are afraid to leave their homes sometimes" because of the violence and discrimination they face, Guggenheim said.
The Integrated Model of Clinical Care
According to Castro, some transgender people living HIV have reported being told by doctors that they couldn't receive gender-affirming care while also undergoing HIV treatment. But, Castro said, that's an opinion driven by misinformation and bias, rather than science.
"There's no evidence that shows that gender-affirming health care has any negative implications for HIV care," she told TheBody.com.
In fact, research shows the opposite to be true. According to the Journal of Acquired Immune Deficiency Syndromes, HIV prevention interventions such as testing, linkage to care and treatment are most effective when gender-affirming care is delivered alongside them.
Experts call this approach "integrated clinical care." Under the integrated model of care, a doctor who provides HIV treatment also provides gender-affirming care, whether it's prescribing hormone therapy or creating a welcoming environment. "When the labs are done for one, they're done for the other by the same person who knows the medications that you're on, understands how they work, understands where there may or may not be interactions," Poteat said, "and basically provides that kind of holistic care."
Furthermore, within an integrated clinical care setting, transgender patients have access to mental health services and social services all in one place. Callen-Lorde is one of a handful of clinics in the United States that offers integrated care to patients -- through a trauma-informed lens. According to Guggenheim, the primary care doctor, behavioral health specialist, dental provider and case manager "all work as a team" to help transgender patients meet their health needs.
Patients are also able to take care of most, if not all, of their concerns on-site, so they're "not going to multiple buildings and multiple appointments," he said. And, when a transgender person is able to access gender-affirming care and HIV treatment all in a safe space, they're more likely to be in better physical and mental health.
"Research is showing us more and more how effective that type of integrated care can be, especially for marginalized populations like the ones that we serve," Guggenheim said.