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The real transgender crisis in Arkansas: health care 

Finally, the doctor is in.

click to enlarge DR. JANET CATHEY: Her work with transgender patients is, she says, the "most rewarding" of her career.
  • DR. JANET CATHEY: Her work with transgender patients is, she says, the "most rewarding" of her career.

While Arkansas lawmakers were wringing their hands this past legislative session over what to do about genitalia sightings in bathroom stalls — a nonexistent problem that, had the legislation passed, would have required bearded, buff men to use the ladies' room — doctors, medical students and activists were working to address a real problem: the dearth of health care for transgender individuals.

Nonscientific ideas about gender crowded out reason, as Republican state lawmakers like Sens. Linda Collins-Smith of Pocahontas and Gary Stubblefield of Branch and Reps. Bob Ballinger of Berryville, Mickey Gates of Hot Springs and Greg Standridge of Russellville promoted bills that would have required Arkansans to wear their original birth certificates around their necks and thrown people in jail if their nudity offended. Their actions, thankfully, were stopped by a business-minded Governor Hutchinson. But Hutchinson only stanched the flow of hurt that such ignorance surely set loose, the sort of bullying that drives 45 percent of transgender teenagers to attempt suicide.

Had legislators gotten their heads out of the stalls, they could have acted to help, rather than further marginalize, their fellow Arkansans. They could have changed state Medicaid rules that disallow reimbursement for hormone therapies. They could have appropriated funds to run the Department of Health's suicide hotline. Or they could have talked to physicians who would have helped them understand that transgendered people are not freaks, no more likely to prey on people than, say, redheads or Razorback fans.

Rowan Rodgers, 27, is one of those burly, bearded guys that, had Collins-Smith's bathroom bill passed, requiring folks to show original birth certificates at the bathroom door, would have been coming to a girls' powder room near you. The Heber Springs man, born with the genital attributes of a woman but who as a toddler asked for boys' underwear on a shopping trip with his father, praised Little Rock gynecologist Dr. Janet Cathey for making his life, and that of his fiance and two kids, better. "She's a one of a kind," he said.

Cathey, along with Drs. Sara Tariq and Sam Jackson are a few of the physicians working to provide better health care for transmen and transwomen, both in clinics and the classroom, at the University of Arkansas for Medical Sciences.

Cathey, an obstetrician/gynecologist, sees transgender patients in clinic one morning a week at UAMS. It's work she said is the most rewarding of her life. She's been treating transgender patients for most of her 30-year career, providing hormone therapy to transmen who, in the days before social media, learned of her willingness to help by word of mouth. It started shortly after she opened her practice, when a caller inquired if she'd provide testosterone to a woman, "and I thought, 'Why not?' " It grew from there.

"I get tearful thinking about it," Cathey said. Her transgender patients "are the most appreciative patient population you could ever have. When you put someone on hormones, and they come in two months later for follow-up, and they say, 'I've just had the best two months of my life ... .' "

That she feels bonded to her patients is obvious: She does tear up while she's talking about them.

In 2009, Cathey injured her spine in an automobile accident and had to sell her practice. That left her transgender patients hanging. As she recuperated, she knew she didn't want to retire. "I thought maybe I could do a gender clinic. I knew there was a need," she said. But how could she afford to set up a new practice?

Serendipitously, she ran into Dr. Curtis Lowery, chairman of UAMS' department of obstetrics and gynecology. He asked her to help oversee the medical college's residents' clinic, and she agreed.

Cathey wasn't the only doctor who saw a need for a gender clinic. A year into her work at UAMS, she was approached by mental health professionals about setting up a gender clinic. With the same determination it took to get back on her feet again — she walks now with the help of braces and a cane — she went to Lowery and told him that's what she and another OB/GYN wanted to do. "He said, 'Just don't lose a lot of money.' "

The administration allotted her two spots for gender patients. "I said, 'Y'all just wait.' "

There is now a four-month waiting list to be seen in the gender clinic: The two spots for appointments have stretched to a morning's worth of appointments. She and Dr. Mary Racher "make about 60 patient contacts" a month. "We've seen, between the two of us, probably around 300 patients," genetic females transitioning to males and genetic males transitioning to female, in the past two and a half years, Cathey said. Men get estrogen and androgen blockers. Women get testosterone. Transmen — the term for a genetically female person who is transitioning to male — can schedule hysterectomies and breast reduction surgery.

What does she think about legislative attempts to pass a bathroom bill? "I promise you have peed next to a transperson plenty of times."

click to enlarge ROWAN RODGERS: His one regret is not telling his girlfriend sooner that he was transgender.
  • ROWAN RODGERS: His one regret is not telling his girlfriend sooner that he was transgender.

Rodgers has been a patient of Cathey's since 2015. "I was very depressed when I went in there," he said. "She knew it."

But his hormone therapy lifted "a huge weight off my shoulders. When I took testosterone ... [changes in my] energy level, my voice, it was like injecting life into myself. That's the best way I can explain it. It was definitely life-changing."

Rodgers cried after his first shot in Cathey's office. After his second, he quit having periods. "I was like, 'wow.' "

The relief and happiness that Rodgers experienced after the start of hormone therapy is common, though the reasons why have not been well studied. "There is something neurochemically going on," Jackson, the Psychiatric Research Institute resident, said. It may be that the hormones resolve the emotional conflict that transpeople experience. Hormones "change the brain so it becomes correct. ... It confirms to me that biologically, there is something there, activating the brain and the right receptors, [telling the brain] yes, this is the correct hormone situation I am supposed to be in."

The hormones alter mood so much, Cathey said, that her patients can quit taking their antidepressants. "I've seen kids come in on SSRis (selective serotonin reuptake inhibitors) and Abilify (an antipsychotic). They come in and they won't make eye contact. In two or three months [after hormone therapy], they're animated. It's too much to think it's not biological. They're getting relief." They're getting what they need, she said.

Though some Arkansas legislators believe that men are men and women are women and never the twain shall meet, medicine knows that human gender is on a continuum.

As Arkansas Children's Hospital endocrinologist Dr. Michele Hutchison explained it, there are several kinds of gender. There is chromosomal gender: one X and one Y for males and two Xs for females. There is hormonal gender: For example, boys born with Androgen Insensitivity Syndrome are born looking and identifying as female because their bodies don't respond to testosterone. Boys with Reifenstein Syndrome —partial androgen insensitivity — may be born with either male or female genitalia and may identify as either male or female. There is something called testosterone transfer in fraternal twins, when the testosterone of the male fetus is transferred to the female fetus and makes the female masculine in genital and brain structure, etc. There is physiological gender: Whether there is a penis or a vagina. There is emotional gender: Whether you feel like a boy or a girl.

"It's a complex system that goes into creating a child," Hutchison said.

Hutchison said there is an "ever-growing body of evidence" that trans children and trans adults differ physiologically from non-trans persons, though the research "is in its infancy."

Male and female brains differ in structure, chemistry and how information is processed. One study, a small brain imaging project, showed that the brains of transgender children acted like the brains of the sex with which the children identified — transmale brains looked male, transfemale brains looked female. "Of course, behavior and experience shape brain anatomy, so it is impossible to say if these subtle differences are inborn," she said.

Arkansas Children's Hospital, which has physicians on staff who address such things as ambiguous genitalia, is looking into creating a gender clinic, Hutchison said. Health care — especially mental health care, given the high attempted suicide rate — for children who identify with a gender their bodies don't reflect would be a good thing, she believes.

"The hospital treats children with diabetes, and adrenal issues and hyperthyroidism [for example]. We're so good at it now. It's a fantastic hospital. We're so good at those things that we don't lose kids. This is an area where we could quite literally save some lives," Hutchinson said. "I have goose bumps" thinking about it, she said. She said clinics in Seattle, Los Angeles and Boston offer a model to look at.

Before she transitioned, Michelle Palumbo moved to Salem (Fulton County) with her wife and four children. She showed up with long hair, wearing earrings. Folks just attributed that to the fact that she was from New York.

But Palumbo had for a lifetime struggled with feelings of being a woman in a man's body. She was a cross-dresser, and her wife was OK with that.

In 2008, after her third heart attack and after doctors told her she could die at any time, Palumbo made up her mind to transition. Because she had been a bench chemist, she made her own estrogen, a fact that she said made Cathey's jaw drop when she finally went to her for proper medication two years ago. "If there is an angel on this earth," it's Cathey, Palumbo said.

"We are not freaks," said Palumbo, 64. She considers people who think so "religious extremists"; by contrast, the member of Pulaski Heights United Methodist Church considers herself a "religious evangelical." Palumbo also described herself as "ticked off" at the legislature, where she testified on various anti-transgender bills in the last session.

Palumbo moved to Little Rock in September after someone she'd confided in spread the word of her transition. (She'd been binding her breasts.) Her high school daughter was getting teased at school; kids were asking, "What's between your father's legs?" Palumbo said. Her wife stopped her from raising hell at the high school, and asked her to move out. The couple is now divorcing, though Palumbo said of her wife, "there's no better person on earth."

Palumbo is of the same generation as many of the legislators who don't understand that there is such a thing as transgender identification. In fact, 30 years ago, she decided to go through conversion therapy. "I wanted to be a man," she said, and her wife at the time had grown tired of Palumbo's "internal battle of identity." Palumbo said she would buy women's clothes and wear them, and then decide to "purge that, be a man, then the cycle would start all over again."

The psychiatrist Palumbo went to told her she could "cure her," and prescribed more sex. After a year and a half, Palumbo realized there was no cure. She researched transgender issues. "I'm not a freak. I'm not nuts."

Also because of her age, she believes, Palumbo is less militant than younger people about getting pronouns right. When a nurse who was looking down while Palumbo was signing in at the doctor's office and, hearing her voice, addressed Palumbo as sir, the nurse became flustered and apologetic. Palumbo told her not to worry. "I was upset because she was upset," Palumbo said, laughing. (Palumbo's voice is not generally deep, but on occasion it can change.)

Medical settings can be problematic, though not always because providers are uncomfortable with transgender people. Palumbo said her medical chart includes information that she is transgender, and at a recent appointment, the nurse who called her in for a heart procedure had a "stone cold" look on her face. Palumbo told her if she had a problem with her gender identity, she'd like to have another nurse, "but if you misgender me [use the wrong pronoun], I'm not going to be upset. Boom! Big smile."

And another thing about coming out as an older person: "You have more guilt," Palumbo said, wistfully. "You've made relationships with more people. When you're young, it's not like that."

"You can't hold people responsible for what they don't understand."

Dr. Tariq, assistant dean for undergraduate education at UAMS' College of Medicine, teaches the practice of medicine, a three-year course, to students in their second year: how to be compassionate, effective and "savvy." About seven or eight years ago, she introduced LGBT care into the course curriculum.

Not surprisingly, the LGBT community is underserved. "The patients are very vulnerable, and not just because they have to take their clothes off and let us poke around," Tariq said. They are called on to reveal information about themselves that they have never told anyone else. She teaches her students "the most irresponsible thing you can do is ignore them."

Many of UAMS' medical students have never been knowingly exposed to members of the LGBT community. As part of the curriculum, Tariq brings in a panel of LGBT folks — most recently, two transgender persons, a lesbian and a gay man.

One of the panelists told the assembled students that when he walks into a doctor's office he looks around for signs that the clinic is friendly to gay people. Even "as a brown woman in the South, that would never occur to me," Tariq said. The panelists gave examples of bad treatment: Doctors referring them to psychiatrists, not to deal with depression, but because they believe them to be mentally ill. Doctors making no eye contact. Doctors referring them to other doctors because they are uncomfortable treating them. (Palumbo recounted the experience of a transgender friend who was upbraided by a doctor for coming in: "There are children here!" he was told, as if he were a pederast.)

Many transgender people choose to keep their body phenotype, especially since surgery is both expensive and sometimes risky. That means pap smears and mammograms for transmen, prostate exams for transwomen. It also means mammograms for transwomen, since estrogen stimulates real breast tissue. "My motive," Tariq said, is to teach her students "to leave their biases at the door."

Part of Tariq's curriculum was contributed by Sam Jackson. In his fourth year of medical school, Jackson did a rotation in primary care for LGBT patients at Kaiser Permanente in Los Angeles. There, he worked with the hospital's transgender support group, which he said was the largest in Southern California.

"I am a story-driven person," Jackson said. "I really liked hearing the patients' stories. ... It just blew my mind." The experience left him with a passion for working with the trans community, and when he returned, Tariq asked him to share his experiences with her students.

"We've done an OK job of talking about LGBT health in the past," Jackson said. "We learn how to interview patients, take a sexual history and not be judgmental. It becomes a rote process ... and makes it easier for you to ask [questions] in a nonjudgmental way."

Now, Jackson is medical director for a clinic for transgender youths, the Rainbow Clinic, which meets quarterly at UAMS' student-staffed 12th Street Health and Wellness Center. Lucie's Place, a shelter for homeless LGBT youth, partners with UAMS for the Rainbow Center. Jackson also hopes to work with Cathey's clinic to provide psychiatric care.

click to enlarge MICHELLE PALUMBO: Had to leave her family and farm to protect her teenaged daughter from further teasing.
  • MICHELLE PALUMBO: Had to leave her family and farm to protect her teenaged daughter from further teasing.

Cathey has heard the stories, too. She recited what a transmale told her: "I remember one of my earliest memories was I got out of Pull-Ups and was going to Walmart to get real underwear, and we go in the girls' department and my mother picks out pink panties. And I said, I want boy underwear." An 18-year-old told her, "It wasn't that I wanted to be a boy. It was that I knew I was a boy." That patient's mother told Cathey that as a child, every picture he drew of himself was as a boy, never as a girl.

"One patient who was transfemale said she was coming home from first grade and her mother asked, 'How was your day?' And the patient said, 'This girl had on a pink dress and a pink bow and could I get a pink bow?' And the mother said, 'No, that's not how God made you, you're a boy."

An older patient told Cathey that in her 30s she'd learned you could buy hormones over the counter in Mexico, and, as Cathey related, "I went over and picked out the highest dose of Premarin I could. It was like magic. The second time, the border patrol started questioning me." She was too intimidated to continue. "Those were the best six months of my life," the patient told Cathey.

"It really gets you," Cathey said. Nobody would choose to be transgender. Palumbo said the same. "No guy would decide to be a woman. ... Who would give up male privilege?"

Dating also presents new issues for some transgender people, and they seek Cathey's advice. When do they tell people they're interested in about their transgender situation? "I don't talk about my genitals on a first date," Cathy said she tells them, "and you don't have to, either." She also tells them not to reveal anything at their apartment or their friend's.

One of Cathey's patients, a transwoman, told her she'd come out to her parents as gay last Christmas, and was thinking of telling them she was transgender this Christmas. "So last year, they had a gay son and this year they have a heterosexual daughter?" Cathey asked.

Rowan Rodgers, who's been with his girlfriend for seven years, first as a lesbian woman, waited a couple of years before he told her he was transgender.

"I didn't know how she'd react. We have two children, and it's just when you live in a world where you don't know how people are going to take things ... . You hear about people disowning their children. It's just bad. If I have one regret, it's not telling her sooner.

"At first, there were a lot of questions. It was a lot she had to take in. But she was very accepting. I call her 'my constant.' "

The children, boys 11 and 13, "are wonderful," Rodgers said. "They are thriving, doing wonderful in school and so smart and the most accepting of a lot of people who I thought were my friends. They said, 'You're my dad and I love you.' "

His parents, Rodgers said, "are a different story." They call him by his "dead name," which is what transgender people call the names given them at birth. "They tell me their daughter is dead." Rodgers has tried to keep the relationship going. "So when they call and want to talk, I'm there. When they tell me they hate me, I turn the other cheek."

Caring for the transgender community has also required that Cathey become a social worker of sorts. She's made her nurse a notary to help with legal documents, and helps her patients navigate the process of changing birth certificates, which requires a name change and a letter from a physician.

One of those persons she's helped changed a birth certificate was Rodgers. "I was lucky," Rodgers said. "I got a very nice lady" at the health department's vital records office. Now, Rodgers always keeps his birth certificate with him. "I'm always scared I'm going to be hassled."

Cathey and her patients have struggled with Medicaid, and Cathey is fearful the current political situation will make things harder for her transgender patients, many of whom rely on Medicaid because of the barriers to work that an anti-transgender society presents. Medicaid will cover top surgery — mastectomy — once a transman has begun to transition and the sex on his birth certificate has been corrected, because at that point, the condition is considered gynecomastia — male breasts. But it wouldn't pay for Rodgers' testosterone.

"Reassignment surgery male to female," Cathey estimated, "is about $50,000, but that's nothing compared to a total hip replacement." She hears people complain their insurance shouldn't have to pay for gender reassignment. To them she would say, "Well, you know what, I don't want to pay for your hip surgery."

Rodgers has found a pharmacy in Heber Springs that charges him a reasonable price for testosterone. He's also had top surgery and a hysterectomy. "Right now, I'm not planning to have any other surgery. I'm fine. The breasts bothered me and having a period every month."

Rodgers is looking forward to summer. "This is the first year I get to go out and swim. That's a beautiful thing."

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