Common Projects

16 Jul 19
Dafurdaf.com

Name: Dafur Bwetlong Solomon Mat No: U16TJ2013 Course : online journalism 2 What is The Internet? Internet IconThe internet is a massive network of networks, a networking infrastructure. It connects millions of computers together globally, forming a network in which any computer can communicate with any other computer as long as they are both connected […]

16 Jul 19

It was the perfect storm when CEO and Founder Liam Reynolds finally decided to start TrueUp, a data-driven growth marketing agency/consultancy based in London. After decades of working for large creative advertising agencies, Liam quit his job right around the beginning of Silicon Valley’s growth hacking trend and plunged headfirst into running growth for early-stage […]

16 Jul 19
Lottie’s 8 months in Malaysia

You’d think I’d loose weight during Ramadan, fasting everyday and all that, but I probably managed to gain at least half a stone. You may be surprised but for a month of fasting, there seems to b a lot of food during Ramadan and don’t get me started on Hari Raya!! Our experience of Ramadan […]

16 Jul 19
TechCrunch
It was the perfect storm when CEO and Founder Liam Reynolds finally decided to start TrueUp, a data-driven growth marketing agency/consultancy based in London. After decades of working for large creative advertising agencies, Liam quit his job right around the beginning of Silicon Valley’s growth hacking trend and plunged headfirst into running growth for early-stage startups. TrueUp has since evolved from a one-man shop into an award-winning agency with a team of dedicated data, paid marketing and conversion specialists. Learn more about how they collaborate with clients and help them develop short- and long-term growth frameworks. TrueUp’s approach to growth marketing: “Rather than just saying 'Look at these amazing results we’ve achieved,' we would say, 'Look, these are your growth opportunities, this is the process you need and here’s the framework unlock your true potential,' We would build business models around this to show the opportunity in numbers, revenue and ROI. Our approach to growth is anchored in delivering the right message to the right target audience in the right channel at the right time. It sounds simple but we’re amazed at how wrong people get this. So we’ve created our own bespoke methodologies and frameworks to really explore and identify these hidden killer messages that drive action. We’ve built our own tools that allow us to do a lot of high-tempo, high-intensity testing. It’s quite common that we have 500 to 600 tests running concurrently on Facebook for any given client. We’re continuously testing, learning, iterating, improving. As a result we’ve achieved some amazing results for our clients." Advice to founders: [pullquote align="right" author="Maninder Saini, SF, International Operations Manager, Quizlet, Inc."]“We approached True Up to help us establish and scale a UK paid marketing function. The team was highly professional from their initial pitch through the end of the project.”[/pullquote] “For earlier stage startups, it's to focus on achieving product-market fit and having awesome user experiences before worrying about growth. We worked with and mentored a lot of startups that immediately jump to, "Look I need to get X number of customers in X months." However their products/services are often seriously lacking. This creates very weak foundations for growth. So their efforts would be better spent on creating products that genuinely meet a customer need. Once they’ve achieved product-market fit, it's to communicate benefits not features. There’s always at least one killer message that cuts through but more often than not it's hidden and not what the founders think it is. So a structured test program to explore this is also very much needed!" Below, you’ll find the rest of the founder reviews, the full interview, and more details like pricing and fee structures. This profile is part of our ongoing series covering startup growth marketing agencies with whom founders love to work, based on this survey and our own research. The survey is open indefinitely, so please fill it out if you haven’t already.  Interview with TrueUp CEO & Founder Liam Reynolds Yvonne Leow: Tell me about how you got into growth marketing and why you decided to start TrueUp. Liam Reynolds: I started my career at a data marketing company called Dunnhumby. They were famous for managing the data science and intelligence behind TESCO’s Club Card, a very large loyalty program in the UK. [tc_premium_cutoff] Here I learned the importance of data, targeting, segmentation and testing that has remained with me ever since. I then spent about 12 years working for big marketing and advertising agencies like Omnicom and the Engine Group. This gave me a much wider context to marketing and all the different disciplines. TrueUp was set up initially as a direct result of working in creative advertising agencies. As a data guy, I wanted to create something where there was a tangible and measurable outcome to the marketing. My previous world was ‘Has your campaign won awards?’, ‘have you been featured in the marketing press’ or ‘can I show my parents our ad on TV?’. I wanted to create a new world that was ‘How much have we spent?’, ‘how many customers & revenue has it generated?’, ‘What have we learned?’ and ‘what should we do next?’ This fortunately coincided with the early-stage growth hacking trend, and I finally decided to set up TrueUp. At the time we were the first UK growth hacking agency and one of only 4 worldwide. I went headfirst into London’s tech scene and also figuring out how companies at the time like Groupon, Dropbox and Airbnb were scaling without using traditional marketing agencies. We ended up creating our own philosophies to growth and accompanying approaches, processes and frameworks. The art & science of testing, learning and iterating at speed was really key in us figuring out how to help companies grow. We ended up mentoring countless startups at Telefonica’s accelerator WAYRA where we learned a lot about what works, what doesn’t and why. Since then we’ve worked with startups, but also larger corporates such as Vodafone, Telefonica, The Economist & Standard Life who wanted to be more ‘startup’, lean and agile in their marketing. Yvonne Leow: What’s TrueUp’s approach to growth marketing? Liam Reynolds: We realized early on that most of our clients wanted customer acquisition and fast. They wanted to see immediate results. So we initially focussed on paid media customer acquisition through Facebook and Google. But we recognized that if CPAs are the end goal, then media is only half the equation. The second half is the post-click user journey and conversion funnel. We then built out our web optimization, A/B testing, app store optimization offering, and by controlling both the pre- and post-click user experience, we were able to get much better CPAs than focussing on just the media. Eventually we asked ourselves, “Okay, how can we get even better results?” We ended up taking a data-centric approach, using numbers to model our clients' businesses and create ‘what if’ scenario planning tools. These showed where the biggest quick win opportunities were and what sort of investment was needed to unlock them. We already knew that a lot of the value we bring clients is the ability to test and experiment at speed. So we started looking at how we could do more and more tests. Facebook and Google weren’t exactly setup to facilitate this, so we ended up building our own tools to help achieve this. We ended up carefully structuring experiments where we run hundreds and hundreds of tests simultaneously. We then learn what overall message works, who the core target segments are, what message works within each segment and what the overall opportunity is for those specific channels (Facebook, Instagram, Google Search, Display, LinkedIn, etc). We then use those learnings and apply to other channels such as the website and ensure those user journeys are fully optimized and working as hard as humanly possible. Yvonne Leow: How is TrueUp structured as an agency? What kind of expertise do you have on your team?  Liam Reynolds: We operate as both a consultancy helping clients identify where their opportunities are and what’s needed to unlock them but also as an agency to execute on them. We flex around our clients' capabilities but can run the entire process if needed. Our team includes experts who know the key platforms inside out (Facebook, Instagram, Google, etc), data analytics, design, UX, CRO & strategy. As a collective, we’re quite T-shaped, so rather than having a team of generalists, we've got a group of dedicated specialists but who come together and create a growth-orientated approach. Yvonne Leow: If I were a founder, how would I know whether or not TrueUp is a good fit for my company? What kind of clients are you looking for? Liam Reynolds: Early-stage startups probably aren’t the right fit for us. In part, because of our fees and our need to work with companies that can already evidence product-market fit. Today, our clients are quite diverse in that there’s a mix of startups and corporations. They all have a proven business model and the challenge is one of growth and scale. More importantly is their attitude, whether they want to be brave, do things differently, be experimental and push boundaries. We also love companies that share aren’t afraid to fail some of the time. Yvonne Leow: What questions would you ask potential clients to see whether they share the same attitude towards growth? Liam Reynolds: We usually ask: Where is their business currently? Specifically asking them to share some key stats around customer numbers, revenue, sales, downloads, web traffic etc. What are the key KPIs such as CPAs and lifetime value? What’s their current marketing strategy? We want to get an idea of their sophistication. What are their main challenges? This helps us understand where they think they need help. What’s their intended spend over the next three to six months? This gives a good indication on how serious they are. What are their goals and ambitions? We want to know what they want to achieve in terms of growth in the short term and long term. We use this as a feasibility test to see how realistic their expectations are. We would then delve deep into the product, why they built it, about their customers and future plans. We’ve worked with enough companies over the years to know whether we can genuinely help or not. Yvonne Leow: Awesome. Say we agree to work with one another, what’s next? Liam Reynolds: We usually start work on a three to four-month pilot basis, where we want to prove to you how good we are by showing an awesome set of results and some killer insights. The first month involves us doing a deep dive into your business. We have various processes and procedures that help us get up to speed. We meet your team, have workshops to understand your business process, we give analysts access to the analytic tools so understand your numbers. Then, we do an audit on existing marketing activity and see how good they’re performing. We would then typically dive into a two to three-month pilot run, which might, for instance, involve a Facebook campaign. As part of that we would develop a messaging platform, which is a way of understanding all the different proof points and messages that convey why users should be interested in your product/service rather than your competitors. We go into a pretty intense testing phase to break down your different target audiences and explore what messages work against them. After doing that for a couple of months, we should come back to you with three things. One is evidence we’ve decreased your CPA's by 50%. Secondly, we share a whole wealth of insights about who your customers are, what messages they're responding to, and how that differs based on different segments. And finally we show you the longer-term opportunity over the next 12 months with a revenue forecast. Yvonne Leow: Got it. What is your fee and payment structure for clients? Liam Reynolds: We either work on a project basis. A typical project would be for four months and cost somewhere between £20k to maybe £60K pounds, sometimes more. After that, we settle into a £5 to £30K pound monthly retainer, which varies depending on the size of the client, the scale of the business, and agreed scope. With some of our clients, we go into a performance-related agreement where we put a percentage of our fee at risk, based on hitting a certain number of KPI's. If we achieve it, there's usually an upside for us so we're closely aligned with our client’s objectives. Yvonne Leow: What mistakes do you often see your clients make when it comes to growth marketing?  Liam Reynolds: There are a number of common mistakes we see. Having tried something once, it not working and therefore totally dismissing it is common. Not knowing your target audience or having a clear value proposition for them is happens a lot. Being hooked to certain channels without fully understanding the impact they have e.g. through multi-touch attribution happens a lot with scale-ups. My favorite is prioritization, too many times we see clients focussing on the wrong thing and now knowing what’s really driving the business and therefore what to focus on. Rarely is the right answer to build out more product features. Founder Recommendations “TrueUp worked together with us to deliver efficient profitable growth marketing in a crowded DNA testing space from production proposition, CRO to ads and channel optimization. End-to-end cycle. They’re like your in-house growth team working side-by-side.” - David Nicholson, UK/USA, Co-Founder, DNA Worldwide Group, Ltd. “TrueUp were brilliant in presenting a completely new approach to testing top of funnel message effectiveness. They helped us test real customer behavior, and bold messages, without risking our brand. This has transformed our view of what customers value in our product, which has led to a step-change in conversion in our pilots.” - Head of Proposition Innovation in Edinburgh, UK “Having worked with other growth hacking agencies and individuals, we were quite skeptical of the some of the promises TrueUp made. However having worked with them now for 4 years, they've obviously proved themselves! They help us with both company and candidate acquisition for our tech jobs fairs, optimizing every part of our acquisition funnel. In particular they ran a lot of ads as tests to find which message messages work best with different target audiences. I think at one point we had 500+ individual tests live on Facebook alone. Importantly for us, they reduced our CPA so played a vital role in our success. They were also lovely guys to work with. The team was so entwined with our businesses that they genuinely felt like an extension of our team. They're highly recommended! - Laura Jones, London, New York and Austin, Co-Founder, Silicon Milkroundabout and The Round “We approached True Up to help us establish and scale a UK paid marketing function. The team was highly professional from their initial pitch through the end of the project. They had an incredibly intuitive understanding of how they would fit well into our organizational structure and how best to add value as an external growth marketing agency which made our lives a lot easier. We spun up paid marketing campaigns across platforms and the TrueUp team followed a clear, concise, and scientific process for testing and improving our campaigns. The end result was a huge gain in understanding PPC, better CPAs than we originally anticipated, and great user growth with solid engagement. We ended up taking a ton of their best practices and workflows in house for our own teams.” - Maninder Saini, SF, International Operations Manager, Quizlet, Inc.
16 Jul 19
PUZZLED PAGAN PRESENTS

  2019 has been a shockingly weak year for movies. While doing my Cinematic Century project here I’ve really learned how Hollywood can have very strange ebbs and flows where one year will be an extravaganza of amazing and seminal films, while the next year will be almost completely bereft of memorable films. And, so […]

16 Jul 19
Whittier Daily News
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-1857061-1 { margin: auto; } #gallery-1857061-1 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-1857061-1 img { border: 2px solid #cfcfcf; } #gallery-1857061-1 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
San Gabriel Valley Tribune
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-1991965-2 { margin: auto; } #gallery-1991965-2 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-1991965-2 img { border: 2px solid #cfcfcf; } #gallery-1991965-2 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
Orange County Register
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-6915048-3 { margin: auto; } #gallery-6915048-3 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-6915048-3 img { border: 2px solid #cfcfcf; } #gallery-6915048-3 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
Press Telegram
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-2240394-4 { margin: auto; } #gallery-2240394-4 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-2240394-4 img { border: 2px solid #cfcfcf; } #gallery-2240394-4 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
Daily News
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-3228148-5 { margin: auto; } #gallery-3228148-5 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-3228148-5 img { border: 2px solid #cfcfcf; } #gallery-3228148-5 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
Pasadena Star News
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-2330082-6 { margin: auto; } #gallery-2330082-6 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-2330082-6 img { border: 2px solid #cfcfcf; } #gallery-2330082-6 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
Daily Breeze
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-1900533-7 { margin: auto; } #gallery-1900533-7 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-1900533-7 img { border: 2px solid #cfcfcf; } #gallery-1900533-7 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
Press Enterprise
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-1586077-8 { margin: auto; } #gallery-1586077-8 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-1586077-8 img { border: 2px solid #cfcfcf; } #gallery-1586077-8 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
Redlands Daily Facts
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-1856685-9 { margin: auto; } #gallery-1856685-9 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-1856685-9 img { border: 2px solid #cfcfcf; } #gallery-1856685-9 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
Daily Bulletin
By Deepa Bharath, The USC Center for Health Journalism Collaborative The possibility of becoming sick keeps Jennifer Leyva up at night. The 38-year-old transgender woman doesn’t have health insurance. Since she began her transition about five years ago, she’s bought female hormones at street corners, swap meets and stores that sell them under the counter. She’s taken on odd jobs and even performed sex work to cover the cost of hormones and laser hair removal, which could all add up to thousands of dollars. “I was in my 30s when I began my transition,” she said. “It’s not easy to turn a manly man into a woman. When you want something so bad, you don’t care what you risk.” #gallery-1969527-10 { margin: auto; } #gallery-1969527-10 .gallery-item { float: left; margin-top: 10px; text-align: center; width: 33%; } #gallery-1969527-10 img { border: 2px solid #cfcfcf; } #gallery-1969527-10 .gallery-caption { margin-left: 0; } /* see gallery_shortcode() in wp-includes/media.php */ Transgender women stand in front of the LGBT Center OC in Santa Ana on Tuesday, June 25, 2019. Many transgender women struggle to get the healthcare services they need. (Photo by Paul Rodriguez, Contributing Photographer) Transgeneros Unidas Program Director Khloe Perez-Rios, at left, chats with Cici Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, and Miah Andrade, 24, of Los Angeles, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Miah Andrade, 24, of Los Angeles, CiCi Lopez, 56, of Long Beach, Transgeneros Unidas Program Director Khloe Perez-Rios, and Africa Avila 26, of Cudahy, from left, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Ika Aragon, who is transgender, talks about health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender patients Simo Love waits for an appointment at St. JohnÕs Well Child and Family Center with transgender Ashley Marks on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) As Rachel Pozo, left, listens, transgender woman Valentina Rodriguez, right, talks about her health care struggles in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses with employees Robby Trauger, a trans advocate, Ethan Patron, an intake coordinator, peer leader Teanna Herrera and transgender patient Simo Love at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. Johns is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, speaks with behavioral health therapist Victor Constantino during a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgender patient Simo Love, who has been taking hormones for four years, follows a behavioral health therapist to a transition appointment at St. John’s Well Child and Family Center in Los Angeles on Tuesday, July 2, 2019. St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat with SCNG reporter Deepa Bharath at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, left, talks with Transgeneros Unidas Program Director Khloe Perez-Rios, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Jim Mangia, CEO of St. John’s Well Child and Family Center, poses at the Los Angeles health center on Tuesday, July 2, 2019. Mangia has a close relationship with the trans community and St. John’s is the largest provider of transgender health services in California. (Photo by Sarah Reingewirtz, Pasadena Star-News/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, Africa Avila 26, of Cudahy, Miah Andrade, 24, of Los Angeles, and Transgeneros Unidas Program Director Khloe Perez-Rios, from left, chat about at the lack of health coverage among the local undocumented trans population. Photographed at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, listens to CiCi Lopez, 56, of Long Beach, left, as she tells her story at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Transgeneros Unidas Program Director Khloe Perez-Rios at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Africa Avila 26, of Cudahy, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Miah Andrade, 24, of Los Angeles, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) CiCi Lopez, 56, of Long Beach, at the Bienstar Human Services office in Long Beach on Wednesday, June 19, 2019. (Photo by Kevin Sullivan, Orange County Register/SCNG) Anahi Avila, left, and Jacqueline Valdez, right, listen as fellow transgender women talk about their struggles with getting healthcare in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender women Rachel Pozo, center, and Viana Leon, right, raise their hands to indicate they do not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Rachel Pozo in Santa Ana on Tuesday, June 25, 2019 relates her struggle with getting health care. She does not have health insurance. (Photo by Paul Rodriguez, Contributing Photographer) Transgender woman Viana Leon explains that she does not have health insurance in Santa Ana on Tuesday, June 25, 2019. (Photo by Paul Rodriguez, Contributing Photographer) While transgender Californians such as Leyva face the same concerns as the rest of the uninsured population around how to pay for routine medical care or hospitalization if they get sick or are injured, the health care challenges often go far deeper for this community. Hormonal therapies used in gender transitions can run thousands of dollars, not to mention the exorbitant costs for sex-reassignment and cosmetic surgeries. The need for mental health and therapeutic services tends to be particularly high among the transgender community as well, given the emotional issues and social stigmas they routinely encounter. Transitioning is the process of permanently adopting the physical characteristics of the gender one identifies with as opposed to those associated with one’s birth sex. Some limit this process to social transitioning, which involves changing their name, preferred pronouns and appearance. Others choose to transition medically as well by opting for hormone treatments, sex-reassignment surgeries and cosmetic procedures such as breast implants. Some may also choose to undergo additional surgeries such as a hysterectomy to remove female reproductive organs, and phalloplasty, which is a procedure to construct a penis using skin from other parts of the body. The transition process can vary from person to person depending on how much they want to change, said Khloe Perez-Rios, 30, of Rancho Cucamonga, a transgender woman who leads a support group for other transgender women in Long Beach. “For some, it’s a lifelong process,” she said. “Many are happy once they reach a stage where they are comfortable. That’s really what it’s about — to be comfortable in your own skin.” Lack of access and care Although estimates vary, national studies show that transgender adults are more likely to be without health insurance than the population as a whole, complicating efforts to provide the trans community with the medical services they need and desire. About 14 percent of transgender adults were uninsured in 2015 compared with 11 percent in general in the United States, according to the U.S. Transgender Survey by the National Center for Transgender Equality, a Washington, D.C.-based advocacy group for transgender people. Transgender people are unable to obtain health insurance for a variety of reasons, including unemployment and lack of housing, said Maddi Behrouzmand-Stratton, program manager at the Gender Health Center in Sacramento, who prefers to use the pronoun “they.” Transgender people tend to distrust insurance because of discrimination they may have experienced in health care settings. Many don’t even know whether they are eligible for Medi-Cal or health care subsidies, they said. Even for those who have access to free or low-cost health care through Medi-Cal or the Affordable Care Act, getting information on care and services they qualify for can be challenging because of stigma and discrimination, Behrouzmand-Stratton said. “The front desk might call them by their legal name, or providers might tell them they don’t want to work with them or won’t give them a referral for hormones. All of this can be really damaging (emotionally).” Indeed, one in four respondents to the 2015 national transgender survey reported experiencing problems with their insurance related to their transgender status over the preceding year, including insurers refusing to change their name and/or gender in their records or being denied coverage for services often considered gender-specific. Nearly one-quarter reported that they avoided seeking health care out of fear of being mistreated as a transgender person. Free services for the uninsured In the Greater Los Angeles area, a majority of uninsured transgender people tend to be undocumented and therefore ineligible for coverage through Medi-Cal or the Affordable Care Act, said Jim Mangia, CEO of St. John’s Well Child and Family Center in Los Angeles, which houses a health program at 23rd and Flower streets for the transgender community, run entirely by transgender people. The clinic provides hormone therapy and primary care to about 2,500 transgender patients each month, about half of whom lack health insurance because they are undocumented, said Mangia, who is gay. “I’ve always been close to the transgender community,” he said. “But what pushed me to start this program is the fact that these people have nowhere else to go. They were buying horse hormones at swap meets and getting really, really sick from it.” Hormone therapy should be administered by a physician on a case-by-case basis, and self-administering hormones or buying unverified drugs off the street can result in serious side effects and health problems, Mangia said. He said his clinic doesn’t charge uninsured patients for the hormones, which typically cost a few hundred dollars per dose. The clinic counts on federal money and philanthropy to fund the transgender program, he said. Mangia’s patients are not just Angelenos. They come from Long Beach, Orange County, San Diego, Riverside, Bakersfield and from as far away as Las Vegas. Fear and hate Leyva is a regular at the clinic. She qualifies for Medi-Cal because her application for asylum was approved two years ago. But, she said, her attorney advised her against applying for the government-funded health insurance program out of fear that the Trump administration may decide to deny legal permanent residency to people who depend on public assistance — the so-called “public charge” rule. If the rule does go into effect, it cannot be applied retroactively, and legal challenges could stop enforcement for some time. But that has not stopped many attorneys from incorrectly advising their clients to take an unnecessary step that can lead to dangerous health consequences. “I don’t know how the law is going to change, and I don’t want it to affect my green card,” Leyva said. “I’m afraid to even go to a (federally qualified health clinic for underserved populations) because I’m worried about my immigration status. I pray to God every day that I don’t fall sick.” Many of the patients who visit Mangia’s clinic and a handful of others in the region are immigrants from Central America and Latin America. Miah Andrade said she fled Honduras because she was the target of violence and hate crimes. “I ran away because I wanted to come to a place where I am free to walk down the street,” she said. “Back home, I would be called demeaning names, and that wasn’t the worst of it. In our culture, there is no word for ‘transgender.’ People would just refer to me as a man who is trying to dress like a woman. It was traumatic.” Andrade, now 24, said she started her transition back in Honduras when she was 19. Here, she faces different challenges. Her biggest concern right now is how to get surgeries such as breast augmentation and sexual reassignment. She hasn’t been able to get Medi-Cal because she is still undocumented, but new state legislation will expand eligibility to undocumented residents up to age 25. Medi-Cal covers hormone treatment, gender-reassignment surgery and other procedures that are considered “medically necessary.” Typically, cosmetic procedures such as breast augmentation are not covered by Medi-Cal. But for the uninsured like Andrade, the lack of access to surgical procedures is a constant source of stress. “Not being able to get the surgeries I need to transition fully, that affects my state of mind,” Andrade said. “I worry all the time about falling sick or being hospitalized and not having the money to pay for it. I know a lot of girls here. We’re in the same fight.” CiCi Lopez came to the United States about 23 years ago from Puerto Vallarta, Mexico. She couldn’t find stable employment, she believes, because of her gender identity. Lopez is undocumented and uninsured. “I was homeless for a while,” she said. “Now I live in a motel, and I’m struggling to pay rent.” A lifelong process Lopez began her transition at age 16 when she was in Mexico, where it wasn’t easy being transgender, she said. Men would call her names as she walked down the street. People would throw stones at her. “My family was supportive,” she said. “But I left Mexico because I didn’t want my parents to suffer seeing me like that.” The biggest issue for her now, Lopez said, is to pay for a doctor or medical services. The hormones she got off the street affected her nervous system and skin pigmentation, she said, holding out her hands that still have white patches. She stopped taking them. “People think transitioning is a short-term thing,” Lopez said. “For most of us, it is a lifelong process. We are all at different stages of the transition.” Rachel Pozos, 36, of Santa Ana, said she stopped taking hormones because they were making her sick. And she says she is happy where she is in her transition. Pozos did pay out of pocket for her surgeries — $3,400 for breast implants and $5,000 for laser hair removal. “I got those things because I don’t want to be bullied,” she said. Mental and emotional struggles Transgender people also struggle to get mental health services, said Dr. Kristen Vierregger, who specializes in transgender hormone therapy. Ninety percent of patients who visit her Buena Park clinic, Metamorphosis Medical Center, are transgender, and about 10 percent of those are uninsured, Vierregger said. Vierregger said she helps uninsured patients who pay out of pocket by keeping consultation rates low. “I’ve seen that transgender people’s mental health really improves when they are able to access the health care they need — be it hormones or surgeries,” she said. “I try to put myself in their shoes. If modifying my body was out of the question because I can’t afford it, why wouldn’t I be depressed? Patients suffer in very real ways when they cannot access the care they need to feel good in their bodies.” Depression is the most common mental health issue for transgender people, and it’s mostly triggered by stigma and prejudice, she said. “When they are out in public and people don’t recognize them correctly, that can be debilitating. Every social interaction is informed by that anxiety. Self harm is common among those who feel their body is betraying them. If despair is acute, suicidal ideation occurs.” The Trump administration has proposed rolling back an Obama-era regulation clarifying that the Affordable Care Act’s prohibition against health care discrimination on the basis of sex includes gender identity. That could prove devastating for this vulnerable and marginalized community, Vierregger said. Medical intervention such as hormones and surgeries can be “truly lifesaving” for transgender patients, she said. “I know people don’t look at it quite this way. But, this is a life-and-death issue.” Sammy Caiola of Capital Public Radio contributed to this report. The Uncovered California project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio. Share your story Are you uninsured? Do you struggle to pay for health insurance? The Southern California News Group is working with a collaborative of journalists statewide to report on whether people can get and keep health insurance in California. Click here to tell us about yourself.
16 Jul 19
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