Care Without Bias

During a routine medical appointment in Pasadena, Bridget Graves — a 57-year-old management consultant who identifies as transgender — realized that her physician knew very little about the standard of care for transgender patients. Graves’ after-visit notes confirmed her suspicions. Her physician had included “transgender” under the list of maladies Graves was seen for. Graves immediately called back to request a correction but never received a response.

Graves explained that these microaggressions — including medical staff who misgender patients and physicians who resist using preferred names on medical records — keep transgender and nonbinary patients from seeking health care.

Today, the mother of five, competitive cyclist and longtime yoga teacher is a patient at Keck Medicine of USC’s innovative Gender-Affirming Care Program, a multidisciplinary collaborative providing comprehensive health care to transgender and nonbinary people while affirming their gender identity.

Graves’ sentiments on her experience before coming to Keck Medicine reflect the struggles of many in the transgender and nonbinary community to find inclusive, continuous health care.

Gender-affirming care in a medical context means supporting and respecting someone in their gender identity, however they identify in their lifetime.

Laura Taylor

“Gender-affirming care in a medical context means supporting and respecting someone in their gender identity, however they identify in their lifetime,” says Keck Medicine primary care physician Laura Taylor, the program’s medical director.

For many people, this care boils down to hormone therapies and surgical interventions. But Taylor emphasizes that at Keck Medicine, it means individualizing all of a patient’s health needs based on their personal goals. These goals can include hormones to induce different physical characteristics or surgery to change somebody’s chest or genitals, but also routine care such as preventative medicine and specialized mental health care.

Keck Medicine was already providing gender-affirming care before the program began, but the process was decentralized and patients had to seek out individual specialists, says Felipe Osorno, Keck Medicine Chief Performance and Transformation Officer. Through the Gender Affirming Care Program, Keck Medicine patients can now access a centralized model where providers holistically monitor every aspect of health, including primary care, mental health, endocrinology, gynecology, urology, physical and occupational therapy, voice training and surgery.

Discussions about starting a centralized program began in 2019, brought about by a deeper awareness of diversity, equity and inclusion across the country. Later, the pandemic and the murder of George Floyd spurred the need for action around health equity and inclusion for populations traditionally excluded from the health care system apparent.

A New Approach

Before Graves became a patient with Keck Medicine, she, like many transgender and nonbinary patients, struggled to find a medical facility where she felt safe and understood.

“Historically, the transgender and nonbinary community have experienced — and still experience — a lot of discriminatory practices in health care, substandard care and so many barriers to health care,” Taylor said. “Unfortunately, these communities often have a harder time getting insurance due to a higher risk of issues with employment and insurance companies that may not cover gender-related services.”

Other barriers to care include transportation, financial constraints, family support and — especially in conservative states — the criminalization of gender-affirming treatments.

Finding Keck Medicine of USC after an extended internet search was a breath of fresh air for Graves. “It was like night and day,” she said. “This physician asked all the right questions and was open to keeping the continuity of my medications, my hormones and what had already been working for me.” This led to her eventually working with Taylor, whose trans flag on her ID badge put Graves at immediate ease.

Having someone willing to help, who knew how to work with me and made me feel comfortable, was amazing.

Bridget Graves

During her initial intake, Graves communicated that there were certain physical exams that typically made her uncomfortable. Taylor offered to personally perform those physical exams, so that Graves wouldn’t have to worry about them in subsequent visits with other providers. Taylor also offered to do more research on an experimental therapy Graves was interested in during an upcoming medical convention for transgender health care.

“The fact that she was already scheduled to go [to a transgender convention] meant a lot to me,” Graves said. “Having someone willing to help, who knew how to work with me and made me feel comfortable, was amazing.”

The program encourages patients to establish a long-term relationship with a primary care physician to foster this kind of continuity of care. The goal is to manage preventative and routine health care alongside gender-specific therapies without patients having to explain themselves repeatedly or see multiple physicians and specialists where the environment may be less supportive.

Starting De Novo

Taylor points out that while other places have historically offered gender-affirming care in Los Angeles — including LQBTQ+-friendly clinics, nonprofits and other academic health systems — a high need remains. “There are not enough doctors and health care providers who are adequately trained to do this care, and it hasn’t been a part of medical education,” Taylor says. “This is particularly harmful to the [transgender and nonbinary] community because often people have to educate their health care team.”

Assistant Professor of Clinical Surgery Roberto Travieso, the surgical director for the program, says one of their goals is for transgender or nonbinary patients to receive care that is supportive and respectful of their gender identity — regardless of whether their needs are complex (surgery) or routine (treating high blood pressure).

“Transgender and nonbinary people have the same health care concerns that others have outside of specifically gender-affirming surgeries and therapies,” Travieso says. While the program is adding services that were not available before — such as newly available surgeries and the consolidation of specifically gender-affirming care such as hormone therapy and primary care — Travieso stresses that the program is sparking institutional change: “We’re also making sure that this training and emphasis goes throughout the entire health enterprise to involve every facet of health care available through Keck.”

To accomplish this, Travieso, Taylor and Osorno — along with Process Architect Lindsey Morrison — regularly brainstorm with a large group of Keck Medicine colleagues. They discuss issues such as the wording on clinical intake forms, the appearance of medical record systems and where to place pronouns on documents so they’re clearly visible.

“Because we’re starting something de novo, we have the potential to avoid mistakes that have been made elsewhere, where patients don’t feel welcome,” Travieso says. Early on, he and the team realized that the key to the program’s success would be including the community during the planning stage.

Allied Collaboration

In March 2022, Keck Medicine of USC announced a strategic collaboration with The TransLatin@ Coalition — one of the largest trans-led nonprofit organizations in the country that advocates for the medical, social and economic needs of transgender, gender nonconforming and intersex immigrants. The collaboration underscores the health system’s commitment to working with the transgender and greater LGBTQ+ community with the goal of greater health equity for all.

It’s important to have this type of partnership between large institutions and community-led organizations; our collective work is great.

Bamby Salcedo

“We’re very appreciative and grateful for our partnership with Keck Medicine,” says activist Bamby Salcedo, president and CEO of The TransLatin@ Coalition. “It’s important to have this type of partnership between large institutions and community-led organizations; our collective work is great. We’re looking forward to ensuring that together, we continue to support and provide optimal health care to the local trans, gender nonconforming and intersex (TGI) community of Los Angeles.”

As a gay man who identifies as Latinx, Osorno is proud of Keck Medicine’s approach to the collaboration. “It was very meaningful for USC to both welcome the transgender community into our campus and have a celebration with our CEO and their leadership. The symbolism of that is very important because it’s saying, ‘We see you, we hear you, we’re here with you and we recognize you.’”

Keck Medicine leadership promoted mutual listening within the collaboration by hosting bilingual focus groups at USC facilities and at the coalition’s headquarters in Koreatown to ensure that transgender and nonbinary community members had a say in crystalizing the program’s vision.

Keck Medicine physicians heard heartbreaking stories of constant misgendering and individuals going to dangerous lengths — including self-administering hormones — to access the gender-affirming therapies they needed.

Based on that feedback, Morrison spearheaded the training of thousands of Keck Medicine staff — from nurses to admitting staff to those who interact with patients on the phone — because one negative or harmful interaction could be enough to turn away a patient in need.

The partnership also produced a peer navigation model: hiring a part-time social worker from the trans community to be the point of contact for patients and to help navigate the program.

According to Travieso, the program’s creation pairs well with Keck Medicine’s overall mission of making health care more accessible to everyone. “It’s not just us physicians who are working day to day; it comes from the top leadership and administration who have expressed significant support for the program and made it one of the core goals of the health care system.”

The program leaders urge people to donate to the continued evolution of the program as the state anticipates an increase in what is being called medical refugees — individuals forced by anti-transgender policies in other states to travel to California to receive the gender-affirming care they deserve.

“Our vision long-term is to provide gender-affirming care to anyone, regardless of their ability to pay,” Osorno said. “With this intentional philosophy, we really hope to become the preeminent gender-affirming care program on the West Coast.”