Meeting the Health Care Needs of Transgender People Without Housing

SHANOOR SEERVAI: Even before the pandemic hit, a growing number of Americans were experiencing homelessness. The housing crisis and health care are inextricably linked. Being without a home makes it difficult to get medical treatment and exposes people to disease and other risks. These problems are even more acute for transgender people who face discrimination when they seek both housing and health care.

I’m Shanoor Seervai, and on today’s episode of The Dose, we’re going to talk about how to address these linked challenges. My guest, Pam Klein, is the manager of transgender services at the Boston Health Care for the Homeless Program. She’s also the nurse liaison for the Center for Transgender Medicine and Surgery at Boston Medical Center and has been working for more than 25 years to improve health care services for this extremely vulnerable population. We will talk about what it’s like to care for transgender people on the streets, how to find them access to safe and sustainable housing, and what health care for trans communities could look like as public awareness and sensitivity grows.

Pam, thank you so much for joining me on The Dose.

PAM KLEIN: Thank you so much, Shanoor. I’m really happy to be asked to be here.

SHANOOR SEERVAI: So you’ve been on the front lines of providing what’s called gender affirming health care for many years as a nurse and a patient advocate. There is increased visibility of trans people, there’s more awareness, but does that translate into meaningful improvements and access to services like specifically health care and housing? Do you see providers being more sensitive?

PAM KLEIN: Certainly there is greater awareness among providers. There’s a lot more, you know, burgeoning services, I think there’s much more awareness now about disparities in health care disparities, in health care outcomes.

I think there is a lot of effort, there’s a lot of training opportunities out there. Lots of centers opening and focusing on this population. There’s a lot of emphasis on providers, to get them, you know, up to speed to be able to care for people and to get people in the door. I think that has definitely improved.

SHANOOR SEERVAI: Now, one of the challenges is that there’s very little data about trans people and their specific health concerns. So, is the data catching up with this increased awareness?

PAM KLEIN: The data is starting to catch up. And when there’s data, it’s showing that transgender folks have worse outcomes on, like, every health care measure. I think the challenge is still to get this population identified in a sort of consistent way. And it’s mandated, if you get federal funds you sort of have to be starting to collect this information and having a mechanism to collect it. But in terms of in practice, how that is, there’s still just a lot of challenges for providers to feel comfortable asking these questions. Patients who might not even know what you’re talking about sometimes, especially if, you know, patients are coming from different languages and cultures. So there’s got to be efforts to get the data to be accurate.

SHANOOR SEERVAI: So spell that out for me. What is the challenge you mentioned, for example, with the level of comfort on the side of the provider or in being linguistically competent with patients?

PAM KLEIN: So, you know, it entails asking patients their gender identity. A patient might not know what you’re talking about. I’ve had lots of conversations where, when I say, what pronouns would you like us to use? Patients don’t really even know what I’m talking about. You know, we try to get pronoun information collected just even at the front desk with registration, so that when people are called from the waiting room that their pronouns are accurate and their names are accurate. And, sometimes even staff, you know, staff absolutely sometimes need education around how you’re explaining this to patients. So even for nothing else, it’s an investment of time, you know. Providers often are very busy, right? You have maybe 15 minutes to kind of cover everything and to take the time to have this conversation. And in terms of sexual orientation that’s a conversation, and sometimes I think providers just feel like it’s not a priority.

And I think that’s the big challenge is getting everyone to recognize that this is actually a big priority. It’s offering patients that opportunity to identify themselves and to be seen, right? So, so many patients aren’t ever asked these questions, are basically invisible to their health care providers and the health care system.

And then, ultimately, hopefully using the data to be able to say, none of these people who are due for their pap smears who are identified as trans men are getting them. Why is that? Well, how, what can we do about that? That’s just one example. But if you don’t even have a way of identifying folks, you’re not going to be able to make appropriate interventions.

SHANOOR SEERVAI: Let’s talk briefly about where insurance fits in. You said that it’s gotten better, but how does a trans homeless person navigate the insurance system?

PAM KLEIN: I am from Massachusetts and everybody in Massachusetts is eligible for some level of health insurance. Virtually all levels of health insurance now do cover medical transition with medications, cover visits, and cover behavioral health visits. Maybe not the sort of lowest level of insurance, but, um, pretty much every other level of insurance will cover surgeries also. So this all happened, I think it was 2013 or 2014, where Medicare basically said gender-affirming care is going to be covered. And so then various insurers, including Massachusetts public insurance, and many other states kind of followed suit. And so that’s been a really big shift. There is still a lot of gaps. Sometimes the policy is really great, but there’s still a lack of access.

There’s still, you know, great, you cover facial feminization now, but if you don’t have any surgeons to do it in your area. I feel like, insurers are listening more now, like I just last week was part of a meeting that the Division of Insurance in Massachusetts is holding, these listening sessions, that is a really great model for everywhere is to have those conversations with insurance, insurance regulators, insurance companies, and community members and advocates working in this space, I think has made some really good gains.

SHANOOR SEERVAI: So you’ve mentioned now that specifically at the Boston Health Care for the Homeless Program, you’re able to try different approaches to maybe what some other states or other programs are doing. For example, housing first is the conventional approach to stabilizing and serving people who are experiencing homelessness. But that doesn’t always work with transgender people. Can you unpack that a little bit?

PAM KLEIN: You know, there’s this effort to say, we don’t want to keep making more shelters, right? We need to get people into housing, get them the support they need. The issue is that the housing has not materialized in that way.

There is an organization, again in Massachusetts, called the Transgender Emergency Fund that is really trying to raise money to create such an entity here. In Casa Ruby in D.C. I visited, you know, kind of only goes up to age 24, 25 and it’s an awesome place. I think there is this gap, there is a lot more attention these days paid, to gender-diverse youth, because there’s recognition of how at risk they are. But there’s this group of older people who are kind of kind of forgotten.

SHANOOR SEERVAI: So let’s talk specifically about shelters. You mentioned that even if staff are trained, maybe, other shelter residents may not be sensitive to transgender people coming in. Historically shelters have been segregated by gender and it’s binary, right? It’s male and female.

PAM KLEIN: And that’s still the case. I think the difference is that it used to be that you had to stay where your state-issued ID said. So if you were male on your ID, you had to stay on the male side. Like even if you identified as female, even if you presented as female, you know, they sort of shunted you over to where you were legally.

And that’s all changed which, you know, is definitely good. I will tell you that I have a patient who told me that she’s a female identifying patient and was given the opportunity to stay on the female side. And she’s actually from Honduras originally. And she said that she felt less comfortable there than on the male side. She felt that on the male side there were a lot of Honduran men who kind of protected her. And that she felt on the women’s side everyone was just really, you know, catty. And you know, that’s her word, that she just didn’t feel as welcome.

So it’s interesting to, you know, you make these assumptions. This came up in a presentation to staff and that gets to another point about working directly with the community in these efforts, right? So I’m sort of touting this, shelters like how that changed and how great it is for everybody. And then when she spoke, she actually — it was kind of contradicting what I said but, you know, it was a great point.

SHANOOR SEERVAI: So let’s talk about how you work with the community, because it’s most important to hear the voices of the people who we’re trying to serve, and how does Boston Health Care for the Homeless do that?

PAM KLEIN: Thinking back to the beginning as you know, I mean, I’ve always been an ally, but I do feel like early on it was all about, what can I do? How do I educate? There wasn’t that much involvement, in a way, with having patients or clients be doing these like educational efforts, or if they did, they would be asked, you know, sort of out of the goodness of their heart, would they do that.

And people should not be expected to share their experience, even in the effort to educate others, without being compensated for it. It’s a much richer, better educational experience to have somebody of the community letting folks know what they need. I’m much more of a, almost a conduit, where I am the R.N., the one with the credentials or whatever, who can sort of get things organized, but I’m definitely making sure that I am bringing along people who can certainly speak to issues a more personal way. And I think that, you know, is really a value. Also though, just more specifically to your question: I have a patient who I met back in like 2010 and she became a community advisory board member for BHCHP, and then joined our board actually. And that’s been really great to have Sarah as part of our board helping determine how BHCHP is going forward.

SHANOOR SEERVAI: And so building on this idea of meeting patients, clients, where they are, your organization is maybe trying to get people to come in to see their primary care provider and get preventive health care. And if somebody is living on the streets, maybe that’s not their number one priority. So how do you reach them?

PAM KLEIN: The COVID pandemic, kind of heightened this. We sort of lost, people, you know, got evicted. People just didn’t come into care because they were worried about their safety. And we started regular outreach. Health Care for the Homeless has a street team and also regular outreach to patients.

Like the HIV team goes out and finds patients and make sure they’re taking their meds. And someone brought to our attention that there was this little cohort of trans identified folks staying out on the street. And so we developed a little pilot. It’s only been about, I guess, a month now, going out specifically to engage with these folks, give them information. Working on a little grant to get some clothing, like chest binders for some trans men, and different clothing for folks to help with gender expression. And that seems like it’s working. There’s a provider and a case manager and AmeriCorps member volunteer who go out together and, a nurse, a Health Care for the Homeless Program nurse. And so this nurse has kind of done these warm handoffs to this little outreach team to introduce different patients to them. And then they’ll come, they’ll meet with me and I’ll kind of make sure they get connected, you know, back to primary care or get connected for the first time to primary care.

SHANOOR SEERVAI: What you’re saying is that someone out on the street, they may not see their primary care provider as their number one priority. They need a chest binder. If you meet them with the chest binder, then you can get them in to see the doctor.

PAM KLEIN: It’s like an engagement tool. Exactly.

SHANOOR SEERVAI: Well, I want to talk a little bit more about the pandemic because the pandemic disrupted health care delivery. You know, we’ve heard about all the elective surgeries being canceled, and I just wonder what impact that would have on gender-affirming health care, gender-affirming surgeries.

PAM KLEIN: Yeah, so certainly on surgeries, they were basically put on hold, and that was very stressful for patients. What I think what added to that is the way that the information comes to the patient, the electronic medical record or the software, whatever, says your surgery has been canceled. It doesn’t say postponed. It does, you know, your elective surgery has been canceled is basically the message people are getting. Because from the medical side, um, elective surgery is a surgery that doesn’t have to be done immediately, like a lifesaving surgery, everything else is elective. That’s what patients are, just getting that message is very stressful because to that patient, you know, it is a medically necessary surgery. And then just, not knowing when they’d get rescheduled and then, if they lose their job because of the pandemic and they lose their insurance, then, you know, that might be another reason that surgery has to get delayed. And so that was a big deal.

SHANOOR SEERVAI: Give me an example of a surgery that’s medically necessary to the patient but that could have gotten cancelled.

PAM KLEIN: Any gender-affirming surgery, is, you know, is medically necessary to that person. People have been living for decades feeling like they had, for example, the wrong genitalia, right? And not being able to really do anything about that. And so then when surgery started covering, that was huge. So these patients are just so grateful and so, you know, and so like finally I can be myself, finally I can look in the mirror and see what I’m supposed to see. I’m in distress. I’m in distress every time I do look in the mirror now and I, you know, I can’t look in the mirror. And so that gender dysphoria, you know, for that to be addressed by surgery, is absolutely a medical necessity for folks.

SHANOOR SEERVAI: And if you’re a distressed, for example, something to do with either your physical appearance or how you feel about your identity, how can you be expected to get a job? How can you be expected to do other things, right?

PAM KLEIN: Yes, absolutely. Having anxiety and distress just makes it hard to, you know, do a lot of things. But then specifically that the long time it’s taken for facial feminization surgery to be covered, you know, you go for an interview, people are looking at  your face and how you present, and so it’s just a mystery to me, how it took so long for that to be seen as a medically necessary procedure. But like I said, I think the number of providers who do it can be an issue in a lot of places in the country.

SHANOOR SEERVAI: So as you said, now, things are changing. There’s more awareness. Let’s talk about this relatively new clinic, Transhealth Northampton. So it’s sort of a model clinic, it’s a very specific place and has abundant resources. It’s not directly targeting people without housing, but it could have huge benefits for the population you work with. Tell me more about what’s different at this clinic, and also if we can replicate what they’re learning there.

PAM KLEIN: It was great when this clinic opened and, I think, what they’re really about, their CEO is a trans person and they’re really making this effort to hire people who reflect the community that they want to serve. And I do feel hopeful that more and more people now in med school and NP school who are identifying openly as trans are going to then to be the providers in the future who will be taking care of people. And not just providers, but just in general, right? Young people now do have it a lot better than the generation before, just in terms of acceptance. And certainly there’s lots still to do and lots of gaps in care. But I do feel hopeful that it will get better so I don’t have a job anymore, right? Like trans people are doing all the work.

SHANOOR SEERVAI: If we zoom out though, from Northampton, Boston, Massachusetts, and think about the rest of the country, what’s going on in other states? Are there successful programs for trans people experiencing homelessness in other parts of this country?

PAM KLEIN: I would say the Human Rights Campaign runs this Health Equality Index. It’s like a guide for for businesses and for health care, right? And they sort of publish, oh, these are the best places to work if you’re trans or gender diverse, whatever, and they rate companies and they have this survey. They also do it for health care and they have this long sort of application process and you get scored. And they have a little map on their website that shows all the places that are health equality leaders. And there’s hundreds across the country, you know? I mean, that’s great. Like I said, the devil’s in the details and everybody kind of has to get together and talk about what our policies are, what our care is. So I do think that yes, there’s a lot more going on.

SHANOOR SEERVAI: Before I let you go, I wanted to ask about the people you work with. Can you share an instance in which a client told you how much they appreciated something that you did or arranged for them?

PAM KLEIN: I have this one patient who was a patient of ours for many years, an older person, who called to make an appointment. And we had just recently instituted this phone thing that you call and, you know, push one for this, push two for that kind of thing. And our transgender program was, you know, number three. This was a new feature and she called and she hadn’t ever heard that before, and she hung up the phone. And it was sort of this thing where she felt she was a woman, but she had never pursued anything.

Then she called back and she, you know, made this appointment, had her come in. And she talks about how we sat in this room and she was worried that I was actually having the psych hospital come get her. Like, I had her in this room so that, you know, I’d be able to tell them where to come find her to take her away. Like she was really, really nervous.

She was in her late sixties, I guess. And she’s now undergone a couple of gender-affirming surgeries actually. She writes poetry about her transition. We’ve had her read her poems at the transgender day of remembrance in Boston, and she’s just kind of blossomed. So she’s somebody who absolutely just has been transformed by the work we do. And she’s managed to get on our Zoom groups that we developed during COVID that took like three home visits to get her to figure out how to do Zoom on her phone, but she is there every week.

SHANOOR SEERVAI: And that sounds like a relatively easy fix, right? It just started with adding a different option on a phone. There are small things that can be done to make things easier.

PAM KLEIN: And I think, you know, other small things can be done, like have posters that reflect the community that you want to care for. It does take some work, but it’s the right thing to do, and it’s very rewarding. That’s why I’ve been doing it for so long.

SHANOOR SEERVAI: Pam Klein with the Boston Health Care for the Homeless Program. Thank you so much for joining me today.

PAM KLEIN: Thank you very much, Shanoor.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Karl T. Wright, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thanks for listening.