When I was 3 or 4 years old, I stood beside a long table where family members had gathered to eat, talk and share stories.
“I want to be a boy,” I said, to no one in particular.
Everyone laughed, from my grandmother to my uncles. I never repeated the notion, though more than three decades later, I did come out as a lesbian, staking my claim to the first letter in the acronym LGBT. But what if my desire hadn’t stayed quiet? What if the conviction had persisted that my body didn’t match my true gender? And what if I were living in Western North Carolina, perhaps in a city and county where health providers wouldn’t or couldn’t take me as a patient, or where I feared losing my job or worried about my personal safety? What if I were uninsured or between jobs?
Like hundreds of other mountain residents each year, I would make my way to the Minnie Jones Health Center in downtown Asheville, run by Western North Carolina Community Health Services.
The parking lot is almost always overflowing. Founded in the mid-1990s, the nonprofit center handles more than 60,000 appointments for some 15,000 patients each year. Most are low-income and lack adequate (or any) health insurance. As one of North Carolina’s 38 federally qualified community health centers — a national program launched in the 1960s — WNCCHS specializes in caring for the area’s underserved populations.
In the waiting room, the patients are young, old, Latino, white, African-American, transgender, straight and everything in between. The staff’s diversity mirrors that of the clients: In fact, it’s not uncommon for former patients to go to work for WNCCHS, which locals pronounce as “winches.”
And despite the prevalence of sick people needing care, the mood is friendly and lighthearted. Staffers talk to patients as if greeting old friends. An elderly patient makes happy faces with a toddler who’s resting her head on her mother’s shoulder. When a child runs, giggling, down a side hall, a staffer laughs and calls out, “Got another one on the loose!” The child is gently steered back to her parents.
“It’s about basic respect for people,” says Scott Parker, the nonprofit’s director of development. “Meet everybody where they are and ask what they need.” Acceptance, inclusivity, accessibility, affordability — “Those are all key to serving any population,” he maintains.
WNCCHS is a one-stop health center where patients can get most of what they need under one roof, says Niconda Garcia, an Asheville native who is WNCCHS’ director of patient support. That includes primary, pediatric and family care; dental services; an in-house pharmacy; HIV-AIDS care; behavioral health services; plus connections to specialists, social workers and other local agencies.
“Being able to do things in one location helps keep patients engaged,” she explains. A single mom with no car might not seek or stay in treatment if the center couldn’t accommodate kids or combine visits to minimize trips to the center. And an integrated approach “helps providers, too, because they can work with a team, with people with different skills and knowledge.”
Against that backdrop, WNCCHS’ transgender health program fits right in — and it evolved naturally from the nonprofit’s core services. Back in 2007, the program “started very quietly, partly because it’s Asheville, with a very diverse community,” says Parker. Patients “came to us, looking for culturally competent care.” Word spread, and more patients came.
The center now sees about 200 transgender clients a year from an 18-county swath of Western North Carolina, he reports, and the need continues to grow.
A recent $10,000 grant from the Campaign for Southern Equality, another Asheville-based nonprofit, will help provide much-needed support for transgender health services. At last year’s “LGBT in the South” conference, notes the Rev. Jasmine Beach-Ferrara, the campaign’s executive director, some of the best-attended workshops focused on transgender health and legal issues. This year’s event, slated for March 18-20, is sold out, with more than 600 attendees registered. Beach-Ferrara expects to see a wide variety of people, including representatives of grassroots groups and health care providers.
A long journey
Zoë Love Hadley and I sit down for coffee at BattleCat in West Asheville. We’re close in age, two women in their mid-50s. She’s tall, her dusky blond hair long, her arms slender and slightly freckled. She’s got 23 tattoos, including one of a mermaid surfing the waves.
“That’s me,” says Hadley, a Florida native who came to the mountains in the late 1990s. Each tattoo tells part of her spiritual journey, she explains, particularly her search for the divine feminine. A wolf tattoo on her back represents such aspects as a strong attachment to, and willingness to defend, friends and family. The wolf “is one of my spirit guides,” says Hadley.
Born male, she always knew she was “different” and, really, female. “But for a long time, I swallowed who I was,” says Hadley. “I didn’t understand.” She took “masculine” jobs, such as operating heavy equipment, fighting fires, doing plumbing and construction work. Trying to fill the role of a traditional, heterosexual man, Hadley married, twice.
“But I looked in the mirror and I didn’t know who I was,” she recalls. Her decadeslong journey included problems with alcohol and other drugs, as well as thoughts of suicide. “Just before I moved up here, I said to myself, ‘I’ve got to change.’ And the first step was learning to love myself.”
In Asheville and sober, Hadley says she felt free to explore her feminine side and to become the woman she had long felt she was. Five years ago, she started hormone treatment. Three years ago, she made Zoë Love Hadley her legal name and changed the gender marker on her driver’s license. “I could be who I wanted to be, so I gave birth to Zoë Love,” she says, adding that her adopted first name means “life.”
Hadley feels the language for addressing gender needs to continue evolving. And while she understands that she may make some people uncomfortable, “I honor that, but I’d like their respect.”
Still, she observes, “It’s been a long, wonderful journey,” and WNCCHS has been an integral part of it. “They’re so accepting, down-to-earth. They reach out and they care for you — gay, straight, whatever.”
More specifically, continues Hadley, WNCCHS staffers make every effort to provide “culturally competent” care. Among other things, that means understanding that a woman like her may have a unique mix of health needs: She hasn’t fully transitioned, so in addition to hormone therapy, Hadley might need help with male health problems, such as prostate cancer. “I’ve got high blood pressure and arthritis,” she reveals. But WNCCHS staffers “really care for people, and you can feel it.”
In a 2010 study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 19 percent of respondents reported having been refused care because they were transgender, and more than 40 percent said they’d attempted suicide, notes Dr. Jennifer Abbott, the director of WNCCHS’ transgender health program.
Those statistics mirror what she’s heard from patient after patient. “They’ll tell me, ‘I’ve called around to 15 different practices and been denied care,’” says Abbott. “That’s just completely wrong.”
Part of the problem, she notes, stems from providers’ basic lack of knowledge. Early on in Abbott’s tenure with WNCCHS, a co-worker asked her to see a transgender patient who needed hormone therapy. Abbott had to admit that she lacked the requisite knowledge and experience. “But I couldn’t say no.” Instead she told the patient, “If you’re willing to meet with me and teach me, I’m willing to try.”
The client shared information on standards of care and guidelines for treating transgender patients. In fact, in the 2010 survey, 50 percent of the respondents said they’d had to teach their providers, says Abbott. “Until recently, there’s been little or no training for doctors or other health providers for medical care for LGBT patients.” And eight years later, she’s still “very grateful to that patient who was willing to teach me.”
More patients followed. “There’s so much demand in WNC for transgender care and other gender-nonconforming patients,” says Abbott. Facebook, she points out, permits nearly 60 different gender choices. “Understanding that spectrum is part of cultural competency.”
One of the first guidelines calls for using the patient’s preferred name and gender, even when these differ from the legal names on medical records. “If a patient is called by a name or pronoun that doesn’t match their gender presentation, they may not respond or may leave the office, because that’s effectively outed them. It’s humiliating and makes them not want to be there,” Abbott explains.
Thanks to that same sensitivity, as well as WNCCHS’ underlying social justice mission, the staff is, very intentionally, a diverse one, both culturally and in terms of gender. A transgender staffer, for example, helps patients navigate medical and community services.
“We have several nongender-specific bathrooms, too, which is especially helpful for someone who’s very early in their transition or nonbinary — those who don’t present as either male or female,” says Abbott.
All in the family
For very practical reasons, Abbott hopes such gender awareness will become more widespread. If a college transcript uses a prior name or gender, for example, a transgender person might have trouble getting a job or getting into graduate school. Or a homeless transgender person could have trouble finding a place to live. “It’s important that we try to get everyone on the same page,” she points out.
Meanwhile, outside Asheville, transgender people still confront a far greater social stigma. And if they have trouble getting care, says Garcia, “Will they be one of those who drop out of care or become one of those 41 percent who attempt suicide?”
Those concerns highlight the need for the services WNCCHS provides, Beach-Ferrara maintains, noting, “There’s no program like it in the Southeast.”
In fact, there are few such programs in the entire United States, particularly in rural areas. “The need is real, and what WNCCHS does is remarkable,” she says. So raising $10,000 for the health center’s transgender program dovetailed nicely with Southern Equality’s overall mission and increased focus on “full equality and dignity and respect for transgender people,” Beach-Ferrara explains. “WNCCHS is a warm and welcoming place, and its transgender program is a model of care.”
Parker acknowledges the compliment but says the health center rarely toots its own horn, preferring to continue quietly serving its community. We all have bodies, he says. “It’s basic biology.”
Abbott agrees. “Transgender health care is not specialty care: It is primary care. And appropriate care should be accessible to all people. That’s what family medicine is all about.”