“We Don’t Get to Go Just Anywhere” Community Health Assessment of Barriers to Gender-Affirming Healthcare in Fresno, California ^†

Abstract

Research on access to healthcare for transgender populations in California remains mostly focused on the major city centers, leaving out many rural and poorer areas of the state. Understanding the barriers to gender-affirming healthcare in a largely rural, agricultural, and low-income area is critical in creating effective policies and programs to address significant gaps in transgender healthcare. This is especially true in regions like Fresno County, which sits within the heart of the Central Valley of California, that are mostly rural and agricultural. This study conducted a community health assessment using a mixed-methods approach, focusing on transgender communities’ experience of accessing healthcare and gender-affirming healthcare in Fresno County and on the various existing barriers and critical needs. The study reveals the critical deficits in accessing gender-affirming healthcare in Fresno County, especially regarding doctors providing gender-affirming care, as well as the larger implications this has on the health and well-being of transgender individuals living in the Central Valley.

1. Introduction

The transgender and gender-expansive communities represent an underserved population in the United States. Transgender and gender-expansive individuals experience intersecting oppressions, especially around race, sexuality, ability, citizenship, and class [1]. Transgender and gender-expansive Indigenous, Black, and persons of color experience some of the country’s highest rates of violence and poverty [1,2,3,4]. Access to primary and gender-affirming healthcare is significantly impacted for transgender and gender-expansive communities [5]. Gender-affirming healthcare refers to medically provided treatments that support transgender and/or gender-expansive persons in becoming their authentic selves, also known as transitioning. Gender-affirming healthcare is not solely the surgical and hormonal medical care that transgender and gender-expansive individuals seek. Gender-affirming healthcare encompasses both the medical side of care, including hormone replacement therapy and gender-affirming surgeries, and mental health support. It addresses physical, mental, and social health needs and affirms gender identity. Without access to gender-affirming healthcare, transgender and gender-expansive people are at higher risk of gender dysphoria, depression, anxiety, and suicidal ideation [6,7].

Research on transgender and gender-expansive experiences of healthcare has shown that access to and utilization of healthcare services are adversely affected, as transgender and gender-expansive individuals face greater obstacles not only to obtaining healthcare but also to receiving comprehensive healthcare [8,9]. Healthcare practitioners’ discrimination against transgender and gender-expansive individuals directly correlated with increased health issues, as discrimination and stigma made it difficult—if not impossible—for individuals to get the required care [10]. Foundational research spanning more than fifteen years has repeatedly shown that healthcare providers discriminate against transgender and gender-expansive individuals and lack knowledge on how to provide affirmative healthcare to transgender and gender-expansive communities [11,12,13]. Lambda Legal reports that seventy percent of transgender individuals have suffered some form of maltreatment at the hands of medical providers, including harassment and violence [14]. This frequency gets worse when intersected with race, as transgender and gender-expansive Indigenous or persons of color experience discrimination from medical providers at higher rates than their White counterparts, as well as more limited access to healthcare in general [15]. The majority of research reveals that transgender and gender-expansive individuals experience intersecting forms of discrimination based on age, income, gender, gender expression, race/ethnicity, and sexuality, either concurrently or throughout their efforts to attain healthcare and gender-affirming healthcare [16]. In addition, rural transgender and gender-expansive communities face additional barriers to healthcare based on fear and mistrust of providers, inconsistency in access to healthcare, disrespect from providers, and mistreatment due to intersecting experiences of gender, race, class, and location [17]. All of this reveals a healthcare landscape in the United States that is at best inaccessible to many within the transgender and gender-expansive communities and at worst a source of further harm.

One way to combat transgender and gender-expansive health disparities is to collect data and document the specific needs of the communities involved [18]. Research on transgender and gender-expansive healthcare is growing, but data about the specific barriers to seeking healthcare are limited and location-specific [19]. Research on transgender and gender-expansive access to healthcare in California remains mostly focused on the major city centers of Sacramento [20], San Francisco [21,22,23,24], and Los Angeles [25]. There has been little research on access to healthcare for transgender and gender-expansive individuals in the San Joaquin Valley, also known as the Central Valley, and specifically Fresno County. Fresno County has a population of 990,204 [26]. The City of Fresno is the fifth-largest city in California and the largest city in the San Joaquin Valley, with a population of 526,147. Outside the City of Fresno, the area is mostly agricultural and rural, with populations having less access to public resources and health centers. The counties surrounding Fresno County (Merced, Madera, Kings, Tulare, and San Benito) are predominantly rural, with smaller cities inside them. Given its position in the Central Valley, Fresno County and specifically the City of Fresno serve as the central healthcare hub for vital resources for thousands in the Central Valley. Understanding the specific healthcare needs for this area is critical.

The Central Valley is an area rich in diversity as well as disparity. It is home to some of the wealthiest agricultural landowners in California and some of the highest concentrations of poverty in the United States [27]. More than twenty percent of Fresno County residents live at or below the poverty level [28]. In the City of Fresno, more than twenty-six percent are living at or below the poverty level. Much of this poverty falls along racial and geographical lines; areas of Fresno that are predominantly African American, Asian American, and Latino experience higher economic disparities. The economic and social disparities present in Fresno County and the City of Fresno impact healthcare needs. Fresno County has some of the highest disease rates and health disparities in the state, with poorer populations and populations of color suffering from disproportionate levels of disease [29]. Fresno has high rates of heart disease, obesity, mental illness, deaths from cancer, infant mortality, maternal mortality, and STDs, as well as the highest rate of asthma in the state. The inadequate healthcare delivery system contributes to these health disparities [30]. The Central Valley has thirty percent fewer doctors than the statewide average, with forty-five primary care physicians for every one hundred thousand people. The effects of the COVID-19 pandemic have only exacerbated an already taxed healthcare system, creating a care crisis in Fresno. Transgender and gender-expansive persons make up a significant portion of Fresno’s inhabitants, as well as those of surrounding counties. Examining transgender and gender-expansive experiences and healthcare barriers in Fresno County not only highlights systemic inequalities affecting healthcare in the area but also works to address other areas of marginalization that impact similar communities.

The results presented in this article come from a 2020–2021 pilot study conducted by California State University, Fresno, Trans-E-Motion, and the Fresno EOC LGBTQ+ Resource Center. The decision to conduct this study came from an initial request by lesbian, gay, bisexual, transgender, and queer (LGBTQ+) organizers and community members of the Fresno EOC LGBTQ+ Resource Center and Trans-E-Motion to understand health disparities in Fresno and the Central Valley for the LGBTQ+ community. The Fresno EOC LGBTQ+ Resource Center offers a variety of services and support for LGBTQ+ persons in Fresno and the surrounding area. Trans-E-Motion is a volunteer and transgender-led organization based in Fresno dedicated to advocating for and supporting transgender and gender-expansive populations in the Central Valley. The study aimed to assess transgender and gender-expansive communities’ healthcare experiences in Fresno County and identify barriers to gender-affirming healthcare. The project was meant to be an initial step toward understanding the social determinants of health impacting transgender and gender-expansive communities in Fresno County. The article is structured to center transgender and nonbinary voices at the center of findings and discussion. The results and discussion sections are purposely combined to highlight the lived experiences of the participants and their critical role as knowledge producers.

2. Materials and Methods

The data collected comes from a 2020–2021 participatory action research project with the Fresno EOC LGBTQ+ Resource Center and Trans-E-Motion. Participatory action research places those most impacted by research at the center of the research’s design, implementation, and end goals or products [31]. The impetus of this research project came from previous collaborative work on transgender homelessness in Fresno, in which both organizations identified access to gender-affirming healthcare as one of the biggest obstacles to transgender well-being and quality of life. In deciding on the parameters of the research project, both organizations wanted to document critical gender-affirming healthcare needs and barriers LGBTQ2+ individuals experience in Fresno County to advocate for further resources and public understanding. The data collected would be used for a public brief shared by Trans-E-Motion.

The study used a digital survey and qualitative Zoom interviews to reach various participants. The digital health needs assessment survey focused on demographic information, access to healthcare resources, and opinions regarding the greatest needs of the transgender and gender-expansive communities in Fresno County. While developing the survey, the researchers reviewed previous research on transgender needs assessment tools from different studies. Before starting, this study was reviewed and approved by the California State University, Fresno Institutional Review Board. The survey was also shared with other Central Valley LGBTQ+ community organizations for comment before its finalization and distribution. The Fresno EOC LGBTQ+ Resource Center and Trans-E-Motion distributed the survey online through social media. The survey was only available in English because of the limited availability of translators and limited funding. Given the diversity of languages in the Central Valley, suggestions for future research include a multi-language approach. Digital informed consent was obtained from all individual participants before starting the survey through a questionnaire. Besides demographic information, individual identifying information was not recorded. Participants’ emails were kept in a secure database by the researchers to send a follow-up email to recruit for the qualitative Zoom interviews. A total of fifty questions were included in the survey, which was constructed using appropriate skip logic for questions not applicable to everyone. Questions included multiple-choice and short-answer formats. Due to COVID-19 restrictions, the survey was distributed primarily through social media, email, and an online advertisement in a local LGBTQ+ news source, Community Link’s social media. After completing the survey, participants were eligible to enter a raffle for a 25-dollar gift card. Eight gift cards were distributed in the raffle and emailed to the participants. The researchers also contacted community organizations not specifically focused on LGBTQ+ communities to distribute the survey. Flyers with a link and QR code were distributed and put up at community centers and libraries in Fresno County. The survey was distributed online in September 2020 and ended in January 2021. A total of six hundred and eighty-five individuals participated in the survey.

After completing the survey, participants could participate in follow-up interviews over Zoom to discuss their experiences accessing healthcare. Ten participants recruited directly from the survey participated in follow-up interviews. In addition to recruitment through the survey, a flyer for the interviews was distributed across social media to allow participants to sign up to be interviewed. Five additional participants signed up to be interviewed through the social media flyer. The interviews were conducted by the authors through Zoom, and the audio was recorded for transcription. Participants could receive a copy of the transcript if they desired. Before each interview, participants were given a series of questions regarding their healthcare experiences and a copy of the oral consent sheet. The oral consent sheet was then read to the participants before the interview started, and participants had to give their oral consent to continue. Demographic information was collected, and participants had the choice of using their first name, initial, or pseudonym to be used in the study. As a thank you and recognition for their time, each participant received a twenty-five-dollar gift card.

3. Eligibility Criteria, Demographics, and Analysis of Qualitative Interviews

Eligibility criteria for the survey and the qualitative interviews were limited to individuals who resided in Fresno County, were eighteen years and over, and who self-identified as transgender or with additional gender-expansive identities. Fresno County residence was determined in the survey by participants, confirming that they lived in Fresno County and listing either a specific address or general location (major city street, neighborhood, community center) at or near where they reside. The information collected was only used to determine eligibility for the study and to remove entries that were outside of Fresno County. Participants provided the year of their birth to determine eligibility. Participants could select one or two demographic categories regarding gender identity, sexual orientation, and race.

Demographics of Digital Survey

Gender Identity

Thirty-eight percent of participants identified as transgender females, and thirty-eight point two percent identified as transgender males. Thirteen percent identified as gender-expansive. Other options for gender-expansive identity included genderqueer (five percent), gender fluid (two point four percent), pangender (point nine percent), bigender (point seven percent), and agender (point four percent). Definitions of these terms can be found in the appendix.

Sexual Orientation

Nineteen point nine percent of the participants identified as heterosexual, and thirty-four point nine percent identified as homosexual. Twenty-seven point six percent identified as bisexual, nine point five percent identified as pansexual, one point six percent identified as asexual, and six point five percent identified as queer.

Race and Ethnicity

Sixty-two percent of participants identified as White. Four point one percent identified as Black or African American. Twenty-one point two percent identified as Hispanic or Latino. Five point six percent identified as Asian American. One point six percent identified as American Indian. Five point five percent identified as two or more races.

Income

Sixteen point five percent of participants identified as having a yearly income under ten thousand, and eleven point nine percent as having a yearly income between ten thousand and twenty thousand. Twenty-six point one percent identified as having a yearly income between twenty-one and forty thousand, and twenty-three point four percent as having a yearly income between forty-one thousand and sixty thousand. Twelve point seven percent identified as having a yearly income between sixty-one thousand and eighty thousand. Nine point four percent identified as having a yearly income over eighty thousand.

Eligibility Criteria for Interviews

The eligibility criteria for the interviews were the same as for the surveys. Residence information was not collected; however, participants had to orally/audibly confirm they resided in Fresno County by providing a street address or identifying a major street, landmark, or community center near where they reside. Interviews were audibly recorded on Zoom, and the transcriptions removed any identifying signifiers except for name or given pseudonym, age, race/ethnicity, gender identity, and sexual orientation. Participants were asked to self-identify for these categories and were open to how they identified themselves.

Interview Participant Demographics

Gender Identity

Five of the fifteen participants identified as trans female or transwoman. Four of the fifteen participants identified as trans male or transman. Four identified as nonbinary or gender fluid. One identified as genderqueer and one identified as agender.

Sexual Orientation

Six of the fifteen participants identified as heterosexual or straight. Five identified as homosexual, gay, or lesbian. One identified as bisexual. Two identified as queer. One identified as pansexual. One identified as asexual.

Race

Seven of the fifteen participants identified as White. Four identified as Hispanic or Latino. One identified as Black. Three identified as being of mixed race.

Income status was not requested or recorded for the interviews.

Analysis of Qualitative Interviews

The analysis of the qualitative interviews first used a deductive thematic analysis, coding on key areas regarding housing barriers [32]. These codes were pre-identified in our initial project design and informed the questions asked in the interview and in the survey. The deductive codes focused on barriers, for example, “Practitioner knowledge of gender-affirming healthcare”, “Refusal of transgender patients”, “Transphobic stereotypes”, and “Access to providers”. After the deductive thematic coding for barriers, additional barriers were coded. These included barriers not included in the survey questions but came up in the qualitative interviews. After the deductive thematic coding on barriers, inductive coding by the authors focused on themes independently generated by each qualitative interview. The inductive coding followed a reflexive thematic analysis, representing the researchers’ interpretation of the patterns of meaning across the interviews. The authors’ positionality informs the reflexive thematic analysis. Moreover, the authors are actively involved in local transgender advocacy, with one currently serving on the board of Trans-E-Motion and the other serving at Gender Alchemy in multiple roles. The deductive and inductive codes were then combined for larger thematic areas for discussion with the results of the quantitative data from the survey. As is evident in the following sections, all of the thematic areas are connected and critically impact the health and well-being of Fresno’s transgender community.

4. A Crisis of Care: Barriers to Healthcare and Gender-Affirming Healthcare in Fresno

We don’t get to go just anywhere. Many of us actively avoid medical treatment for that reason, because it is not worth getting scrutinized and harassed or put in danger just to go to the doctor for something that may be small. We already have to outweigh our everyday life in everything. And now we have to do that with healthcare.

—Alex

Transgender and gender-expansive persons experience the brunt of Fresno’s health crisis. As a marginalized population, they experience difficulty accessing healthcare and transgender healthcare. Transgender healthcare encompasses a wide range of services primarily focused on gender-affirming care and helping with medical gender transitioning if desired. This includes access to hormone replacement therapy; mental healthcare for transgender and gender-expansive individuals; reproductive healthcare; and gender-affirming surgeries, including vaginoplasty, phalloplasty, metoidioplasty, orchiectomy, hysterectomy, masculinizing chest surgery, breast augmentation, facial feminization or masculinization, and other gender-affirming medical procedures.

The Central Valley has few resources for the transgender and gender-expansive communities, especially regarding gender-affirming healthcare. As noted previously, no definitive procedure, treatment, or medication defines what it means to be transgender or gender-expansive; instead, it is up to the individual to decide what gender-affirming medical practices and procedures they want to pursue. Many within the transgender and gender-expansive communities opt out of medical gender transitioning. However, those who do want to access transgender healthcare in Fresno encounter several barriers. These barriers include a lack of information or training on transgender healthcare among primary care doctors and medical staff, discrimination and harassment by medical professionals, and being publicly exposed as transgender or gender-expansive by medical staff. Structural barriers also affect access to transgender healthcare in Fresno County. Few medical professionals provide transgender healthcare in the area, causing patients to travel considerable distances at their own cost. Insurance for transgender healthcare is an additional challenge, as many plans do not provide or have limited coverage. In addition, the limited access to affirming and supportive mental health therapists and pharmacists is an ongoing barrier to transgender healthcare in Fresno. The following sections detail the barriers affecting healthcare and transgender healthcare in Fresno.

Lack of Knowledge on Transgender Patients among Medical Practitioners and Staff

I feel like a lot of doctors don’t really know most things about transgender people.

—Carli

The first step in seeking non-emergency medical attention is meeting with a primary care physician or nurse practitioner. Navigating the healthcare system can be frustrating, especially for those whose health needs are dismissed or misdiagnosed due to racism, sexism, and/or ableism. Transgender and gender-expansive individuals are often forced to navigate a resistant medical system that is, at times, openly hostile to their needs [33]. Many of the participants in this study described encountering doctors, nurses, and medical staff with limited knowledge about transgender patients. Ninety percent of the participants surveyed said they had to educate their doctors about what it means to be transgender and/or gender expansive. Interview participants corroborated the survey results, as the majority of interviewees discussed having to educate doctors, nurses, and staff on their gender identity.

I definitely have had to educate my physicians and tell them, ‘Hey. So, I’m trans. I am not binary. I use they/them pronouns.’ That happens every time I step into a doctor’s office. I have to do it… Anytime I’ve been to the doctor, I’ve had to do that… It makes going to the doctor difficult.

—Kaede

Kaede’s commentary reveals the stress and exhaustion caused by the constant need to educate doctors, nurses, and staff about what it means to be transgender or gender-expansive. All healthcare providers must be competent in providing care. However, many do not receive training or feel qualified to provide this care. Johnston and Shearer’s [34] study on medical education and practitioner preparation for transgender and gender-expansive care found that only forty-five percent had prior education on the care of transgender patients. Far fewer had the specific training, especially around gender-affirming care, that practitioners need to feel confident and comfortable prescribing hormonal or surgical therapy to transgender patients. In a similar study by Rowan et al. [35], more than forty percent of respondents said they would need further education and training about transgender healthcare needs to provide appropriate healthcare. Kaede’s frustration regarding their experience with doctors correlates with previous research showing that many transgender and gender-expansive individuals become frustrated by teaching their healthcare providers about transgender healthcare. Many interview participants described feeling anxious about seeing a doctor because they knew they would again have to explain their gender identity. Despite explaining it previously, several described repeating this experience every time they had an appointment. While some participants described educating doctors, nurses, and medical staff about their gender identity as a positive knowledge exchange, many described experiencing confusion and intrusive or aggressive questioning by doctors, nurses, and staff.

When I was homeless and went to the hospital because something was wrong, and the ER was my only healthcare provider, they spent over an hour trying to figure who I was, even though I gave them my ID and told them my name… They asked really intrusive questions about my genitalia that had nothing to do with why I was there. I was not there because I had an STD or a UTI. I was there for something else. So why ask about it? But they kept on asking. They asked if I got bottom surgery, if I had a penis, did I get a hysterectomy. They finally asked, ‘What are you?’ Like I was an alien or something.

—Alex

Once the nurse knew I was transgender, she kept asking if I had, like, a penis or not, and asking if I had plans to get surgery. Nothing to do with why I was there. She admitted that she was only asking me because she was curious and wanted to know. She was nice, but those questions can be really triggering and painful for trans people. It’s a very private and personal thing, something that you don’t want to talk about unless you need to. Those types of interactions really scare you from going to a doctor. It’s those interactions that have really put me off seeing the doctor.

—Holden

The results from the survey and the interviews connect to previous research on transgender healthcare experiences. The stress of constantly having to educate one’s doctor or the anxiety that comes with having to reveal one is transgender to every new medical practitioner contributes to patients avoiding medical care. In Fresno County, this is compounded by the limited availability of medical practitioners, let alone practitioners who have the necessary training to successfully and appropriately practice with transgender patients. There are just fewer options in medical care due to the lower number of practitioners in the area.

Limited Availability of Gender-Affirming Healthcare

I think it’s important for people to know that in Fresno, you have few places to go to find transgender healthcare.

—Alex

Interview participants identified the limited availability of and access to gender-affirming healthcare as major challenges for transgender and gender-expansive persons in Fresno. Participants described seeing their primary care physicians and asking about starting hormone replacement therapy, which is often considered the first step to medical gender transitioning, only to be told that their doctors knew nothing about gender-affirming healthcare and they would need to be referred to an outside specialist. For some of the participants, this meant trying to find a medical professional in Fresno within their insurance network who was knowledgeable about gender-affirming healthcare.

Well, we only have one doctor. So that’s a problem.

—Jack

It’s been a nightmare trying to get steady treatment. I first had insurance through my mom and they denied everything. I tried to reestablish care a couple of times, and it’s really expensive outside of Planned Parenthood and, you know, if you don’t have good insurance. The blood work and everything’s ridiculous. It got me really depressed.

—Shae

“Only one doctor” was a phrase repeated over and over by those interviewed. The phrase referred to the idea that within all of Fresno County, only one well-known doctor provides gender-affirming healthcare: Dr. Julie Nicole at Central Valley OB/GYN in Clovis. Dr. Julie Nicole has a long and well-respected history within the local transgender and gender-expansive communities, not only as a practitioner who treats transgender and gender-expansive clients but also as an advocate for more gender-affirming care in the Central Valley. Trans-E-Motion most often refers community members to her for gender-affirming care. While it should be noted that there are other medical professionals and institutions in Fresno that provide some gender-affirming healthcare services, such as Kaiser Permanente and the University of California, San Francisco Fresno, the sentiment speaks to the overall perception that access to comprehensive gender-affirming healthcare is severely limited. The two most common sources through which survey and interview participants reported receiving gender-affirming healthcare were the Planned Parenthood offices in Fresno and Madera, and Dr. Julie Nicole at Central Valley OB/GYN in Clovis. Both of these offices are in high demand, making it challenging to get an appointment. Maintaining appointments and keeping consistent care becomes more difficult for those with unsteady employment or a frequently changing insurance status. Without steady care, some participants described experiencing greater gender dysphoria, which led them to experience further stress and mental anguish.

As noted above, Fresno County serves many outside of the county limits. This is especially true in the case of gender-affirming care. Populations in the neighboring and more rural counties of Tulare, Madera, Mariposa, and Merced rely on Fresno for gender-affirming care. For example, in Visalia, the county seat of Tulare County and its largest city (population 141,384), there is currently no Planned Parenthood office and only one family care practitioner publicly known to accept transgender and gender-affirming patients. The counties of Madera and Mariposa currently have no known medical practitioners who offer gender-affirming care. Merced County does have some access to gender-affirming care through the University of California, Merced; however, it is not accessible to those outside the university. This means that several patients from outside of Fresno County need gender-affirming care and face the limited availability of practitioners.

Fresno is not limited only to practitioners that provide gender-affirming healthcare, but also in terms of what specific gender-affirming healthcare can be provided. Those who can access gender-affirming healthcare practitioners in Fresno will most likely have access to hormone replacement therapy. Planned Parenthood provides low-cost to no-cost hormone replacement therapy and reproductive healthcare for those without insurance or on Medicaid. Dr. Julie Nicole provides hormone replacement therapy, transgender-inclusive reproductive healthcare, and post-operation care for those undertaking gender-affirming surgeries. Other gender-affirming healthcare procedures, such as gender-affirming surgeries, are not available.

If you don’t have the money, the support, resources, then getting the care you need becomes impossible. I know many who have to travel to the Bay Area or L.A. to get healthcare.

—Carli

Almost thirty percent of those surveyed said they had to travel outside of Fresno for gender-affirming healthcare not provided. This lack of safe and affirming care for transgender people in rural areas can often force transgender and gender-expansive individuals to travel long distances to larger metro areas with more resources. However, this is expensive and time-consuming. The costs associated with travel and lack of access to transportation make gender-affirming surgery inaccessible for many. Of those outside Fresno, thirty-one percent surveyed stated they had to travel more than fifty miles. The travel and accommodation necessary to obtain transgender healthcare not provided in Fresno, create additional costs, especially for gender-affirming surgeries, which usually require multiple consultations and preparation visits and extra hotel or hospital accommodation post-surgery. Patients sometimes need to pay for private nurses or stay in a private hospital for their recovery. Many rely heavily on family and friends for financial and emotional support and care. These costs are not usually covered by insurance and may not qualify for sick leave. Faced with these financial and logistical obstacles, many do not have the option to pursue medical gender transitioning.

Refusal of Care and Discrimination by Practitioners

Once they [the doctor and medical staff] learned about me… The doctor said, ‘Well, I don’t know how to treat you.’ I was like, ‘Well, what do you mean you don’t know how to treat me? I have a cold.’ I was there because I was sick. I had to find another doctor after that.

—Amanda

There was another doctor who flat out said, ‘I don’t feel comfortable treating you because you’re trans.’ And then I was like, that’s weird, because sometimes I would go to the clinic because I have carpal tunnel in both hands and they’re very shaky. I can’t give myself a shot all the time without hurting myself.

—Alex

Twenty-two percent of those surveyed discussed being refused care by their primary care doctor because of their gender identity. Several participants discussed being refused medical care by doctors and nurses. This refusal always came after the participants revealed to their primary care physicians that they were transgender or gender-expansive.

Once they [medical practitioners] know you are trans, they don’t see anything else… I don’t know. It kind of makes me question if I’m getting the right care or what I need. You know? Am I really being treated in all areas?

—Shae

Shae’s comment was echoed by several participants describing their experiences seeking healthcare in Fresno. Some interview participants described their health concerns as being dismissed or underdiagnosed and not receiving comprehensive healthcare once their transgender or gender-expansive status was revealed. These experiences made participants reluctant to seek further medical care.

His words were, ‘I’ve treated all kinds of patients. I’ve treated patients who are sexually attracted to animals.’ And then he smiled and said, ‘I can fix you.’ So, and I was, like, so confused. And I was like, what does that have to do with me?

—Alex

In addition to experiencing doctors or nurses dismissing their health concerns, twenty-two percent of those surveyed claimed doctors or nurses mistreated them because they were transgender or gender-expansive. One specific way providers are ignorant and discriminatory in treating transgender and gender-expansive individuals is through a phenomenon dubbed “trans broken arm syndrome” [36,37]. This occurs when an individual seeks care, and no matter the patient’s health concern, the provider blames the problem on the patient’s gender identity. Those interviewed discussed mistreatment ranging from being misgendered and given strange looks by medical practitioners and staff to being directly compared to sex offenders. These experiences left participants feeling degraded and objectified.

There’s a lot of obstacles and barriers for us, and we do face a lot of discrimination. And part of me feels like the fear that you’re going to be discriminated against prevents people from asking. When I go to a new medical provider, I always dress extra femme [feminine]. I don’t like dressing feminine at all. I do it because I am afraid that I will be misgendered. Like, that is the first thing in my head whenever I go to a doctor. I’m trying to game the system. What makes it worse is that my name and gender marker is female. I show them my ID; it clearly shows my name and that I am a woman. Yet, I still have gotten misgendered by doctors. I’ve had front desk people call me by the wrong name. It makes me super-paranoid and stressed. I’m not alone in this. We shouldn’t have to worry about making people see us for who we are.

—Carli

Front desk staff and nurses’ misgendering of patients and publicly revealing them to be transgender were common occurrences mentioned by those interviewed. Interviewees described having their birth names, also known as dead names, called out by front desk staff in the waiting room despite telling them their preferred names when filling out paperwork. Part of this confusion and subsequent outing by medical staff can be attributed to identification and insurance documentation not matching the patient’s preferred name and gender identity. Having this documentation changed is a financial and legal process that can last for several months and can be difficult for minors and those who are low-income or without stable residency. However, even when their documentation matched their name and gender identity, some of the interviewed participants were misgendered. Much of the misgendering had to do with medical staff and practitioners’ biased conceptions of the person’s gender.

I went to Clovis Community Hospital. I had a pretty intense UTI, which is fairly common with trans women who tuck. I got signed in and everything. This was after I had my legal name and gender changed. And they gave me my wristband. The name was correct, but the gender was wrong…So, when I went back to the front desk, I let them know. I said, “Hey, so, you have my information wrong.”

And the nurse, the first thing out of her mouth was, ‘Well, have you had the surgery?’ Flat out, she said, ‘Did you have the surgery?’ And I said, ‘What surgery is that? What are you trying to say?’ Because I’m not going to talk about this in the waiting room with everyone watching. And she got very aggressive with me. She would not help me. And I said, ‘I need to speak to somebody else; this needs to be fixed.’ And so, finally, somebody else came in. And they put me back in the waiting room. They didn’t even help me.

—Luna

Asking whether Luna had undergone gender-affirmation surgery was irrelevant to having the correct gender marker on her medical wristband. Luna provided the nurse with documentation that showed her legal name and gender identity. The nurse purposely marked Luna as male because of perceived beliefs about Luna’s gender identity. Asking to correct it only led to further discrimination and harassment, with the nurse publicly outing Luna as transgender in the waiting room. Being publicly outed as transgender or gender-expansive causes stress and embarrassment and can lead to further harassment or possible violence outside of the medical establishment.

Harmful stereotypes and biases about transgender and gender-expansive individuals not only contribute to ongoing anti-trans violence but can also impact medical practitioners’ care and interactions with transgender and gender-expansive patients. Several participants described medical professionals’ assumptions that they engaged in drug use and sex work.

There is so much stigma and stereotypes around being transgender. People assume about your life. One time I went to the emergency room, Fresno Community Hospital. I had shingles. I am autoimmune and I got it really bad. I was really sick. I had shingles all over my body. The doctor was not very helpful. It seemed like he did not want to treat me. He never blatantly said it, but he said—basically inferred—that I was a sex worker. And while I am pro-sex work and sex workers’ rights, I am not a sex worker. I found that incredibly offensive. It’s a stereotype that is often thrown at trans people. That we are all sex workers. And yes, some trans people do engage in sex work. Not everyone does.

So, after he accused me of being a sex worker, he had another doctor come in. And while he was there, he told me that the only way I could have shingles, this-that, at my age, which was like, three years ago, was that I was HIV positive. And he told me flat out. He’s like, you’re HIV positive. He never tested me. He just said I was HIV positive, supposedly by looking at me…

I’m like, no, I’m not. And not that that’s a stigma anymore as much, but it was very rude to assume this just because I am a trans woman. And there was no convincing him otherwise until the tests came back. I never saw him again. It was a different doctor that gave me my results. Because, clearly, he was not having it. He refused to treat me. I was still sick with shingles.

—Luna

Assumptions about lifestyle and sexual health feed into false narratives of transgender and gender-expansive people being deviant or dangerous. These stereotypes contribute to violence and discrimination, adding further trauma to a marginalized population. In Luna’s case, these assumptions meant she was not treated for her illness, and she became reluctant to seek further medical help. Luna suffered with shingles for months because of this experience. These experiences of harassment and discrimination when seeking medical attention add to the daily experience of being objectified and rejected that transgender and gender-expansive people must navigate daily. This can leave individuals feeling further marginalized and fearful of seeking help.

Additional Barriers to Transgender Healthcare: Insurance, Therapy, and Pharmacy

While the majority of this study focuses on interactions with medical practitioners and providers, transgender and gender-expansive persons identified several obstacles outside of medical establishments when seeking gender-affirming care. Insurance, pharmacy, and therapy were all described as barriers to gender-affirming healthcare in Fresno County. All three are necessary for gender-affirming healthcare.

Insurance

Of those surveyed, seventeen point four percent reported not having insurance coverage. Of those with insurance coverage, fifty-three point nine stated that their insurance came from their employer, twenty point six percent bought directly, five point two percent were on Medicare, and eighteen point one percent were on Medi-Cal. Federal and state laws prohibit most public and private health plans from discrimination based on gender identity and presentation. Most insurances are banned from automatic or categorical exclusions of gender-affirming care, including medical transitioning procedures. Despite these provisions, access to coverage can be difficult to obtain. The amount of documentation needed for gender-affirming procedures varies depending on the insurance. Getting the name and gender on the insurance card to match the patient’s identity can also be a long and sometimes arduous process. The amount of documentation and time required for referrals can add further stress and barriers for those seeking transgender healthcare. An additional challenge is obtaining steady insurance, especially when dealing with economic or social instability. The lack of insurance speaks to the larger economic and social barriers transgender and gender-expansive individuals experience.

Honestly, it’s easier without insurance because then you can go to Planned Parenthood. When you have insurance, it’s, like, a bigger pain in the ass, I found.

—Shae

I am still dealing with my insurance over having my correct name on it. And it’s, like, I would call one day and someone would tell me some information. And the next day somebody else would tell me something completely different. And so eventually I started documenting all the different things that they told me to do. They told me to go to different websites to upload different documents.

—Carli

Many individuals experience difficulty navigating insurance coverage when seeking healthcare. For transgender and gender-expansive individuals, the situation can feel impossible, as insurance may not cover all aspects of gender-expansive healthcare. Finding out what is covered and not covered can be challenging, as the information may not be easily accessible on the company’s website or through speaking with a representative. Determining the available coverage usually requires referral letters from specialists, mental health therapists, and medical practitioners diagnosing the patient with gender dysphoria. Getting these referral letters can be challenging when they are outside of a person’s insurance coverage. Collecting documents, calling insurance reps, and meeting with specialists for a diagnosis is time-consuming and costly. The situation becomes ever more frustrating without stable or consistent insurance. More support and guidance are needed in navigating insurance and insurance-free gender-affirming healthcare options.

Mental Health

Seeking mental healthcare from a mental health provider can be incredibly beneficial for transgender and gender-expansive individuals and can provide needed confirmation, support, and guidance. Eighty-four point three percent of those surveyed reported barriers in seeking and using mental health services in Fresno. Transgender and gender-expansive people are at a higher risk of mental health concerns [38]. Recent research shows that transgender adults are more than three times as likely to consider suicide and almost six times more likely to have attempted suicide than their cisgender peers [39]. Transgender and gender-expansive individuals are four times more likely than cisgender adults to experience serious psychological distress, and more than three times as likely to have emotional distress that interferes with their daily life, relationships, and work performance. Lack of access to gender-affirming care can increase the adverse mental health outcomes for transgender and gender-expansive individuals. A recent study by Seelman et al. [40] shows that transgender persons who delayed care out of fear of discrimination not only had worse general health but also experienced negative mental health impacts, with three times greater odds of experiencing depression, almost three times greater odds of suicidal thoughts, and—most concerning—three times greater odds of suicide attempts.

The need for a referral letter from a therapist, counselor, or mental health provider to access certain gender-affirming care treatments and procedures is an added stress for transgender and gender-expansive patients. For several decades, any kind of transgender healthcare or legal name change was only accessible with approval from a mental health provider and a diagnosis of gender dysphoria. Referral letters are no longer required for a legal name change or to start hormone replacement therapy. However, referral letters from a mental health provider are still required for insurance coverage of gender-affirming procedures that involve surgery. Some surgeons have been able to forgo referral letters by practicing informed consent with patients, in which surgeons provide information about the surgery that includes methodology, duration, potential risks, and aftercare. Patients are typically required to sign a legal release form that confirms their understanding of the procedure and its permanent nature, and that they are undergoing the procedure at their own responsibility. Even if a surgeon does practice informed consent, referral letters are often required for insurances, including Medi-Cal and Medicare, to cover the procedure.

Participants described finding a therapist in Fresno who would provide letters for gender-affirming surgery as a significant challenge, as transgender-inclusive therapists are limited. Some interview participants described setting up appointments with therapists only to be told that they do not provide letters or would not work with them. The therapists indicated they did not have training in transgender mental healthcare and therefore felt unqualified. Two interview participants described being refused letters because their therapists believed they did not need gender-affirming surgery.

When I asked for my letter, my therapist said, “Well, I’ll see what I can do, but I don’t think insurance is going to pay for it.”

That’s not your job to say whether you think they are or not. It’s your job to evaluate me, assess me, document whatever dysphoria or issues I have, say whether or not I’m a candidate for it. Even if you don’t think my dysphoria’s that bad, can I handle the surgery?

I finally just said, “Forget it. I’m not going to come in. You already have it in your mind you don’t want me to have it. You already have it in your mind that I don’t need it, so you don’t want to write the letter.”

—Amanda

The experience of being denied a letter can feel like an erasure or invalidation of a person’s gender identity. There is also a significant cost in accessing referral letters, as some mental health providers require several visits before a letter is written. Insurance coverage for mental healthcare services can be limited depending on the provider. Several interview participants described paying for their therapy appointments out of pocket, with prices ranging from seventy dollars to one hundred and fifty dollars per one-hour visit. Therapists may have an additional charge for letters, with the prices ranging from the cost of a therapy session (seventy to one hundred dollars) to more than three hundred dollars. The limited number of therapists who offer referral letters, combined with the high cost of therapy, presents another hurdle to accessing transgender healthcare.

Pharmacy

One surprising finding from the interview portion of this study was that participants faced barriers and discrimination when trying to obtain their medication at local Fresno pharmacies. The pharmacy was overlooked in the survey design, and there were no specific questions on experiences with pharmacies or pharmacists. However, this information did come up in the interviews when discussing barriers to transgender healthcare in Fresno. Going to the pharmacy for hormone medication is usually one of the first steps to medically transitioning. Discrimination and difficulties obtaining hormones from pharmacists were brought up by several of the interviewees. Even when patients had a written doctor’s note, pharmacists would challenge the prescription by changing the dosage or refusing to fill it. This often happens for individuals needing to fill a prescription for testosterone, a controlled substance.

Pharmacists can be weird towards us, I’ve noticed. I’ve had a pharmacist change my dosing on my hormones. Like, I’m on point three every week. When you take hormones it’s very specific because if you overdo it or underdo it your estrogen can rise. It can cause health problems. The pharmacist took it upon herself to change my dose to point three every three weeks. I kind of freaked out. I had a meltdown. It was about two, three years ago. I was like, ‘You guys can’t do this. You can’t just mess with my medication.’ She just seemed confused. I called the upper management and they had to talk to her. My dad picks up my hormones now. I don’t really deal with them. I don’t want to. I call them, but that’s as far as I’ll go. He picks up his meds and he just go ahead and picks up mine at the same time.

—Jack

I’ve had issues at pharmacies. I’ve tried to go through Target. I was maybe five or six months on testosterone, and the pharmacist told me, ‘I’ll only fill your prescription if I agree with the doctor’s decision.’ I’m like, what the hell?… So, that’s another scary thing, honestly, is, like, going to the pharmacy. You never know what will happen.

—Shae

Pharmacists’ refusal to fill a prescription or alter the dosage from what the doctor prescribed is another component of the accumulating stress many interviewees experienced when seeking transgender healthcare. For Jack and Shae, the experience made them not want to return. In addition to their prescriptions being denied, some participants discussed being publicly misgendered or misnamed by pharmacists and having their identity questioned, which adds further harm.

Pharmacists are awful here. I had one pharmacist in Fresno that refused to gender me properly. And then even when I updated it, he just wouldn’t help me at all. He would have somebody else help me. And that’s like a regular thing, honestly, with a lot of trans folks in pharmacies is a lot of misgendering. I’ve had them find my dead name in the file and use that… even though my name was legally changed. You know? Call it over the intercom. Which is awful and hurtful.

—Luna

These experiences indicate the need to address transgender healthcare comprehensively. Rather than focusing only on what happens inside a doctor’s office, efforts must include all institutions that transgender and gender-expansive individuals must navigate to seek care. Training on transgender-affirming and -inclusive care is especially needed in public-facing medical institutions like pharmacies, where patients’ confidentiality may be jeopardized.

5. Conclusions and Future Research

“One thing I’d want people to know? … That our medical needs are valid, that we deserve healthcare. That’s the biggest thing. And then that we’re just normal people. We’re no different than anyone else.”

—Amanda

Access to affordable and affirmative healthcare is a right for every person. However, several logistical barriers make access to transgender healthcare extremely challenging in Fresno County. The limited numbers of trained transgender healthcare and mental healthcare providers and practitioners mean fewer access and options. Discrimination and harassment from providers can lead to more trauma and the avoidance of healthcare for the transgender and gender-expansive communities. This survey and interviews show that healthcare is interwoven with other basic needs to live a fulfilled and productive life. Most importantly, healthcare is fundamental to mental health and well-being for transgender and gender-expansive populations.

Creating an affirming space can be a straightforward process. The first step is training front desk staff to respect pronouns and patient privacy. Creating gender-inclusive forms and a policy on preferred names can go a long way toward creating a more accepting environment. As the transgender and gender-expansive communities continue to live in Fresno or travel to Fresno for healthcare needs, there is a greater need for more training on gender-inclusive healthcare and transgender healthcare. Medical and mental healthcare providers should engage in opportunities for training or service support to better educate themselves and their teams. This will require collaboration between civil society organizations and medical practitioners. Research from this study was used in advocacy efforts to provide financial and institutional resources to train practitioners and provide gender-affirming care. The “Advancing Excellence in LGBTQQ+ Health” Virtual Symposium was created by the University of California, San Francisco Fresno Medical School faculty and practitioners, including Dr. Julie Nicole, to build LGBTQQ+-inclusive healthcare in the Central Valley. Part of this symposium was dedicated to training local family practitioners and pediatricians in providing hormone replacement therapy and gender-affirming care procedures. Currently, Trans-E-Motion offers LGBTQ+ inclusivity training to front-desk medical staff in local hospitals and offices. Findings in this study also assisted Trans-E-Motion in applying for grants to create free gender-affirming care practitioner training aimed at primary care doctors, nurses, and mental health providers. Trans-E-Motion received grant funding in July 2023 and August 2024.

This study was meant to be an initial step in assessing the major barriers and obstacles to accessing gender-affirming healthcare in Fresno County. While the research documented key barriers to healthcare and gender-affirming healthcare and brought forward community voices on this issue, much more research needs to be carried out. First and foremost, this study was limited regarding access and accessibility to community participation. During the study, COVID-19 decreased the possibility of going directly to community gathering spaces such as community centers, LGBTQ+ bars or social spaces, and public events. Only those who could access the information about the survey and interviews online and had the required technology (cellphones, personal computers, iPads, digital notebooks, etc.) and reliable internet or cellphone service could participate. Others may not have been aware of the study or could not participate. The survey and interviews were conducted in English, excluding a significant population of Spanish-only speakers or those with Spanish as their first language from participating. These limitations ultimately impact the results and findings, providing a less-than-comprehensive understanding of the barriers to healthcare. This is especially true in understanding the intersections of race, gender identity, and sexual orientation regarding how Indigenous and persons of color experience healthcare barriers. This study also does not look into the experiences that undocumented transgender individuals have when accessing healthcare. Immigration status was not collected in the survey or the interviews. Fresno County has an estimated 85,000 undocumented people living in the area, most Spanish-speaking (Immigrant Fresno). A future study should not only be multi-lingual but should have more of a focus on how race and immigration status affect access to healthcare and gender-affirming healthcare.

Despite the limitations, this study is a promising first step in documenting and understanding the barriers to healthcare and gender-affirming healthcare for transgender and gender-expansive communities in Fresno County. Much of what was documented correlates with the findings of other studies, but it also provides specific insight into the particular stressors happening in Fresno. More research is needed to tease apart the intersections of race and immigration and how these impact marginalized transgender and gender-expansive Indigenous persons and communities of color. What is revealed in this research is how an area already impacted by healthcare deficiencies creates an increasingly stressful and harmful environment for marginalized transgender and gender-expansive individuals to navigate to receive critical healthcare. By focusing on the most underserved, counties and cities like Fresno can advocate for these stressed populations while addressing larger systemic issues impacting the total population’s health. Community-based research like this study is a valuable contribution in advocacy, and more research is needed across the country in places similar to Fresno, which have far fewer resources.