Gender Equity and Transgender Clinic

by Sarah Kinkade

Growing up female, Avery Gragg always felt better wearing masculine clothing. By the time he turned 15, he knew he was transgender, cut his hair short and wore even more clothing designed for men. He began wearing a “binder” around his chest to hide feminine, physical distinctions.

“Most people didn’t really know or care about how I dressed, but then I came out trans,” he said. “I knew back then I was transgender, but my mom wanted me to wait until I was little older before I did anything about it – as far as hormones go.”

According to research from the National Institutes for Health, members of the LGBTQIA community seek care less often due to a variety of socioeconomic factors, discrimination or simply because of fear or feeling not accepted by the medical community. Patients in these communities typically participate in fewer preventive health care measures, like regular doctor appointments, and are at higher risk for mental health concerns.

“Transgender” is an umbrella term used to describe people whose gender identity and/or gender expression differ based on the sex they were assigned at birth. Transgender people have diverse sexual orientations, gender expressions and gender identities, and transgender identities do not depend on physical appearance or medical procedures.

Growing up in a small town in central Illinois, Gragg didn’t talk about his experiences much, but once he moved to St. Louis for college three years ago, he started to open up. It was then he also started taking hormone therapy, though he continued to struggle with gender dysphoria – something many LGBQTIA people experience. Gragg recalls how difficult it was to find a health care provider for hormone therapy.

Hoping to alleviate the challenges often faced by those in the LGBTQIA community, SIU Medicine’s Center for Family Medicine in Springfield launched a Gender Equity and Transgender Clinic to serve patients in central Illinois. Led by Careyana Brenham, MD, and Priyanka Bhandari, MD, the multidisciplinary team offers comprehensive care and referrals to other SIU specialists.

“We saw a need in the community. There was a lack of access and we knew some members in the community were not seeking preventive care, or sometimes care at all,” said Dr. Brenham. “We are offering preventive health care as well as other services in a primary care setting with a multidisciplinary team approach. All of our patients are offered a visit with a behavioral health consultant who is a social worker and great at providing care to the LGBTQIA community.”

Many patients are seeking hormone-affirming management with either masculinizing or feminizing hormones. This is seldom provided in a primary care setting; patients have previously received this care, when possible, from Planned Parenthood or SIU Medicine’s Division of Endocrinology.

However, those settings do not have mental health services incorporated into their clinics, and patients are often required to seek a mental health provider before being prescribed hormones,” Brenham says.  “It was an additional barrier to care for some of our patients.”

The Gender Equity and Transgender Clinic offers hormone therapy and mental health care within the same setting. The team also offers injection training for patients to give their own hormone injections.

“I didn’t have a way to present as a masculine person other than my hair so the binder and testosterone have helped so much,” Gragg said. “Think of dysphoria as putting on clothes that you know don’t look right on you because they don’t fit, but you can’t take them off. Like a dress is too tight and the zipper is stuck and no one can undo the zipper for you. Now, I have a beard and chest hair, which makes it much easier to identify as a trans guy.”

Throughout the opening of the clinic, SIU Medicine worked in partnership with the Phoenix Center, which supports central Illinois’ LGBTQIA community.

“They have been great partners with us to get this clinic going and provide education and support,” Dr. Brenham said. “The Phoenix Center often refers patient to us and we can send patients to them for support groups and to be involved in the community.

“The staff at the Phoenix Center also helped provide education to our team to help us plan for working with the transgender community and help us determine what services they may need here,” Brenham continued. “It has been a great working relationship that we plan to continue building.”

During the pandemic, Gragg moved back home and started seeing Dr. Brenham for primary care, as well as his hormone therapy. Dr. Brenham recently referred him to see Nicole Sommer, MD, professor at the SIU Institute for Plastic Surgery, to consider top surgery. Dr. Brenham has referred several transgender patients to SIU Medicine’s plastic surgery team for top surgery, a reconstructive surgery performed on the chest for individuals who wish to alter their chest size, shape or overall appearance.

“We also provide referral services for surgical-affirming care and can provide written documentation for insurance coverage for these procedures,” said Brenham.

“I’ve had a good experience with SIU and Dr. Brenham,” Gragg said. “It’s nerve-wracking to walk in and not know how people are going to react – whether or not they are insincere if they say the right words. The struggle is also compounded by finding somewhere insurance is accepted. Each plan is particular on the phrasing on what gets approved, and money is always an issue. SIU has done a great job of working with insurance.”

Dr. Sommer and others follow guidelines from the World Professional Association for Transgender Health, which provides standards of care to meet the diverse health care needs of transsexual, transgender and gender-nonconforming people.

SIU offers male-to-female and female-to-male top surgery. Male to female top surgery is breast augmentation with implants or with a patient’s own fat. This surgery is ideal for patients who do not develop breasts while on hormone treatment. Female to male top surgery is the removal of natural breasts, and then the tightening of skin and repositioning and downsizing of areola.

“To make sure patients are prepared and committed to surgery, I discuss their options and like to start by finding out if they have plateaued in regard to changes from the hormone treatment first,” said Dr. Sommer. “We also make sure they have seen a psychologist or psychiatrist in regards to gender dysphoria.”

“Once I have my surgery, I think it will really help with my mental state and body dysphoria, especially with my chest,” Gragg said. “I will be so relieved.”