JoAnne Keatley: Since 1995 Dr. Zevin has served as Medical Director at the San Francisco Department of Public Health's Tom Waddell Health Center and Homeless Programs. He has also led the Center of HIV and Substance Abuse Teams. Dr. Zevin is a Certified Diplomat in Internal Medicine, and is also an Assistant Clinical Professor at the UCSF School of Medicine. During his Residency in Primary Care, Internal Medicine at the Cambridge Hospital, Dr. Zevin held appointments as Chair, Joint Labor and Management Committee and Coordinator, Residence Journal Club Conference. It is my pleasure to introduce Dr. Barry Zevin.

Barry Zevin: [applause] Thank you very much. This is a huge group, and I'm really amazed and pleased that the level of interest in this topic is here. I think that when we first started talking about the transgender community as a medically underserved community -- about seven or eight years ago -- I think I can safely say that the levels of interest and engagement around that topic was not comparable to what it is now. And it really is -- it's heartwarming, actually -- that the level of interest is at this level now. Because it is something that is important when we look at treating each other as human beings, and respecting each other's humanity.

What I want to do today is just talk a little bit about Transgender Tuesdays, which is a four-hour per week primary care clinic providing multidisciplinary health care for self-defined transgender people at Tom Waddell. Tom Waddell is a large community health center specifically serving homeless people, serving other severely under-served populations, and working along a multi-disciplinary model of heath care.

We planned Transgender Tuesdays with input from a variety of communities: transgendered people, advocates, consumers, and providers. And I think that was very important in our being able to start a clinic and have the support of the community. Eligibility to be seen in Transgender Tuesdays is open to people who self-define as a transgender person, and San Francisco residents who are poor or uninsured receive free or sliding scale care.

Since it started we've seen over 700 unduplicated people. Many of them are still active patients, most of them are still active patients. And we're continuing to see, to follow people, and in fact, we continue to see people who we saw years ago, who've come back to see us after an absence of years.

What I'm gonna talk about today is a snapshot of some information that we've gathered retrospectively on patients who are active with our clinic in the past year. The information I'm gonna tell you has all of the faults of any information that was gathered retrospectively. It depends on information that was not gathered for the purpose of doing research or making a presentation like this. And understanding that is important. I make no claims to the statistical significance of any of this, and just submit it as interesting information that can help understand the health needs and the community of transgender people in San Francisco.

We attempted to review approximately 296 of the charts of active patients. We found that of the active patients -- there's a misprint -- maybe not. 82 percent of the patients self-defined as male to female, 18 percent self-defined as female to male. We've seen a steady increase in the FTM patients who we've seen, from very few in the beginning to increasing numbers. And I think that I expect that to continue to increase. Looking at ethnicity there's a diverse population. 40 percent are European American or white, 30 percent are Hispanic, 13 percent are African-American, 10 percent Asian-Pacific Islander, 4 percent Native American and 3 percent mixed.

That's somewhat different than the demographics of our health center as a whole, in which, in terms of the demographics of our health center as a whole we see a higher proportion of African-American and a lower proportion of API patients. I think also what is interesting and informative when you think about creating health services, is in the first year we had something like 8 percent Latino/Latina population. We knew that that population was out there. We knew that was a population who had a health risk, but we didn't have credibility, we didn't have outreach, and we didn't see the people. Each year since then we've seen a higher proportion of that population by creating services in which most of our service providers are bilingual and many are bicultural-bilingual. And by enhancing relationships with outreach and community organizations, now we've been able to have an excellent amount of relationship with that community, and are providing health care for that community.

Age range, the -- as you can see, there's a wide range. We don't focus on youth, but we see some youth. Looking at the numbers we also are not seeing elders; and I know that the elders are out there, and I worry about whether they're getting health care at all. We looked at country of origin and found that overall, 63 percent were US born and 37 percent were foreign born. Now interestingly, if we look at the community as a whole that the Community Health Network, which we're a part of, provides care to, those numbers are very similar. And I think that we're seeing that kind of cross-section. More of our MTF patients are foreign-born then our FTM patients, and it may point to even greater amounts of discrimination, greater amounts of oppression in FTM communities in foreign-born than in other populations.

Our health center mainly does health care for the homeless. Our initial reason for establishing care for transgender people is we were seeing many homeless transgender people. We were seeing many transgender people who were in SRO's or completely homeless, and who were not getting medical care, or who reported very appalling stories of discrimination in medical settings. And we expected to see that population when we started. I think what we didn't count on was the level of non-access to care in all populations throughout San Francisco. And that in fact we have a very mixed population. In total 13 percent in a snapshot were completely homeless in shelters or on the street. Another 32 percent were in SRO minimal kind of housing.

On the other hand 48 percent lived with a roommate or a partner in an apartment. So a fairly mixed picture. It also is something that is a worry for me -- that we're not seeing the homeless, least-connected population, which we have originally and continue to target. All the barriers to care that homeless people have are present, if not amplified, in the homeless transgender populations that we have. And I think that this information also leads us to the conclusion that we need more outreach and more work with that homeless and SRO population.

Certainly looking at the numbers we're seeing less homeless FTMs and less FTMs who are living in SRO's. I know that the numbers are not zero, and it concerns me again. Is that a population we're just not seeing because it's an even more hidden population and perhaps an even more oppressed population? Going on to the second page, or the back if you have this on a hand out -- and I apologize for not bringing enough. The health risks -- we looked at injection drug use and saw that 32 percent of our patients had presently or in the past used injection drugs excluding hormones. 32 percent had exposure to injected, illicit drugs. That's kind of an overwhelming number and that's something that we need to be very aware of in terms of health risk.

I apologize because I was not able to get the information beforehand about how many of our transgender patients used injected hormones outside of conventional medical settings. We have actually gathered some of that data. And the numbers are -- hover around 50 percent in both FTM and MTF populations -- having used injections in, outside of medical settings, or in medical settings in which there was no supervision. Again, that's significant because of the health risk related to injection drugs.

We looked at experience with sex work. And again I will say that this is retrospectively looking through charts, and that information was not necessarily always gathered on this particular area. Where it could be evaluated we found that 48 percent of these patients had engaged in sex work at some point or another. And the numbers were even higher for MTF's. There are health implications for that.

Of health issues known HIV positive, 18 percent of the people we're seeing are known to be HIV positive. We don't test every single person who comes in. We don't insist that people have tests. In the course of primary care, we do counsel people that it is wise to have HIV tests, and that is 18 percent overall. And I wasn't able to calculate the percentages. Clearly the percentage is higher in the MTF population and insubstantial in the FTM population that we are seeing. And I think you've heard more information about HIV prevalence in the communities from the Transgender Health Study, and that was done by the Department.

We have not consistently tested for hepatitis C, although we now have added hepatitis C counseling and testing to our intake. We have seen a 10 percent rate of hepatitis C in those -- looking across the board -- including -- that includes many people who their hepatitis C status in unknown. Looking at a rate of 32 percent for ever having used injection drugs, and rates of 50 percent or more in having used injectable hormones, I'm very concerned that that 10 percent is an underestimate for hepatitis C, and that we need to probably institute a widespread screening at least in the primary setting for hepatitis C.

We have looked at people who had a diagnosis of a mental health disorder and found a diagnosis present in 36 percent. We work primarily with poor people, people who are coming to us are primarily indigent. We did not expect to see many people able to afford surgery. In fact, of the people that we looked at 20 percent have had surgery of some kind. Ten percent have had breast augmentation, 3 percent have had vaginalplasty, 2 percent of all the patients have had mastectomy or chest procedures. That's something to be aware of. Because even if you're, as a health provider, not expecting that you'll to be knowledgeable about what is involved in health care when people are having surgical procedures, we've found we've needed to become knowledgeable about that.

Some other observations. Most patients have not received any primary health care prior to coming to Transgender Tuesdays. Most patients request and receive prescriptions for hormones from us after a psycho-social needs assessment and evaluation. And I'll say that that's generally a one-time only evaluation by a professional or non-professional staff. That is out of step with the Harry Benjamin Standards of Care, but what is available in terms of our resources, and to some extent what is the conclusion we've come to as far as what works for people's health.

The standard of care for prescribing hormones that we use is based on informed consent, assuring that our patients are knowledgeable about what is involved, what the risks are, what the benefits are of being prescribed hormones.

A very substantial number of our patients have had at least one suicide attempt. And I apologize because it says one suicide on the page, and that's obviously a word missing. In the first year, we systematically asked 69 of the patients whether they had ever attempted suicide and when asked directly, 48 percent said that they had had at least one suicide attempt. That is again, from a health point of view, very important information.

We know -- and again I since writing this at midnight I have revised it -- and we know of seven deaths in our Transgender Tuesdays, three by suicide, two from AIDS, one killed in a fire in an SRO Hotel, and one of unknown cause.

I'll make some conclusions: Transgender Tuesdays sees a very diverse group of self-defined transgender people. Many of these people have medical problems that were previously neglected. I realize I have virtually no time for questions, but I will take as many questions as I can in the three minutes that I have left.

Audience Member: I have a question about hormone treatment therapy. I work in a clinic, Castro Mission Health Center, in a sub-clinic of that, the Dimensions Clinic, which is a clinic for queer and questioning transgender, bisexual, lesbian youth. And we've had, we're working on a program, we're looking to Tom Waddell, to Lori, sort of working together in a collaborative to try to put together protocols especially for younger people. And we've got requests for hormone therapy to transgender just "all the way," but to transgender somewhat in between, as the patient would define where they want to be. And to some doctors that's been very disturbing. For others it's been okay. But I was wondering how you folks deal with it at Tom Waddell -- acknowledging that there is a spectrum that someone doesn't perceive themselves as over here or over here, but more over here. And how do you [titrate?] to follow the patient's request:

BZ: Thank you. I think that is a very important question. I think it's very important. As I said, we have defined that the definition of transgender is a self-defined one. We haven't imposed that. That's, I -- that is controversial. That is not something that is straightforward. That is not something that is particularly in the medical or scientific literature. The whole concept of being somewhere -- not a man or not a woman -- is something that, at least in the traditional literature on this, is something that many of the psychiatrists and surgeons who have dealt with it have had a lot of difficulty with.

Based on pragmatic experience many of our patients are in that. And the question about what do we do in terms of hormone therapy for those people is we listen very carefully to what it is that people want; and spend quite a lot of time as medical providers trying to understand and clarify what it is that people want. And then try to tailor a regimen to them that will make some sense in terms of what they want within the very great limitations of what is actually realistic in terms of what hormones can do or what other medical treatment can do.

I think that we spend a lot of time educating people on "this is realistic, this is not realistic." And a lot of time listening to the response to that, and trying to determine what can we really do? I will refer people who are interested to the protocols that we have developed which comment on some of those issues. And I will say, you know, a lot of it is a lot of unknowns. And it's being creative and understanding the medical aspects behind what we have.

Audience Member: My question is, once we start therapy, as patients we get concerned about side effects. And I haven't been able to get help from my own provider, because he has no clue about hormone therapy. I mean he must know something, but.... He is not my doctor just for transgender, he's my own medical provider. So where can I go? I don't have a job, so I can't go to a non-profit to find out. Am I taking too many, and I taking too little? And also the difference between pills and and injections. I know most doctors are reluctant to prescribe injections because of drug abuse.

BZ: Without answering that in detail, let me say that when we started Transgender Tuesdays one of our goals was to be able to gain and then disseminate information. As we've revised our protocols for hormones, I would say a larger and larger proportion of what is written there has to do with adverse effects, has to do with side effects, has to do with what to expect and how to manage those. And one thing I would say is that those protocols are available by giving me a call, or Dr. Lynette Martinez a call, at Tom Waddell Health Center; or giving Lori Kohler a call at the Family Health Center. And I think that there's nothing I like more, actually, than to get these protocols out to other physicians who are treating transgender people, but feel like they're doing it in the dark. And hopefully we can shed a little bit of light on that.

As far as the difference between parenteral hormones, injections and transdermal patches, and pills, particularly when it comes to estrogens, there are somewhat different effects metabolically in terms of how they're processed by the liver. In theory, all of the hormones are working on the same receptors. Clearly, like many other kinds of medicines, different particular types work better on different particular people. And it's hard to predict who it's gonna work on and who it's not. So again to some extent it's by trial and error, and to some extent the protocols are of some, I hope, somewhat educational to allow people to know what that is. So thank you. [applause]