Courtesy Cameron MacGregor
Cameron MacGregor, a student at Ithaca College who chose the school because of its reputation for serving the transgender community.
Henry Trettenbach was settling into summer vacation last year when he received an alarming Facebook message from his college physician. Annamaria Kontor had been abruptly fired from the Rochester Institute of Technology for prescribing hormone replacement therapy to transgender students.
“I was devastated,” says Trettenbach, now twenty, who began transitioning in high school. “I had just been denied health care.”
The Rochester Institute of Technology (RIT), located in upstate New York, is not alone in denying gender-affirming hormone therapy. Although hormone replacement therapy, or HRT, is relatively inexpensive and easy to prescribe and monitor, few colleges and universities in the United States cover it under their student health insurance—roughly 110 out of about 4,700—according to Campus Pride, a nonprofit that annually rates how well institutions of higher learning serve the needs of LGBTQ students. Even fewer offer HRT at their student health centers.
In December 2017, seven months after Kontor’s firing, an investigator with the New York State Division of Human Rights found that RIT likely discriminated against the pediatrician in terminating her. Earlier, an internal grievance review committee concluded that the Kontor’s supervisor failed to communicate her concerns about the doctor administering HRT. The committee also recommended the university “move as quickly as possible to offer hormone therapy to transgender students.”
“I was devastated. I had just been denied health care.”
RIT declined to comment on Kontor for this article. But in an email, spokesperson Bob Finnerty wrote: “Students can expect the Student Health Centers’ staff to be sensitive and responsive to Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex and Asexual students’ medical issues . . . . In terms of Hormone Replacement Therapy, we are currently reviewing services that exist on the RIT campus today.” Case managers at the student health center now refer transgender students seeking hormone therapy off campus to community providers “with expertise in this area,” officials said.
Kylie Blume, a transgender woman and a second-year medical student at the University of Minnesota Medical School, strongly believes HRT should be available at all college health centers.
“Deferring care is the same thing as delaying care, which isn’t a whole lot better than denying care,” says Blume in an interview. “We go to health care providers because we expect them to care for us. If someone says, ‘I’m not willing to learn how to do that,’ it feels like they’re not stepping up. You would never say that to someone with diabetes, which is way more complicated to treat than hormone care.”
Many transgender youth wait until college to come out, notes Blume, making this a critical period to connect with caring, informed medical providers. “If you get support and succeed in college, it sets you up for life.”
It’s been ten years since the American Medical Association passed a resolution stating that treatment for gender dysphoria—in which individuals experience significant distress with the sex and gender they were assigned at birth—is medically necessary. Other professional health organizations have followed suit, yet transgender Americans still have trouble accessing health care, particularly in some areas of the country.
Not all transgender or gender nonconforming individuals want hormone therapy or gender-affirming surgeries. Some are comfortable with cross-dressing and “social” transitioning, such as using their affirmed gender pronouns and bathrooms. But for those who experience significant gender dysphoria, HRT and gender-affirming surgeries can be lifesaving.
“The key component is the level of distress [the gender dysphoria] is causing the patient in their physical body,” says Izzy Lowell, MD, founder of QMed, an Atlanta-based medical practice that provides HRT via telemedicine to those who live in areas where it’s unavailable.
“Deferring care is the same thing as delaying care, which isn’t a whole lot better than denying care.”
“I have some patients who have such an extreme dislike of their body and hate to be out into the world and be perceived in the gender they [don’t identify with] that they basically don’t leave the house,” Lowell says. “HRT allows them to re-enter society and feel more comfortable in their body. When people are allowed to express themselves and begin the transition process, it significantly improves their whole outlook on life.”
The level of acceptance transgender people experience in society plays a “huge role” in gender dysphoria, Lowell stresses. And most Americans are ignorant about transgender people.
According to the Williams Institute at UCLA, there are about 1.4 million transgender adults in the United States—a greater number than those diagnosed with Type 1 diabetes. But a 2017 poll found that just 16 percent of Americans know anyone who is transgender.
Bullying, rejection by family or friends, and health care discrimination can lead to severe emotional distress. Nearly half of the eighteen to twenty-four year olds in a 2011 survey of 6,450 transgender and gender nonconforming people reported having attempted suicide.
Health care providers interviewed for this article say learning to monitor and prescribe HRT is easy and inexpensive. Hormones can be delivered through a variety of different methods, such as orally or via implant, and cost around $1,500 per year. Individuals often take hormones year after year.
Emory University in Atlanta has been providing hormone therapy for about eighteen months, says Sharon Rabinovitz, MD, director of clinical provider services for family medicine. The student health center hired an endocrinologist to work half a day, once a month, to provide HRT and to train the medical staff. The goal was to make sure transgender students could receive care easily, inexpensively, and in a safe setting.
“It can take months to get hormone therapy off-campus,” Rabinovitz says. “We have a very large LGBTQ community and we knew there was a need.”
The cost of training staff is minimal if health centers take advantage of free online medical guidelines posted by the University of California at San Francisco Center for Transgender Excellence, or seek mentorship from local health care providers, says Beth Kutler, clinical director of women's and sexual health at Cornell University’s student health center.
Many transgender youth wait until college to come out—making this a critical period to connect with caring, informed medical providers.
According to the World Professional Association for Transgender Health, primary care clinicians can, with a little training, prescribe and monitor hormones. Over the past three years, the nonprofit professional organization has trained 2,000 primary care doctors and physicians assistant to provide HRT.
Many physicians require transgender patients to obtain a letter from a therapist confirming a diagnosis of gender dysphoria before they will administer HRT.
Cornell University, located in Ithaca, New York, began offering HRT ten years ago. “It was a natural move for us,” Kutler says. “We provide inclusive care to all our LGBTQ students. If we’re not giving hormone therapy, we’re missing a big part of that.”
Hormone treatments are covered under Cornell’s student health insurance. Students can be recommended for treatment by mental health counselors knowledgeable about transgender health or by primary care doctors qualified to diagnose gender dysphoria. Patients often begin hormone therapy on their third visit, after blood work and a physical are completed.
“Providing gender-affirming therapy is the most rewarding part of my job,” Kutler says. “I get to see my patients blossom. I get to help students overcome gender dysphoria and become who they are most comfortable being.”
Cameron MacGregor chose Ithaca College, also in Ithaca, New York, because of its reputation as being one of the most transgender friendly schools in the nation by Campus Pride. The college, with just over 6,000 students, uses gender-affirming names in student rosters and on ID cards, and employs mental health counselors knowledgeable about LGBTQ issues. But for hormone therapy, students must seek care at the local Planned Parenthood, a bus ride away.
“It’s a little bit of a burden because I don’t drive,” says MacGregor, nineteen, who has undergone HRT for the past eight months. “It would be really nice if [Ithaca College] had health services on campus, but it’s a relief to take a bus and walk ten minutes rather than having to deal with a therapist, endocrinologist and all that.”
Before hormone therapy, MacGregor says, “I didn’t really feel like I was myself at all.” Now his once high-pitched voice has deepened enough that “people read me as male,” and he has facial hair. “The more schools that offer this and the more opportunity people have to seek HRT where they couldn’t before . . . it will save lives, I think,” says MacGregor, who majors in theater studies and history.
Legal advocates cite three federal laws that protect transgender people from gender-based discrimination in health care: Title IX, the equal protection clause of the U.S. Constitution, and the Affordable Care Act. This remains true despite President Donald Trump last year rescinding Obama Administration guidelines that protected the rights of transgender students to use bathrooms corresponding with their gender identity. And in April, the Trump administration stated plans to rollback the health protections for transgender people under the Affordable Care Act, which prohibits sex discrimination, including discrimination based on gender identity.
M. Dru Levasseur, senior attorney and transgender rights project director for Lambda Legal, a nonprofit that defends the civil rights of LGBTQ Americans and those living with HIV, is angered by Trump’s “bullying” of transgender people but undeterred. “Legal advocates have been winning gender-based anti-discrimination cases for years,” he says. “In spite of all the attacks the Trump Administration has made on transgender people, we’re still winning in the courts on this issue.”
In April, the Trump administration stated plans to rollback the health protections for transgender people under the Affordable Care Act.
Levasseur points to two high-profile cases settled this year in favor of transgender teens seeking to use public school bathrooms of their identifying gender. In May 2017, a federal court judge ruled that under Title IX, a Kenosha, Wisconsin transgender teen, Ashton Whitaker, be permitted to use the boys’ bathroom in his high school. And on May 22, a federal judge in Virginia cited Title IX and the Constitution when she denied a motion from the Gloucester County School Board to dismiss a case brought by Gavin Grimm, a transgender teen who had sued to use the boys’ bathroom. The school board is appealing the decision.
Any college or university that receives federal funding and is denying HRT, or not insuring it, is breaking the law, Levasseur says. “They can wait to be sued or change practices to be in line with the law.”
For some students, it can be a matter of life and death.
As an undergraduate at the University of California at Davis in approximately 2005, Kylie Blume was deeply depressed after trying for years to access hormone therapy. She walked into the university’s student health center with a letter from a therapist stating she had gender dysphoria. She remembers a staff doctor telling her, “Right on! I don’t know how to do this but I’d love to support you.”
The doctor learned how to provide HRT, and a few years later helped Blume get gender-affirming surgery. Blume, now thirty-five, credits that physician with saving her life and inspiring her to become a doctor.
Says Blume, “It’s really profound when a health care provider says, ‘I don’t know how to do this, but it’s within my capacity to take care of you. I’ve got your back.’ ”
Donna Jackel is a Rochester, New York-based journalist focusing on mental health, animal welfare, disability rights, and criminal justice. Her work has appeared in CityLab, The Chronicle of Higher Education, The Bark, Next Avenue, The Chicago Tribune and other national and regional publications.