Upon returning to Montgomery County in 2015 after a stint in New York, Lee Blinder was hoping to find a medical practitioner able to continue their gender-affirming care treatment. But they found there were no county physicians who were experienced in administering gender-affirming care.
“It is lifesaving care. It is urgently necessary like any other medical care. Like with any other medical issue, you don’t want to wait,” Blinder said. “It can be a very profound experience to bring your body in line with what feels correct for you.”
In a March 2023 report, the United States Department of Health and Human Services defined gender-affirming care as “a highly specialized model of care that uses evidence-based practices to address distress arising from gender dysphoria.”
This care can vary based on the individual, but may include hormone replacement therapy, surgery and alterations to various parts of the body, voice therapy, and other healthcare intended to help align a person’s body with their gender identity.
Even in a county that is often lauded as progressive by political observers, Blinder found they had to often explain what being transgender and nonbinary meant and what care they needed. They ended up having to advocate for their treatment at a primary care provider. After finding support from that physician, the practice closed, and Blinder was back at square one. And Blinder’s experience isn’t an uncommon one for many trans Montgomery County residents.
An LGBTQ+ community survey report released publicly by Montgomery County earlier this month revealed that more than 41% of trans and gender expansive county residents faced difficulty finding gender-affirming care and gender-affirming mental health support. One in six of trans and gender expansive respondents to the survey reported that a provider refused to provide them with gender-affirming care. Over a quarter of respondents said they had to “teach their provider about their sexual orientation or gender identity to receive appropriate care,” according to the survey.
About 0.5% of Maryland’s adult population–24,000 people–is transgender, and an estimated 6,000 trans Marylanders rely on Medicaid, according to a study from the Williams Institute at UCLA.
Out of 842 participants in Montgomery County’s LGBTQ+ community survey, 30.6% said they identified as transgender, nonbinary or gender expansive, and 7.4% said they were questioning or “not sure” about their gender identity.
The majority of Montgomery County’s current elected officials have been vocal about their support for the LGBTQ+ community this year. In March, the County Council adopted a resolution condemning anti-transgender acts and hate crimes. County Council President Evan Glass (D-At-large) and County Executive Marc Elrich raised a pride flag on June 1, in the county’s fifth annual recognition of LGBTQ+ Pride month.
Glass, who joined the council in 2018, is the county’s first openly-LGBTQ+ councilmember. And Gov. Wes Moore (D) declared Maryland a sanctuary state for transgender health care access in June, making it the 11th state to do so alongside the District of Columbia. California was the first, with Colorado, Connecticut, Illinois, Massachusetts, Minnesota, New Jersey, New Mexico, Vermont and Washington following.
Despite these demonstrations and proclamations of support, several transgender and nonbinary community members and LGBTQ+ advocates who spoke to MoCo360 say it’s still incredibly difficult to access gender-affirming care in Montgomery County.
“We have so many resources in Montgomery County, but there are significant gaps for queer and trans people,” Blinder said.
Major medical organizations including the American Medical Association, American Academy of Pediatrics, and the American Psychological Association designate gender-affirming care as medically necessary. The federal government has named gender-affirming care as an “essential health benefit” protected under Section 1557 of the Affordable Care Act, and earlier this year, Maryland passed the Trans Health Equity Act sponsored by Montgomery County-based Del. Anne Kaiser (D-Dist.14), which requires Maryland Medicaid to cover gender-affirming care for transgender residents.
“Gender-affirming care is absolutely vital,” said Dr. Julius Johnson-Weaver, a primary care physician who runs the practice Resolve MD in Howard County and specializes in hormone replacement therapy. “Not having gender affirmation leads to high rates of anxiety, depression and suicide as well as risk-taking behaviors such as drug and alcohol use. You’re not going to be doing well in life when you’re not presenting yourself and moving in the way that you feel you should be.”
About 82% of transgender individuals have contemplating taking their own life and 40% have attempted suicide, according to a March 2022 study from the National Institutes of Health.
A 2021 Harvard study found that gender-affirming care, specifically surgery, was associated with a 42% reduction in psychological distress and a 44% reduction in suicidal ideation, in comparison to trans people who desired gender-affirming surgery but had not yet had it. There was also a 35% reduction in tobacco smoking among people who had gender-affirming surgeries, according to the study.
A February 2022 study from the National Institutes of Health found that “gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months.”
Blinder’s experience led them to start the organization Trans Maryland in 2018, which advocates for the trans community and helps connect trans Marylanders with resources, from healthcare to legal assistance in name changes. But Blinder says the gap in access is back to where it was when they started the organization, and advocates are working to change that.
“People deserve to be able to go to the doctor just like any cisgender person and receive quality, affirming care,” Blinder said.
Accessing gender-affirming care as a MoCo resident
Burtonsville resident Camila Reynolds-Dominguez receives gender-affirming care from Planned Parenthood in Gaithersburg–the only clinic the organization runs in Montgomery County. It is also the only major provider of gender-affirming care in the county. She says the treatment has been life-changing, and she’s seen an improvement in her mental health and her ability to succeed in graduate school.
“I’ve been really, really lucky,” she said.
In an email to MoCo360, Dr. Divya Shenoy, director of Primary Care at Planned Parenthood of Metropolitan Washington, D.C., said the organization “provides gender-affirming hormone treatment, including estrogen, testosterone, and other medications that aid in affirming gender identity.”
“We also provide referrals for gender-affirming surgeries and trans-friendly specialty care, including mental health care, and resources for supportive services such as hair removal, speech therapy, and legal services,” Shenoy wrote.
But Reynolds-Dominguez said while her experience with her services at Planned Parenthood has been positive, scheduling hasn’t been ideal. In the wake of the Dobbs v. Jackson Supreme Court decision that overturned Roe v. Wade and left abortion access to the states, Maryland has become a sanctuary state for abortion access. That means more people are coming to the state for both reproductive health care and trans health care, putting a strain on resources.
“It’s like a one-two punch type of crisis, it’s compounding,” Reynolds-Dominguez said. She said she’s concerned about the county’s ability to act as a sanctuary for trans people under these conditions.
Shenoy said in an email that the Gaithersburg clinic has experienced a “high demand” and sees about 60-70 patients per month for gender-affirming care. The wait for an initial consultation can be six to eight week to schedule an initial consultation and 2-4 weeks for follow-up consultations.
“We do offer gender-affirming services over telehealth, which reduces barriers for patients, such as transportation and the need to take time off from work for appointments. We continue working to expand our reach to meet the needs of our community,” Shenoy said.
Because of the demand for Planned Parenthood’s services, sometimes Reynolds-Dominguez has had to wait long periods of time for an appointment to renew her prescription, leading her to have to ration her hormones, which experts including Johnson-Weaver agree can be dangerous.
“Your emotions get thrown off, your body doesn’t feel good and it can be pretty distressing,” Reynolds-Dominguez said. “If you’re in crisis mode, that can be a reason that you engage in self-destructive behavior or even end your life. Even if you do everything right, even if it’s legal and protected in our state, your health care can still get taken away from you.”
Johnson-Weaver said it’s not advisable for patients receiving hormone replacement therapy to have lapses in treatment.
“Going on and off hormones is not going to feel good in your body. You’re [going to] have changes and maybe regression. It’s also not good for your mental health. So continuity of care is very, very big,” Johnson-Weaver said.
In reality, many Montgomery County residents have to travel out of the county to access gender-affirming care. Blinder said while there are a couple of endocrinologists in the county who will provide hormone replacement therapy, many trans county residents end up seeking care at Chase Brexton Health Care in Howard County or Whitman-Walker Health in Washington, D.C.–both large medical centers that specialize in LGBTQ+ health care.
According to a 2019 article in The Washington Post, more than half of Whitman-Walker’s 1,837 patients served in 2018 lived in Virginia or Maryland, even though the clinic is in D.C. Whitman-Walker did not respond to requests from MoCo360 for updated statistics.
In an email to MoCo360, Sam McClure, executive director of the Center for LGBTQ Health Equity at Chase Brexton Health Care, but said the center sees patients from Montgomery County and other surrounding areas outside Howard County. McClure did not have specific data available but said over the last five years demand for gender-affirming care has been high and continues to grow.
“There are longer waits for some appointment types than others and we are constantly working to expand our capacity to serve the community,” McClure said. “For transgender and nonbinary Marylanders seeking affirming gender care, there has never been enough providers to meet all the needs across the state and in our region.”
McClure said Chase Brexton developed a training and education program in its center for LGBTQ Health Equity to provide clinical training for health care professionals to learn how to provide gender-affirming care.
“Affirming gender care must become widely available and we all have a role in making that happen,” McClure said.
Johnson-Weaver said his practice offers a unique and accessible model of care because he conducts many of his appointments online. He said many of his patients live outside Howard County.
While Montgomery County is near D.C., Blinder said there are still barriers to accessing care in the city. The Metro red line and WMATA bus into D.C. only reach some parts of the county, so transportation can be an issue. Blinder said it’s a privilege to be able to travel for care. When they were younger they would travel to D.C., but said they thought things would’ve gotten better by now.
“It’s a little bit heartbreaking in 2023 that we’re still having to go into D.C.,” Blinder said. “We’re an incredibly wealthy area and there’s a huge gap in the financial access for a lot of our community members. And not every trans person can just slap down a credit card.”
Councilmember Kate Stewart (D-Dist. 4) is concerned about the lack of access in the county. And for Stewart, the issue is personal. Her adult son is trans, and when he was a teenager, the family had to drive into Howard County for his gender-affirming care. And while Stewart said her son received excellent care from his physicians at Chase Brexton, she recognizes her family was in a privileged position.
“When my own son was transitioning, getting the right size needles for his [hormone replacement therapy] was really difficult and the local pharmacies didn’t always carry the size that was needed,” Stewart said. “I’d have to drive to Columbia just to pick up needles for him. Sometimes I’d have to take off work. I was able to do that, but that’s a huge barrier to access for many people.”
Maryland residents who need needles and other injection supplies for hormone replacement therapy can now receive free items from the Baltimore Harm Reduction Coalition in partnership with Next DISTRO, a harm-reduction nonprofit.
Mary Anderson, spokesperson for the Montgomery County Department of Health and Human Services, said that the county has been working on making it possible to provide hormone replacement therapy needles. At a pop-up event at Pride in the Plaza in Silver Spring in June, the county partnered with a harm reduction organization to do just that, but the department is working on a long term, consistent way to provide this.
Reynolds-Dominguez said she feels a lot of privilege to even be able to access the care she receives.
“A lot of trans people are in crisis mode,” she said. “Trying to go from job to job or not even having a job, not even having housing, not even having a phone with which to schedule a telehealth appointment to get their prescription. For all those reasons, it’s so inaccessible.”
Becoming a sanctuary
Blinder said while they’re pleased to see leaders such as Moore taking steps toward prioritizing trans healthcare, and Trans Maryland has worked with the governor’s office on this issue, there is still work to be done. Blinder said it’s not just about gender-affirming care–it’s about making sure housing is affordable, and that everyone has access to healthcare in general.
Nearly one in eight–12.8%–of respondents to the county’s LGBTQ+ survey said they have experienced homelessness at some point. That number was 3.1% higher for respondents who identify as trans, gender expansive or questioning. About 20% of trans respondents said they’d had difficulty finding housing in Montgomery County, while almost 15% of all LGBTQ respondents said they’d had that struggle.
One in six respondents reported having “formally or informally housed a displaced or unaffirmed LGBTQ+ person” in the county, according to the survey.
“We don’t have the providers here and the cost of living and housing is so high. We can’t currently house and help everyone already here. It’s a crisis. One of the uncomfortable things is we have Marylanders right now who don’t have access to healthcare,” Blinder said.
Respondents to the county survey also reported difficulty in accessing nondiscriminatory general primary healthcare services. Almost 47% of trans and gender expansive respondents said a medical provider had misgendered them or used the wrong name for them. Almost 8% reported abusive language from a medical provider, 4.4% reported physical abuse and 4.6% reported instances of medical providers refusing to treat them due to their gender identity or sexual orientation.
Stewart said there’s a variety of actions the county could take to work towards addressing the issue. Her office has requested a report from the county’s Office of Legislative Oversight looking into what services are available to transgender people in the area. The goal of the report is to identify what gaps there are in available services, Stewart said, so that her office can work on ways the county can address the disparity.
“Under COVID, we got very good at looking at how the county can provide vaccines,” Stewart said. “So I think there are lessons learned from that and what we need to identify is, where are the gaps?”
Stewart said there’s also a precedent for the county offering training and support through the Department of Health and Human Services, as the county has done for abortion providers, so that physicians can learn how to provide care to trans patients.
Blinder said ideally, gender-affirming care should become standard for primary care physicians in medical school. But until then, one way of increasing access that many advocates have focused on is encouraging trans physicians to go into gender-affirming care practice, especially because they have received that care themselves.
“The ability of having a lived experience is really key,” Blinder said. “Then the patient is not having to educate the physician.”
Reynolds-Dominiguez agreed.
“When you’re going to the doctor as a trans person, there’s a big power imbalance in some cases if the doctor hasn’t worked with trans people,” she said. “You have to do prep work to understand the medical terminology that you want to talk to this doctor about.”
But Blinder also said it’s hard to get physicians – especially trans physicians – excited about practicing gender-affirming care when there is a prevalence of anti-trans hate. And in the wake of increasing transphobic sentiment across the country and anti-trans laws passed across the country in the past year, Trans Maryland doesn’t publicly share a list of providers anymore, and instead works with people on a case-by-case basis, Blinder said.
Johnson-Weaver said his experience as a trans person is part of why he wanted to start providing gender-affirming care as a physician. But he also said part of the reason he conducts many of his appointments through telehealth is to eliminate potential physical transphobic threats.
“When I have a first-time patient, I don’t know for sure if it’s an actual patient or some person who’s just trying to mess with me,” Johnson-Weaver said. “If we’re just hopping on a Zoom call, then I’m not going to feel as unsafe.”
Stewart said a possibility would be offering county support for security at medical centers that provide gender-affirming care.
“Over the past couple of years, the county has worked with houses of worship and places and nonprofits that have been targeted by hate to help them with their security,” Stewart said. “And so if this is an issue, and practitioners and providers need that assistance as well, I think as a county, we would step up for that.”
When asked how she’d respond to criticism that the government shouldn’t get involved in gender-affirming care, Stewart said it comes down to ensuring the well-being of all constituents.
“This is about health care. And I think health care is a right, and making sure that members of our community are physically and emotionally and mentally healthy, and making sure they have the access to the care they need to ensure that is exactly the role of government,” Stewart said. “The suicide rates among trans individuals are very, very high. That has an impact on our entire community… this is an investment in our entire community.”
Blinder said while the community is facing a crisis when it comes to gender-affirming care access, they are hopeful that as the trans community becomes more visible, more people will understand the importance of this care.
“It really comes down to having that lived experience of knowing and talking to a trans person,” Blinder said. “We’re at the precipice of a broadening of care.”