A collaboration between Planned Parenthood and Metro Trans Umbrella Group has helped almost 700 gender-expansive folks in the region access gender-affirming hormone therapy in the past year and a half. The program, funded by a four-year grant from the Missouri Foundation for Health, is called TRANSforming Community, TRANSforming Care, or TC2. TC2 prioritizes access for patients and cultural competence from providers.
“The genesis, if you will, was a gap in trans-affirming health-care providers in the St. Louis area,” says Beth Gombos, outreach coordinator at the Metro Trans Umbrella Group. “There was less than a handful [of providers] that were openly accepting transgender patients who wanted to start their medical transition.”
Gombos knows this problem from multiple angles. Through their work with the Metro Trans Umbrella Group, they’re on the programming side of TC2. Thanks to a frustrating interaction with their lifelong physician, they were among the first of its patients.
Gombos says their doctor was aware of their queer and trans identities. They had been seeking care for PMS symptoms, which beyond the dreadfulness of PMS on its own, were dysphoric for them. The doctor wanted to provide birth control pills to regulate the PMS — a common treatment.
But birth control contains female hormones, and Gombos had another idea. They told their doctor they’d done a lot of research and given it a lot of thought, and they were ready to start masculinizing hormones. Initially supportive, the office called back the next day and said that not only would the office not provide gender-affirming hormone therapy but that Gombos would need to find another primary-care physician.
“This is my family doctor,” Gombos says. “My mother goes to this doctor. My grandmother goes to this doctor. I thought it was the best care for me at the time. Hearing that they would not only tell me no but that I should find another doctor was devastating.”
Gombos sounded off about the experience at work to executive director Sayer Johnson, who reminded Gombos of Metro Trans Umbrella Group’s nascent relationship with Planned Parenthood. That appointment and follow-up, Gombos says, were a very different experience.
“When I got to my appointment, I was told that my journey and my experience and my knowledge were valued, which is not commonly what happens at doctor’s appointments,” Gombos says. “They assume they know more about you and that you don’t know what you’re talking about with your own stuff.”
The doctor walked Gombos through a lot of information about hormone treatment.
“My doctor helped me understand the risks and benefits,” Gombos says. “We had a long conversation about informed consent — a lot of it was information I already knew. She acknowledged that.”
Before prescribing gender-affirming hormone therapy, physicians often require patients seeking it to provide documentation from a therapist.
“No one who wants liposuction or breast augmentation or a nose job has to go see a therapist for procedures that, let’s face it, are also gender affirming for cisgender people,” Gombos says. “This gatekeeping has been removed.”
TC2 stresses informed consent, but no therapist’s letter is required. The program follows international best practices for informed consent, adhering to the standards of care published by the World Professional Association for Transgender Health: “persistent, well-documented gender dysphoria; capacity to make a fully informed decision and to consent for treatment; age of majority in a given country; [and] if significant medical or mental health concerns are present, they must be reasonably well controlled.”
The standards of care also state that “with appropriate training, feminizing/masculinizing hormone therapy can be managed by a variety of providers, including nurse practitioners and primary-care physicians.”
The collaboration between Planned Parenthood and Metro Trans Umprella Group explicitly works to overcome barriers to care, including the expense and logistics of a visit to a therapist.
“Historically, the health-care system has not been a reliable or safe space for transgender and gender-expansive folks,” says Willow Rosen, education and care support specialist at Planned Parenthood of the St. Louis Region and Southwest Missouri. “The partnership between the Metro Trans Umbrella Group and Planned Parenthood is a step toward closing that gap to care.”
Underserved populations, including trans or gender-nonconforming people, especially those with intersecting Black or brown identities, Gombos says, can have financial hardships that prevent them from seeking care.
“A unique aspect of this program is something called the Opportunity Fund,” Gombos says. “It’s part of the grant. It allows us to help transgender and gender-nonconforming patients pay for the services that they can’t afford. It makes a really big difference for people [who] cannot afford an appointment, knowing that there is financial assistance available.”
Both Rosen and Gombos stress the importance of having trans and gender-expansive people making decisions about the program.
“The majority of TC2 team members identify as gender expansive, which helps us live our mission: ‘nothing about us without us,’” Rosen says. “We are proud to represent our diverse identities in the communities we serve.”
Gombos says the depth of contact and training that the Metro Trans Umbrella Group staff have with Planned Parenthood staff has been comprehensive.
“I’ve been to every single one of the health-care locations in the St. Louis affiliate,” Gombos says. “I have met each one of the providers [who] are going to be providing this medical transition care for the community. I help train and consult with front-desk staff, lab technicians, health-care assistants.
“I speak with every single employee [who’s] going to come into contact with a patient. I work with them on pronouns and affirmed names — some are starting with the very basics.”
Since January 2021, TC2 has served 670 patients across 1,489 appointments. About 68 percent of patients are in the 20 to 34 age range, with 23 percent of patients between age 16 and 19, and 10 percent over age 35. Most, about 57 percent, visit care centers in St. Louis, with another 23 percent in southwest Missouri and 20 percent accessing care by telehealth. About 46 percent self-pay (with some accessing sliding-scale fees, though specific data on that is not available), while 42 percent use commercial insurance and about 12 percent use Medicare/Medicaid.
Both points of access — Metro Trans Umbrella Group and TC2 — aim to provide comprehensive care, with referrals between the two. Both hope to continually increase access to care through the collaboration.
“While health-care access is a critical part of ensuring patients can live authentically, it is just one facet of the program,” Rosen says. “TC2 provides wraparound services including a research program that documents the needs of patients and the disparities they face in health care. The Needs Assessment survey is one important tool to better understand the reality our patients face. Additionally, medically accurate and affirming sex education is another core TC2 service that closes the gap in an education system that doesn’t adequately represent the gender-expansive community.”
Gombos says that Metro Trans Umbrella Group is about to launch a telehealth service, where people can link with their provider from Metro Trans Umbrella Group’s space. They’re also launching an injection workshop and partnering with a mail-order pharmacy company, which cuts out the possibility of coming across a pharmacist with an objection to filling a particular prescription. Planned Parenthood is partnering with a health-care transportation agency to provide rides to the Metro Trans Umbrella Group — where patients can do those telehealth appointments and get injection supplies, bloodwork, food, clothing, toiletries and more.
“We have been referring a lot of folks to Planned Parenthood to start their medical-transition journey,” Gombos says. “It’s been life changing for folks. I get folks that are struggling. They feel like if they could start their medical transition, it would improve their quality of life. They don’t know how easy it is!”