Accessing Mental Health Care While Trans

Trigger Warning: physically and sexually violent imagery, transphobia

I recently moved to Boston from NYC. Moving can be stressful for a variety of reasons. As a trans man with mental illness, it can be especially stressful for me to try to make sure all of my healthcare continues without gaps.

I asked around for recommendations before I moved. The only suggestions I received were to go to Fenway, Boston’s LGBT health center. Some cisgender people assured me that it was very trans-friendly. The trans people I spoke do didn’t go quite that far, but did say it was the place everyone they knew went for hormones. I called several weeks before I moved to make an appointment for primary care and behavioral health. They don’t permit making appointments with behavioral health before first seeing primary care, so I took the first available appointment with primary care, which was for around six weeks after I called.

The day after my primary care appointment, I called back to make an appointment for behavioral health. They asked me if I would prefer to see a man or a woman. I said that that didn’t matter to me, but if they had any trans people on staff I would prefer to meet with them. They told me that they did not have any trans people on their behavioral health team, but that everyone was very well trained and up on trans issues, so I had nothing to worry about. They scheduled an intake appointment for me for four weeks later and told me it would be another 4-6 weeks after the intake before I could see a psychiatrist, and 6-8 weeks after the intake before I could see a therapist. Fortunately, the PCP agreed to write prescriptions for the psych meds I have already been taking until I could see a psychiatrist, and the therapist I was working with in NYC had already agreed to continue phone sessions with me.

As is probably predictable, I’ve been having a hard time emotionally. My sleep has gotten worse again, and when I do sleep I get tortured with a barrage of violent dreams. They are just quick images, usually, like someone getting shot in the head right in front of me or someone stabbing me in the stomach. Sometimes they are longer with a bit more plot, like someone raping a young girl while her family and I look on unable to intervene or my partner dying on my birthday and me dying on hers. When I’m awake I find it hard to focus on my new job and I generally feel profoundly sad and lonely. When I last spoke to my therapist she expressed concern and urged me to try to get an appointment with a psychiatrist sooner than someone at Fenway would be able to see me, because she thought my medication needed to be adjusted. I felt overwhelmed by trying to figure out how my new HMO worked and whether I would need a referral from my PCP to have a visit to a psychiatrist covered.

My partner was also worried about me and wanted to help, so she called Fenway to find out about getting a referral for me. They weren’t open at the time, so she spoke to the answering service and explained the situation. They asked her if it was an emergency, and out of her concern for me and commitment to advocate for my care, she said that it was.

Before long, someone from behavioral health called me. I explained the situation as best I could. He said that he didn’t give out referrals; I would have to call back during their business hours if I wanted one. He also told me that I already had an appointment coming up in just a couple of weeks and that no psychiatrist anywhere in the city would be able to see me sooner. He also said that this service was really for emergencies and usually he was talking to people who were suicidal; he seemed annoyed to be talking to me.

As he told me these things, I calmly agreed with him, saying “ok” over and over. It was pretty much what I expected. I thought it was probably true that he couldn’t get me a referral, and while I thought he was probably wrong that it would be impossible to see a psychiatrist more quickly I certainly didn’t see how it would be helpful to say that to him. Also frankly I was feeling somewhat humiliated and vulnerable and just wanted to be a “good patient” and get off the phone as soon as possible. I didn’t honestly think of my situation as an emergency and wouldn’t have called it that if I had made the call (although for that matter, I might never have called at all).

But then, before hanging up, he said, “I just want to make sure I have your first name right. Is it really G-A-B-R-I-E-L?”

I sense of dread rushed in as I realized he was skeptical that Gabriel could be my name. “Yes, that’s right,” I said.

“Ok, I just wanted to check, because usually only men spell their name that way.”

My vision became a field of black and red with stars prickling through. “I am a man. Why would you assume that I am not a man?”

“Well, it says clearly here that’s you’re female.”

“Well then your records are wrong. I don’t understand why your records would say that. I have only ever said that I am male.” I thought back to the original intake forms I filled out at Fenway. They asked about gender in four places. In one place they asked for “legal gender,” saying they needed to know for insurance purposes. As a lawyer, I know that “legal gender” is a pretty nonsensical concept, but as one of relatively few trans people who has had enough privilege to get all of my documents (health insurance, driver’s license, birth certificate, passport, social security card, employment records, etc.) listing my true gender, I had no doubt that I should check male. I did. Then they asked what my gender identity was. I again marked male. Then they asked what my assigned sex at birth was. I had hesitated. While it was painful, I thought I should probably share the information, so I checked off female. Then they asked what my preferred pronouns were. I marked he.

It was that goddamned female at birth that did me in, clearly. In the end, nothing else mattered.

“Well, are you trans? Maybe a trans female, or a trans male?” he asked as if I didn’t already know that was why they were misgendering me, and as if that weren’t exactly the reason why they shouldn’t be.

“Yes, I am a trans man.”

“Oh, well then that’s why we have you as female!”

“You really shouldn’t.” I said, tightly.

“Well also you only registered recently. Probably that’s also why. When you come in you can ask them if they could change that for you. I don’t know, maybe they can. Certainly that’s not something I can help with. You’re definitely female here.”

He didn’t seem capable of stopping talking. Eventually I cut in. “Okay, good bye.” I hung up the phone.

I felt dazzled with hurt and shame. My partner was upset and wanted to think of options, but I couldn’t do it in the moment. We went to a park bench and I sat and wept silently in her arms. Various questions circled in my mind.

Some were angry and dismayed. Why is an LGBT health clinic more transphobic than the state and federal government agencies I’ve dealt with? What would have become of me if I had been suicidal and spoken with someone like him?

Some were a mess of internalized transphobia and ableism. What did I do wrong? Should I have pitched my voice lower? Should I have been more assertive? Less? Should I have gone to some other psychiatrist from the start and not come out, just passed as a non-trans man? Do I even deserve mental health care anyway since I’m not suicidal and can still more or less function? Why can’t I just feel better on my own and stop asking for so much help? What is wrong with me that getting misgendered still bothers me so much after all this time? How can I expect anyone to treat me like a man when I’m sitting here crying in public? What is wrong with me that I am still thinking in terms of fucked up gender stereotypes like “men don’t cry?”

Some were scared and sad. Will this sort of thing ever stop happening to me?

To which, of course, I had to answer no. I socially, legally, and medically transitioned over a decade ago; I will never pass better than I pass now and I will never stop being trans. Amazing people have been resisting a coercive gender binary system since long before I was born; I believe we can make meaningful change, but I don’t believe we will end transphobia within my lifetime.

So now, a few days later, I feel a little trapped. I need health care and I intend to get it, but I’m not sure how to do that in a way that won’t further crush my mental health and dignity. And I am also aware that I have so many more resources for navigating this shit than most people do, as a white professional US citizen with health insurance and passing privilege in a large urban area. I feel worried for us crazy trans folks.

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