JoAnne Keatley: Our next presentation actually is gonna be a community panel, and Lin Fraser will be the Moderator. Lin is an EDD, an FCC. She is the practicing psychotherapist here in San Francisco. She has specialized in transgender issues for the past 28 years -- primarily in private practice, but also in community mental health, and in teaching. Her doctoral dissertation was a manual for practicing clinicians on the Assessment and Management of Transgender Identity Issues. She is a charter member of the Harry Benjamin International Gender Dysphoria Association and assisted in the development in the original Standards of Care. Dr. Fraser has lectured and taught widely on transgender and other gender related issues, and has always practiced in the Bay Area. So with that, it is my pleasure to introduce Lin Fraser. [applause]

Lin Fraser: That was quite an introduction. I've been working in the field for 28 years, and it continues to inform and fascinate me. This last paper was stunning. I had no idea even after 28 years in the field. Today we are very fortunate to have a panel of community members who have an impressive array of health care credentials as well. They're outreach workers, we have a chiropractor, we have a corporate executive in the insurance industry, we have case managers. So we have people who are not only transgender, but are providing transgender care and other health care.

The purpose of the panel is to introduce you to key issues in transgender health care, and to introduce you to community members' perspective. I think this conference is a first. I think San Francisco seems to be always on the cutting edge. I notice this when we go to conferences worldwide. We are -- we're ahead, and we lead the way. So this is very, very exciting. And when I think back to seeing my very first transsexual client, in 1972, there was absolutely no information available. And so what I did in the absence of anywhere to go other than extremely pathologizing literature, was to listen to my client. And she took me by the hand and taught me everything, and then referred her friends to me. And that's how I got started. She was my first client. I was a beginning counselor. And so we thought the best way for you to learn today -- it still stands even though there's a lot more information out there -- is to have the opportunity to hear people's stories, and to meet people themselves.

You can't overemphasize the importance of exposure to demystify an often very, very confusing condition for many, many people and providers. To depathologize -- the literature itself pathologizes this condition, or a lot of the literature does. And to increase people's comfort level. I just want to get a sense before we start hearing people's stories as to the -- how many people have seen transgender people in practice? Wow, wow! This is very unusual when I speak. Usually when I speak about this condition, one or two people raise their hands. This is San Francisco. [laughter]

Even so I feel we all have a lot to learn. So what we're gonna do today is each person will speak individually and will probably speak for about five, three to five minutes by himself or herself, giving you history, a very brief history -- and what, and talk about what makes, what makes you identify as TG, what is your definition of being TG. And then after they finish we'll all just open up to the panel and ask them questions that specifically relate to health care. What do you want from your health care provider? What do you want your health care provider to know about you to enhance your care, and how do you introduce the idea that you're transgender? And then, we'll hear some good and bad experiences with the health care system. I think hearing stories is very, very useful. So, we'll start with Kim. Can you see Kim?

Kim Makoi: My name is Kim Makoi, and I am a chiropractor here in San Francisco. I identify as transgender, FTM. Somewhere in the middle of the scale. For me hormones and surgery are not really something I want right now. And I identified as transgender since around four years old, which is when differences start coming out. You try to dress yourself, and your parents say you can't wear that, you need to wear this. I'd think but no, I need to wear those.

So that's when it started as an issue for me. And then I remember in third grade when kids were laughing in a corner, and I went over to see what they were laughing about. And they were - they'd seen something on TV the night before about a sex change. They were all like, there was this guy that turned into a woman, and they were -- they thought it was hilarious. But to me I thought, wow, I want to get that, you know. When I grow up I'm gonna change. So for most of my childhood it's been a heavy issue. And around 17, 18 years old is when I started to learn the official language for it. I started to learn more about transsexuality, transgenderism; and again I always thought, well when I'm independent, when I can do it, I'm gonna change.

And then a funny thing happened, after I finished my education and actually got out there and started living on my own. I moved across the gender spectrum, got around the middle, and got really happy. And now I'm really, for the first time in my life, comfortable in my own skin. Really comfortable where I am, so I no longer think that I will pursue surgery or hormonal, hormonal change. It could change somewhere down the line, but right now I'm real happy in the middle, and I'm not comfortable with being called Ms. or Mr., so I just became doctor and that took care of that. [laugher, applause]

So with health providers the biggest thing I'm concerned with is a lot of health providers think that transgenderism is pathological in and of itself. And it's not. For some people it may be, but you can be transgender and not have to be fixed, of anything. It can be okay, it is what it is. So I like to know that my health provider understands that. And sometimes, a lot of times, it's their -- depending on their level of awareness -- I may not read as TG. So sometimes I've been in situations where staff members will start making jokes about TG individuals, or comments. And I don't, I'm not comfortable with that. I don't feel good about that. So I don't go back. So within your practices I'd just make sure that you have a good policy with your staff. If a transgender client comes and goes, and someone starts makes comments, you need to cut it. It's not appropriate. And, but experiences in my life when I've entered an office where I've seen transgender people employed or waiting around I feel good. I feel like okay, they're gonna be open here. And like I said, bad experiences are when they start making snide comments or if they start to talk down to you, like "Oh, maybe you should get some psychiatric counseling; maybe it's a problem." And it's not always a problem. So that's basically where I've come from and where I am now. Thank you. [applause]

Lisa: Hello there, and thank you for being here. My name is Lisa Milton [?], and in the audience somebody has to be a traditionalist. Unfortunately I guess it's me. I am in my 40's. I identify as transgender. I have completed, I guess, the entire process. I have been on hormones for many years, and in 1997 I had sexual reassignment surgery up in Montreal with Dr. [inaudible].All of the treatments, everything that I've received I've been thrilled with. I have no complaints with regard to the care and regimen that I went through. It was appropriate for me. I can't -- I knew at four years something was wrong. It made absolutely no sense to me, and I kept waiting to grow out of that. And for what, that had to be a phase, and it made no sense at all. But it was there.

It was interesting listening to Judy Van Maasdam talk about all the books disappearing. I never stole any of the books. [laughter] At a very early age I had learned to read an awful lot about the Transval in South Africa because in the card catalogs that we used to have in the olden days, Transval came before transvestitism and transsexualism. And whenever the librarian came up to see what I was doing, I immediately flipped back to the Transval and ask for on book on the Transval in South Africa. [laughter] ......[inaudible] We read absolutely everything. And I guess if I had one very negative experience, it would be that so much of the literature in those days was related to the stereotypes that we have of sex and gender that were with us before the Women's Movement really got started. And I remember reading very, very clearly that the fact that I enjoyed playing sports, and that I even liked watching them, meant that I could not be a transgender. I must be something else. What that something else was, they weren't quite sure according to the literature. But all of the social stereotypes at that age were clearly there. And they did have an influence. And there were not folks out there to take and provide that moderating influence to say, no, there's something else going on.

So in 1974, recently after graduating from college, instead of running to what was my future, I ran to marriage as a cure. That resulted in two beautiful children who are the joy of my life. And I achieved everything that I set out to achieve. I rose through the ranks in my organization, and by 1994 I was Vice President of Claims for the fourth largest Worker's Compensation carrier in the United States. Had all the success and all of the privilege associated with that, and all of the emptiness that's associated with walking through every single moment of your life knowing something is missing. It doesn't matter what you do, or how much you enjoy what you do. I invite any of you, to spend just an hour learning how to try to do 24, living without relating to your gender. Living without the ability in any of the subtle little things that you do, to express the gender part of that, that's in all of us. And everything you do is less because of that.

And today because of care and everything else, I've made it. I got the rare privilege of standing in front of dozens, and sometimes hundreds of my colleagues earlier this decade, and tell them about my personal life. I'm a private person, it wasn't a lot of fun. It was a piece of cake compared to standing up to my six year old daughter, at that time, and my nine year old son, and say, "Dad has a problem." Today we have a wonderful and warm relationship. But that was the hardest day of my life. And therapists and caregivers helped me to get through those issues with my children, and those issues with my colleagues. And that's what I needed help with. Thank you.

Veronika Cauley: My name is Veronika Cauley. Where do I begin? I have been in San Francisco for four years. I'm an African American transgender woman. I wear the moniker transgender even though I am technically intersex. But I like transgender because it seems to be an umbrella term, and I feel very comfortable with that. It doesn't make any definitive judgment or gender, you know, it just covers everything, and I like the term transgender.

Let's see, I've known about my sexuality or that I was different from the age of probably three -- early recognition. But being African American and raised in a, I guess African, Methodist, Episcopalian, Baptist Church -- that's a lot of words -- being raised that way it made it difficult in expressing who I was and things that I did innately, in expressing myself, I was hit on the arm and scolded and reprimanded and terrorized by the men in my family. So that took me -- by the time I was in my teens, I was -- not a psychological mess, but kind ofI was kind of scrambled eggs. I was very confused and just had no, no sense of who I was. But by the time I was 12 I was experimenting with my different feelings. I remember at the time the only time that you could put on a wig or anything was during Halloween. So when I was I twelve, I kind of turned Halloween out in my elementary school, because I bought an 88 cent wig from a five and dime store and put rollers in it and ran around the street and played in it, out in the street. It was my hair. And then when I went out people from my school kind of like gave me a double take. And then by the time I was in junior high school I played Florence Nightingale in a one-woman play. Even though I was a boy in junior high school.

I went into the Service, I was so confused. I wanted to try and be what my family wanted me to be which was a, you know, Johnny America, or whatever a good for the African American populace. The service was very difficult for me, just -- there were so many things. I was in the Navy and I think the Navy has a lot of military transgenders and people that are experiencing their own sexuality maybe for the first time. I came here after the Navy, got out and I stayed in California and later went to New York, and became a nurse, an LVN. And I came here in '96. I found out in '89 that I had HIV, and I had lost a lot of people -- my youngest brother in '92 and my fiancee in '92. And you know, I just had -- I wanted to get the care that I felt I would need to survive. And San Francisco seemed to be on the cutting edge. I came here, thanks to the AIDS Foundation who walked me and talked me through everything. And I started. And I was homeless. And I moved on up to where I work currently with JoAnne Keatley at the UCSF CAPS Transgender MTF Health Studies Project. And I'm on the Mayor's HIV Care Counsel, and I advocate for transgenders all the time. I mean, all the time.

So I found out at the Millennium March on Washington that I'm also now a trans-activist. Recently, there's been papers that came out of the AIDS office that I was very upset with, because it listed gender. And nowhere was transgender on there. And I was upset because after all this time they should know. They should know better than to let stuff come out of the AIDS office. I called Mitch Katz I was like you shaking and saying how did you let t his stuff come out? And he told me to calm down, and then he agreed with it. So there should be no stuff that comes out of the AIDS office anymore that talks about gender that so doesn't include transgender. Because unless people start saying the word and feeling comfortable with it -- I find a lot of times that transgenders -- that people have a tendency no matter what you are and what you do, to try and -- or kind of diminish you and dismiss you. And I think that's a horrible feeling. Certainly it's been horrible for me; and to be Black and have myself diminished by others is just not only unfair, but it's not realistic. And it means that people aren't listening.

So for care providers I think they really, really need to hear what you're saying about where you're coming from as an individual. They need to listen to your, about your cultural differences and your care. Because what works for Suzy Creamcheese who's White doesn't work for, you know, Shaquita, who is Black. Everybody isn't the same. You can't just lump people together, and you can't just lump people together like that. And so when they say well you know her -- she's so and so -- I'm Veronika, I'm an individual. I am not grouped with anybody, and while I've use transgender as an umbrella, I say it's all encompassing for everything under that and any variation of that.

I'm comfortable in my skin -- it took a long for me to be able to accept who I was, but I'm thrilled at who I am. I learn more about myself all the time. And what I don't know I have therapists that help me sort it out, and people that have been very supportive. So I think that this meeting, while it's the first of it's kind, certainly will not be the last; and I'm thrilled because this is what I wanted to see for long time. Because you need to know that transgenders are out here. We count, we matter, and it's important that you use the word, don't be afraid to use it, and that you ask questions. And feel free to ask me anything you want at any time you want. If it doesn't concern you, I'll tell you that, too. But otherwise feel comfortable, be comfortable. That's it. [applause]

Crystal Catamco: Well, this is very nice. There are so many people. Well, my name is Crystal Catamco, and I work for the Asian and Pacific Islander Wellness Center, as the Transgender Program Supervisor and the Prevention [inaudible] Case Manager. Well, I'm gonna start telling you my story as, you know, when I was, in childhood. And growing up. I am, I should add that I identify as a female to the straight community. And I identify as a transsexual to be counted for fund raising, to be counted for -- to get, you know, funding for the prevention for the transgender community to have better services for the transgender community.

And to start with, what I said, as a child growing up in the Philippines. I'm a Filipino. And I grew up in a family who was very strict. I grew up where my stepfather, knowing that, you know, he's my dad -- and every time I acted feminine and queer inside the house I'd always get slapped, scolded, hit. And it's a very, very difficult feeling because I couldn't express what, you know, I really am. And what I'd do is I'd go to my friend's house and that's how I'd express myself. So they'd think that they would, you know, stop me from expressing myself, but little did they know that I'm smarter than that.

So luckily growing up my parents came here in 1983, and that gave me so much time and freedom to explore myself, and express my, who I am and my gender. And learning about hormones at the early age of 17, I decided to take hormones at that age. And I've been taking for 12, 13 years now. And so by doing that, learning from taking hormones -- I started taking hormones, and I see the changes in my body. And basically, I'm taking it as like M&M's. And I didn't know what's the side effect of it. Because I wanted to have bigger breasts right way. But it doesn't take overnight. It's a long process, that I know now. And then I moved here in '88, and worked as a medical assistant. And at that time I felt like my life wasn't complete because I didn't know anybody who is a transgender, who is a transsexual like me, who have the same feelings like me.

So I decided to you know, socialize in San Francisco. And I learned that there is, you know, other people like me who have the same issues. And so by doing that and working as a medical assistant in the East Bay and trying to move out of my parents in the East Bay in Oakland, I moved here in the City and volunteered my free time to Asian AIDS projects. And I find out being a peer leader, which is, you know, that's what I wanted to do to basically help my community and help them through the process of transition, because I went through a lot. And learning too myself, going through a lot of process learning about hormones and all that, the transition, and how can I get, you know, change my name, get surgery and all that? And that's basically what I wanted to do. I was, you know, I was in a place where I felt comfortable. I was in a place where I could express myself and help my community, my transgender female girlfriends.

And so from doing that there was an available position, and I applied for it. And they hired me, fortunately. And that's when I started my work with my community. And from then on learning that -- going to different health providers, I've learned that some health providers didn't really hear our story, hear our information, hear our history, our personal history, what we went through. And I think that it's really, really difficult if you're a health care provider to serve your clients if you don't even know about them, or who are they? And I think you should have a close relationship with your clients, especially, you know, if you don't really know, if you don't really know them and how to identify them. And it's also, I've learned that from that experience that different health care providers -- some of them want just money. They give you hormones, and not even lab test results. And so I've been jumping to one health care provider to another. And now I'm so satisfied with my provider right now because she does the things that I want her to do basically. I got what, everything that I want, you know, from her. And she got what she wants from me. So it's kind of like a close relationship with your provider.

And I think it's very, very important that you listen to your clients, you hear their stories, you hear their issues, and so by doing that, we can also incorporate if they have any high risk behaviors -- that you can educate them about. You know, either harm reduction, you can educate them about different kinds of STD, and also explain to them what are the lab works that you are doing to them. Because sometime I find that, you know, lab the lab tests that they did, they're not being explained to you. And sometimes some, you know, transgender folks that are just too shy to ask you what it it is or what kind of blood test you're doing. And it's really good to explain that to them thoroughly. And, um, basically, that's where I'm coming from and that's what I'm doing -- basically helping my clients through the transition. And also doing counseling and support and basically serving them and giving them the services that they want. And linking them up to different types of services. Thank you. [applause]

Dion Manley: Hi. I'm going, you know, just to tell me story a little bit and then go into little scenarios for FTM's. And I came out as, I came out in the lesbian community in '75. And I still ID as butch, and I hold my lesbian history pretty close to me. I'm, you know, proud of that. I ID as FTM, and I have for approximately three years.

Really my transition kind of started by me just saying, I'm just going to be more myself. And that was really presenting as male. Or you know, it just was me being myself, but then I had some internalized transphobia, just like when I came out in '75 I had a lot of internalized homophobia. It took me a long time to kind of get through that and unlearn it. So with my coming out as a trans has been, you know, like ten years thinking about it prior to my finally taking some steps and not really calling it that, but slowly but surely getting honest. So to me, you know, being trans is you know, Ilike it was -- for me it was kind of a turn off. I didn't relate a lot to a lot of trans people out there. A lot of my friends who transitioned and, you know, like there's a huge spectrum of ways that we identify in the trans- community as far as our gender identity and our sexual identity -- which are two different things. And a lot of what I thought would really relate to -- so that kind of postponed it for me. I finally, you know heard an FTM talk about -- it is really about who you are in the inside. And that's something that I related to and hold close. It's not really about how much access you have to the medical establishment. Or whatever you choose, you know, to express yourself. It's really about -- and it's, you know, not about surgery if you have or have not had surgery. I mean, I don't identify myself by my surgery, or if I'm pre-op, post-op, or whatever. Like I identify myself by who I am inside. And I want that to be recognized and respected. And who I am inside is a lot more male than female. I have both, but that's just me and it always has been.

So jumping into some medical stories. I'm President of FTM International. We have meetings once a month here. There are other meetings that are huge meetings once a month and, I'm kind of nervous.[laughter] I just want to talk and tell a little story about a youth that comes to -- he takes the bus, about a three hour bus drive to our meeting once a month. And he was leaving early. So of course I noticed, and I went outside to talk to him. And he was saying you know, after we talked for a little while, how he had just gone to the doctor and you know, it was this hugely, horribly traumatic thing. And I just want to like run down -- try and listen -- this is really typical. You know, he, his experience is first he goes in the waiting room and it's all women so he feeling totally out of place, and like in the spotlight. And then he, being a youth, he has to show the receptionist his ID which says he's female, and that's kind of degrading for him. Then he goes in the room with the provider and someone else watching. He says, he doesn't like to admit that these are his body parts. He doesn't want anyone else touching them, or talking about them. And having a self-breast exam demo was totally degrading. The language in the routine questioning, you know, "As a girl...", "Now about PAP's...", "I'm gonna insert the speculum...." All these, you know, his reaction was that he was blushing, sweating, twitching, hiding his chest, just wanting to be out of there, not wanting it to be happening at all. He knows this doctor is trying to be respectful throughout this whole thing, but it really doesn't help.

So at that same meeting I had an FTM come up to me, as far as recently being diagnosed with cancer. So I hooked him up resources, women's cancer resources, and they were, he was totally put off. He lives in his vehicle, and you know, like just a very isolating, kind of demoralizing, degrading, defeating kind of place to be. So I go home and I call a long-time FTM who's been in the community for years and years and years. And he tells me that he's losing his eyesight. And it's the most upsetting thing to him is not that he's losing his eyesight, but that he has to start all over with another provider and, you know, go through the hunt, and go through educating them. And these are all non-transition related medical stuff. This is just getting basic health care. So this doesn't even touch like, trying to talk to or get a provider to deal with transitioning, hormones, and/or surgery.

Invisibility is a very huge thing for FTMs, that's why a lot of us didn't even know FTM's existed until about six months ago. And I didn't either. I didn't know know until about ten years ago. I thought our only option is to go to war to be a man. Go to war pretending to be a man, you know, whatever. So, you know, we're all up here just trying to give you a touch of, you know, the variety without our community and, you know -- the thing is I'm really not a natural speaker or whatever, but I'm really proud to like be a part of our community. And we also have huge amounts of shame, judgment, self esteem issues. And you know, people who are put off by the HBGDA standards, or have experience by like this FTM, this youth, he's like telling me, I'm never going to the doctor again. And that happens frequently, and a lot of people turn to like to popping down to Mexico, or going through the mail or whatever. And they're not prepared for like any -- how to deal with any problems that could arise, or just focusing on the physical.

So one of the things that works the best for me is when my doctor really treats like more than the physical. She touches me -- you know, she doesn't just like totally talk to me from behind her desk; you know, which I've had doctors do that too. And you know, it's important to be talked to. I don't need a shrink or someone, but I need someone to talk someone to talk to me, because it's more than a physical. But she talks to me, you know, its more of a holistic approach that works for me. And you know, that means a lot because it being such a degrading experience, just having that like respect and have contact and, you know, recognition, you know, it made all the difference for me. And it helps me to go back. Because I've never gone to doctors. I don't go to doctors. My family doesn't go to doctors. But I have to, I have no choice.

So I just also want to touch on like, you know, for research. There's almost no research, medical research for FTMs and there's really, you know -- I 'd just really like for people to recognize there's an immediate need for research and studies on long term heath effects for us, dealing with cancer, whether to have a hysterectomy or not, a oophorectomy or not, post-surgery effects, and the effects of taking hormones.

And then the last thing I want to touch on is the other critical areas for us are anger and depression, which is huge -- drug and alcohol addiction is huge. Relapse is huge. And of course, high risk sexual behaviors. So on that note, thank you all for being here very much. [applause]

Lin Fraser: We've covered a lot. It sounds to me like what is needed is the same that anybody needs. To be listened to, to be seen, to be heard. To have some understanding of what your needs are. You answered many of the questions, or some of did, that I had planned to ask after your introductory bios -- and that's just fine. But I want to ask them again and open it up to people to add something. And also if any one has a burning question from the audience about health care, please raise your hands. But the questions, the specific questions again -- what do you want from your health care provider? Things that weren't already mentioned. To enhance your care what do you want your health care provider to know about you, and how do you bring up that you're TG? And what, based on your own personal experience, what works with health care providers and what doesn't work?

Kim Makoi: Something that I thought, you know, a lot of people in the room were uncomfortable just coming out and saying, hey doc I'm TG. It's weird. Maybe on your patient intake form, you know a lot of the intake forms has sex -- male, female. If you had a little box on your form that said transgender, that would be a really discrete, quiet, easy way for someone to be able to let you know where they are without having to make a big show of it. And then you can know for yourself, Okay, this is what this person is. And then if it comes up during care, you will have already known. And it's a very painless, very easy thing to do, and it doesn't have to interfere with your other patients. It doesn't interfere with them either. It's just a real tiny box on your form. And that's the one thing I think that helps.

Lisa: I got lucky in one sense. I know a few doctors and things, and I asked a doctor who I knew was a gay man, and a very close friend, to recommend someone that he felt would be able to work with me. But how do you tell your doctor that you're transgender? I've seen this physician, he's a wonderful man and still my general practitioner. And in the course of the interview he asked me if my periods were normal and regular. [laughter] I gulped real -- four times and said, well, there's something you need to know. But I was scared, I was really scared to do that, and didn't want to do it. And there wasn't an easy way, other than to say, "Doctor, there's something you need to know." I think it would have been very easy to have said, "Yes" to his question, and then move on to the next one.

Veronika Cauley: I remember an experience that I had at the VA Hospital, and it was like in Marion, Illinois. A nurse, a gay nurse came in and sat on the side of the bed and sat down. And I've always wondered how you was able to find me. And I guess these were my HIV care team, unbeknownst to me. So no matter whenever I came there he was always there -- "Hi, how you doing?" On this particular day he came in and sat on my bed, and we were talking and he said, "Well, you know, you're not a real woman." And I said, "Excuse me?" And he said, "Well, you know, you're not a real woman." And I said, "You know what, get the expletive out of my room." And I left through the front desk and I asked to see the administrator of the Hospital because, you know, I know myself better than anybody. I felt horribly insulted that he would sit on my bed and tell me who I was, because he didn't know me.

He doesn't know of my experience and what I've been through. And real is real. And real is how you perceive it, and how you are. And that's, you know, so I was very upset that he would come to me and say that. So that was a horrible experience. And then I remember before him saying that "we won't say that you're a transgender," I had no trouble with saying it. But before I used to not say it, when I would go to the Emergency Room or something, they would throw you in a bed or in a room with a pregnant woman. And then they would go read my chart, and then they'd come and rush me right out and move me somewhere else, you know, in amazement. Another horrible experience that I had at the hospital was when I had a bladder infection, and because I was trangender, I think they just really tried to like almost hurt me. When they put the tube in my urethra, the doctor just cut the end of it, the catheter off. And it was jagged and rammed it on up in me. They were gonna put some dye in me, and I had blood and pain for days afterward. And I think it was just because I was transgender and they were trying to punish me for being who I am. And I think that is horrible.

I think that is what we need to guard against and have people more aware so that we can be respected in the way that we're treated. Now all of my experiences are good. My doctor gives me a breast exam on request, and, you know, I get a Mammogram when I need one. I'm 47 going on 48, and I've been around for awhile, so I'm very comfortable when I go, and I don't have a problem telling them. There is another thing, I keep hearing about this shame, this shame that I'm supposed to be laden with, that's supposed to be all over me. And I just don't feel any, you know, I don't think the shame applies to everybody. I'm not ashamed of who I am, you know? I'm very proud. And so this shame that I keep hearing about -- I went to an AIDS Camp, and they said, well, you know, you all are covered with shame, and you have this shame. I don't have any, you know. I'm not ashamed, I have no shame.

Crystal Catamco: I've had the same experience as Lisa. I've been asked how's my period cycle or menstruation cycle, and I waited for a while to answer it; and the doctor was just looking at me, and I was so scared and embarrassed actually, too, to tell him that I was a transgender person. But I decided anyway to tell him; and he was just, you know, he was just shocked and looking at me, and told me that "Oh I couldn't even tell." And I was like, "Oh really?" So and then that's where I started, you know, telling him my history and what I wanted, what I might need the clinic for. And before that, I -- what I do is I call different doctors that accept different insurance. So what I did is go through the list and call the doctors and see if they have, if they see transsexual clients, or how many transsexual clients they have. So I know what kind of experience they have.

And also I think one of the recommendations, too, that if you wanted to know more information on how to serve the transgender population, is you can contact different agencies and get in-service training for your staff in your facility, facility staff. We can do that too. There's many different organizations. One of them is my agency, which is the API Women's Center. And the Human Rights Commission does that type of in-service training. Projecto Contra SIDA por Vida, there's the Tenderloin AIDS Resource Center that you can ask for in-service training.

Dion Manley: CUAV also does training, the Training Pacific Center, and you can also get speakers through FTM International that do it as well.

Lin Fraser: Any questions from the group?

Audience Member: Let me have one of those hand-held mics.

Veronika Cauley: One more thing that I wanted to say was that on the -- when you talk about the gender, you have male, female, and transgender in the little box, don't assume that transgender is, you know, they go the whole spectrum. So transgenders have sex with men, sex with women, sex with each other, sex with, you know. I mean, so you need to list that next to it, and say who do you have sex with? And put a box for "other." So that you can identify who they're having sex with. And don't always assume that they're having heterosexual sex or, you know, gay sex, or whatever. I mean, that needs to be identified because there are transgenders that are lesbians and go the full spectrum just like anyone else. So that was what I wanted to say.

Audience Member: According to you -- Kim suggested earlier that you should have that little box on your forms that says transgender. It also would be very helpful for you to have two little boxes besides that. If just write down MTF which is male to female, or FTM which is female to male. And then you could ask them later about their sexual practices. Thank you.

Audience Member: My question is for the insurance expert. I think it's Lisa? For some people it's been proven that sexual reassignment surgery, it's a mental or health issue -- why is it that insurance does not want to cover it?

Lisa: Oh Christ. [laughter] Coverage is a very, very difficult question in general, and one of the charts that the San Francisco Health Project had was that something on the order of less than 25 percent of the individuals identified had some form of surgery, yet close to 75 percent of the individuals wanted to have surgery. How distressing is it when you've got half of the population that is desiring medical care, needing medical care, and the only reason they're not receiving it is they don't have the funds for it. Even those who are covered by insurance largely, there's tremendous discrimination. I've written articles and I can go on forever on insurance coverage issues.

Most of the law on this stems from a number of cases that were handled in the Federal Circuit Courts in late 1970's and the early 1980's. And case after case after case laws that existed, mostly in medicare type funding situations were overruled, and it was found that surgery was a medically appropriate procedure given the medical standards that says this is a treatable condition and should be recognized. There was a case out of Georgia in about 1983-1984 in which Georgia argued that this was an experimental procedure, and the results could not be predicted. And therapists who I would like to see in a very closed room -- argued very, very strongly that this was experimental and that it shouldn't proceed. And on the basis that it was experimental, it was possible for Georgia to deny it, and that was the [inaudible] appeal. Shortly thereafter president Reagan and President Bush eliminated almost all funding for Legal Services Agencies. It was largely Legal Service Agencies that were prosecuting these cases and prosecutions fell. The former head of the Legal Services Administration under President Bush has publicly stated on a number of occasions that one of the primary reasons for doing away with funding of the LSA was that they were getting into things as crazy as bringing lawsuits to see that people could have sex changes.

Most of the insurance policies say "No services related to sexual reassignment" as an exclusion. And you have to be very careful and have to challenge the carriers: What do you mean by that? "No services related to" could be extended, anything from diagnosis on through post-operative care. Could be, has been. So I don't want to cut short your question, but obtaining coverage requires that there be a medical condition. For a medical condition they have to have medical protocols and define what appropriate gender care is supposed to be; and you have to have a condition that is treatable. And I know some in the community say that that is following a medical model. For coverage, in my experience, you have to have a medically treatable condition. If all this is, is a social condition, then it's not something that would be covered under health insurance policies.

Lin Fraser: I think we're going to have to stop. I want to thank all of you. [applause]