MACON, GA.

For years, Newell overcompensated, dressing in pink and experimenting with makeup, as other girls his age seemed to be doing. Eventually, he couldn’t fake it any longer.

It took time for Newell to make sense of what he was feeling. Only after hours behind a computer screen, scouring the internet for answers, could Newell put a word to his experience.

At 16 years old, Newell realized he was transgender.

Coming out to friends and family in his conservative community in Augusta was agonizing. Classmates teased him at school and relatives struggled to understand his gender identity.

It’s been easier for the Mercer University sophomore to live openly as a male since getting to college, but he still faces stumbling blocks.

Accessing health care has proved one of the most difficult obstacles yet.

Newell’s student insurance covers primary care and weekly mental health therapy sessions at the Macon Counseling and Psychological Servicescenter, but he hasn’t found any doctors in Middle Georgia who specialize in care for transgender patients. Most of the resources are in Atlanta, Newell said, and he doesn’t have a car to drive there.

Newell has considered dressing as a woman for doctor’s appointments, just to avoid uncomfortable questions. That’s not an option he wants to pursue.

“I think people don’t understand and probably will never understand the degree of distress involved in that and in being misgendered, especially in a medical context,” Newell said.

For now, Newell is putting his health care on hold.

LACK OF RESOURCES FOR A POPULATION IN NEED

About a quarter of transgender individuals in Georgia chose not to see a doctor when they needed treatment out of fear of discrimination, according to the 2015 U.S. Transgender Survey. Nearly half avoided the doctor’s office because they could not afford it, the survey found.

Lack of access to health care could pose a dire risk, especially for a population that suffers disproportionately high rates of mental illness.

Transgender individuals often feel that their sex assigned at birth does not match with their gender identity. Many suffer from gender dysphoria, a mental health condition recognized in the latest edition of American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

Multiple studies have found transgender individuals face higher rates of depression and anxiety than their counterparts in the general population. They also attempt suicideat drastically higher rates.

High incidences of hate crimes and sexual violence against transgender individuals have stoked a sense of fear in a group often pushed to the margins. It’s also prevented some transgender patients from seeking out health care, said Kwajelyn Jackson, executive director of the Feminist Women’s Health Center in Atlanta.

“Social stigma, discrimination, bigotry are definitely issues that make it challenging for folks to seek services in traditional health care systems,” Jackson said. “So, if you are going into a space to get your care needs met and you’re immediately misgendered or you notice people’s, like, physical discomfort when you come into the room, that’s not a place where you want to stay and get care.”

It can be especially difficult for transgender individuals to access health care in Georgia.

The state doesn’t protect against discrimination on the basis of gender identity, even in the case of employment or health insurance coverage. Georgia’s Medicaid policyexcludes coverage for “transsexual surgery” and its state employees are not insured for transgender or transition-related care.

No state in the U.S. has fewer gender identity policy protections, according to nonprofit think tank Movement Advancement Project, which researches state-by-state policy disparities.

“The lack of will to protect the folks who are in so many ways the most vulnerable, the most marginalized, is really, you know, disheartening” Jackson said. “There’s a lot of work to be done, I think, in order to try to create the world that we want to see where folks can get what they need.”

The nation’s largest medical associations, including the American Medical Association, the American College of Physicians and the American Psychological Association, have recommended that public and private insurers cover gender identity-related health care, which they deem medically necessary. But many insured transgender patients are still denied coverage.

Houston County resident Anna Lange was scheduled to undergo gender reassignment surgery on Jan. 31. She’d made multiple calls to her insurance provider to work out the details and had rented out an Airbnb for her three-week recovery in New York. Days before the procedure, she found out her insurance plan wouldn’t cover it.

Lange has worked for the Houston County Sheriff’s Office since 2006 and came out as a transgender female in 2017. She’s already spent about $15,000 out of pocket on hormone therapy and cosmetic procedures but hoped insurance would cover the final step in her gender transition.

The county’s insurance provider originally told Lange her treatment would be covered. She later learned her employer had opted to exempt gender reassignment surgery from its self-funded Anthem Blue Cross and Blue Shield health insurance plan.

Lange was devastated. She said she felt like the county didn’t value her as an employee.

“I work hard for the people of Houston County,” Lange told The Telegraph. “What I’m asking for is medical care. It’s not unreasonable.”

At a Feb. 19 Houston County Board of Commissioners meeting, Lange asked the county to include transgender-related care in its insurance plan. County attorney Tom Hall said the County Commission would not change its health care policy this year and advised commissioners “not to discuss this matter due to potential litigation.”

Lange’s lawyer plans to file a complaint with the Equal Employment Opportunity Commission. Houston County Attorney Tom Hall did not respond to multiple requests for comment for this story.

MAKING SACRIFICES FOR HEALTH CARE

When insurance coverage isn’t an option, transgender patients face a unique set of barriers. The majority of patients at the Feminist Women’s Health Center’s Trans Health Initiativeare uninsured, Jackson said.

“There are many times where individuals have to make choices about what they’re going to prioritize,” she said. “So, if their hormone therapy is key, what we have seen is that folks will possibly sacrifice other financial obligations in order to make sure that they’re able to consistently have that prescription filled.”

Money isn’t the only issue. As awareness about transgender identity and gender dysphoria gradually grows, many health care providers are still catching up with best practices.

At the Trans Health Initiative, Jackson said, it’s been difficult to hire enough physicians to meet the clinic’s demand, especially to treat transgender women who were born with male genitalia.

“That’s one of the things we’ve been working on over the past, maybe, two years, is hiring additional providers, developing additional protocols so that we can expand our services to anyone who needs it and not have to turn away patients because we don’t have the capacity to serve them,” she said.

Trained practitioners are especially scarce outside of major cities. Jackson said patients travel to the Atlanta health center from across Georgia, and even from out of state, for care. Lack of transportation adds another layer of difficulty for such patients, she said.

For many transgender patients, though, traveling hundreds of miles for health care is worth it. Patients want to know they’ll be treated in a comfortable environment, Jackson said.

Many transgender individuals hesitate to seek out health care from an unknown medical provider, because they’ve had a bad experience in the past, said Stacy Sampson, a certified sex therapist at the LGBT-friendly Oasis Counseling Center in Athens.

“They’re going into every new medical situation with fear,” she said. “Even if they’re engaging with a medical practitioner who might be fine, maybe where that individual is at that point in time emotionally, they’re struggling to advocate for themselves or empower themselves or even ask simple questions like, ‘How up are you on transgender issues?’”

Sensitivity is important when treating transgender patients, Sampson said. Well-intentioned mental health professionals aren’t always equipped to counsel transgender individuals, she said. Therapists who haven’t undergone additional training might ask questions that make patients feel uncomfortable or judged, Sampson said.

“That’s not helping you when you’re already anxious and you’re already depressed,” she said.

Sampson added that some counselors feel awkward delving into questions of gender identity.

“A lot of therapists, even if they’re lovely, wonderful therapists, feel uncomfortable and don’t know the ins and outs of working with someone who’s transitioning from one gender to another,” she said. “And you need to be comfortable and you need to not be afraid to ask them questions about their sexuality, questions about their partner, questions about, you know, their support system.”

Other therapists, she said, might see transgender identity as a disease that must be cured. The American Psychiatric Association declared conversion therapy unethical in 1998. Georgia is one of 35 states with no lawbanning conversion, though representatives proposed a bill in the Georgia General Assembly this month to prohibit the practice.

“We’re in the Bible Belt,” Sampson said, “and, unfortunately, there are some therapists that their perspective when working with a trans individual would be to cure them of that.”

About 700,000 LGBT adults have received conversion therapy and about 80,000 youth will undergo such treatment from either a licensed health care professional or religious adviser before they turn 18, according to estimates from the Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy at the UCLA School of law.

Late psychologist Joseph Nicolosi, Sr., founder of the controversial practice known as restorative therapy, once wrote: “every effort should be made to help a gender-disturbed boy accept his biological maleness, and be comfortable in life with the intact (not surgically mutilated) body with which he was born.”

Multiple studies and surveys, however, have found that conversion therapy is not only ineffective, but can also cause psychological harm. A 2016 American Academy of Pediatrics paper found that transgender children have better mental health outcomes when they are supported in the expression of their gender identity.

Sampson tries to “meet people where they’re at.” She relies on her patients for direction on their preferred gender pronouns and seeks to provide them with the support they need to be “their most genuine, authentic self.”

There’s no one-size-fits-all model for transgender patients, Sampson said. Some of Sampson’s clients continue to live in secret. They come out to her as transgender and then never open up to family and friends or choose to transition. Others leave her office and find renewed confidence in the gender identity they’ve hoped to express for years.

“It’s fascinating, just by making those transitioning changes, how much of their depression and anxiety relieves,” Sampson said.

The therapist has found such steps often go beyond the effects of medication or cognitive behavioral therapy.

“Just by having the outside of their person and the inside of their person align and feel authentic and feel congruent, how much that alleviates their distress is amazing,” she said.

Health care providers at the Trans Health Initiative also emphasize the importance of health care without judgment.

“For trans folks who may not feel safe or welcome, we want to try to be a respite and be a place where people can go and feel safe,” Jackson said.

HOPE FOR THE FUTURE

Sampson thinks things will be better for younger generations. New innovations, like telehealth, can provide both physical and mental health care to patients outside of major urban hubs. Kids and teens also seem to feel more comfortable in their own skin, she said.

Coming out as transgender has taken a toll on Newell’s mental health. He constantly wonders what people think of him when they pass him on the street.

“I definitely worry a lot about, like, can people tell? Are they going to, like, do something? You know, when’s the day I’m going to be the victim of a hate crime?” Newell said.

It might sound absurd to most people, he said, but Newell thinks his fears are justified.

Newell hopes health care providers will take steps to learn more about how to care for transgender patients. He wants to find a doctor who understands what he’s going through and will treat him with respect.

One day, Newell plans to medically transition. But right now, it’s not an option. He can’t afford it.

Newell is trying not to think about that process too much. First, he has to graduate from college and find a job — hopefully one with a health insurance plan that will meet his needs.

“I would definitely love to get a job that would offer trans-inclusive health care,” Newell said. “But I am not holding my breath for that.”

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