Like many in his community, S.F. Makalani-MaHee spent a lifetime avoiding doctors — particularly the gynecologist, a physician who specializes on an area of the body that has always felt foreign to him.
Born a female but identifying as a man, the Fort Lauderdale community activist dreams of having surgery to complete a transition fulfilled in every other way but one: He still has a woman's genitalia. Changing that would mean going to the doctor and risking the very experiences he has long dreaded: ugly incidents that experts and studies say are all too common for the transgender community.
In an effort to improve the quality of and access to health care for what it calls "a small but substantial population," the American College of Obstetricians and Gynecologists is urging OB/GYNs to create a more open, welcoming environment for transgender patients.
The hope is to make a dent in the abusive treatment that traditionally has scared this unique community away from doctors. The snickers and stares from the nurses ' station. The irrelevant questions about birth control and family planning. Judgmental looks, statements and — for 2 percent of the population, according to a recent study — outright violence and physical harassment from doctors and staff. Some have even been refused treatment.
"The ignorance runs its course," said Makalani-MaHee, who hasn't had a pap smear in more than a decade after several uncomfortable doctor's visits. "A lot of us have avoided these types of experiences."
A recent survey found that almost 30 percent of the transgender community postpones care due to discrimination concerns. Transgender people represent 1 to 3 percent of the U.S. population (or 3 million to 9 million Americans) and 1.5 percent of Florida's population (or 200,000 Floridians), according to what many consider highly conservative estimates from the Florida Organization Regarding Gender Equality.
For its part, the medical community is becoming increasingly concerned about the obvious health implications.
In the December issue of Obstetrics & Gynecology , ACOG issued a committee opinion recommending that doctors add a transgender option to their patient forms; post a non-discrimination policy in their offices; train staff to treat transgender patients with respect and sensitivity and offer them the same routine care and screenings they give others.
Defined as someone who strongly identifies with the other sex, a transgender often lives full time in the cross-gender role, but he or she does not always seek surgery to complete the transition — either because of financial limitations, fear of discrimination or similar factors.
The fears are well-founded. A 2011 study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force found that 19 percent of 6,450 respondents had been refused care due to their transgender status; 28 percent were subjected to harassment by medical personnel; and 2 percent were victims of violence in doctor's offices.
"The consequences of inadequate treatment are staggering," the ACOG opinion states, noting high suicide and self-mutilation rates among transgender people, more than half of whom also seek illegally obtained hormone or silicone injections from unlicensed providers.
And then, of course, there are the illnesses and diseases that, without routine preventive care, go undetected — until it's too late.
"It's a flipping tragedy when you have someone with Stage 4 cervical cancer , and you find out that the reason they haven't had a pap smear in 20 years is because the first doctor they saw was mean," said Dr. Lanalee Araba Sam, a Fort Lauderdale OB/GYN. "With that first exam, you've got to make it good, or they'll disappear into the woodwork forever."
Gynecologists, especially, can prove critical to a transgender patient's care — for transitioning males who still have female biological parts; for transitioning females taking hormone injections; and for those going through gender-affirmation surgery.
For the past several years, Rajindra Narinesingh, 44, has been getting her estrogen hormone injections from an open-minded and friendly general practitioner. But she's leery of trying out any more doctors after an earlier experience with a snickering, giggling nursing staff.
Born a man but living as a woman, Narinesingh wants surgery to complete the transition, but she's put off a final decision, partly because of financial concerns and partly for fear of discriminatory treatment. The ACOG recommendations, though, give her heart that she may one day feel comfortable enough to fulfill a longtime goal.
"Do you realize how comforting it would be to know the OB/GYN community would be open and receptive to it?" the Hollywood resident said. "It's definitely a plus when you're factoring in life after surgery. That's a very big step for a trans-person."
Gynecologists like Sam already have taken the step, making their waiting rooms more unisex, their questionnaires more trans-friendly
and their staffs more sensitive to a diverse patient population. Such changes, said Makalani-MaHee, 39, are "going a country mile in welcoming and affirming" patients like him.
His quest for gender affirmation surgery, and Sam's welcoming practice, have inspired Makalani-MaHee to make an appointment for that long-dreaded gynecologic exam.
In the nine years since she's been a practicing OB/GYN in South Florida, Sam said she's noticed a gradual difference in the gynecological field's openness to LGBT patients, a receptiveness reflected by ACOG's recommendation. And she attributes the evolution to the fact that young doctors specializing in gynecology today are overwhelmingly female and grew up in a more tolerant era.
"I feel that the Hippocratic Oath — do no harm — includes 'have some charm.' The thing that needs to be recognized is customer service and respect for your patient, and that excludes your biases."
Still, the old-fashioned biases remain pervasive, and "a large percentage" of gynecologists will ignore ACOG's appeal and won't change their practices, she predicted.
"But those that are cognizant," Sam said, "will smile and go, 'The world is changing.'"