Meeting the Healthcare Needs of Transgender People

In the early 1990s, when Robert Beil, MD, came to Montefiore for his residency in social internal medicine, his enthusiasm about working with marginalized populations was mixed with anxiety. AIDS was ravaging New York City, causing more than 8,000 deaths a year. Treatments were not effective enough. And as a gay man, Dr. Beil feared that he, too, might die of the disease — and he had no desire to specialize in AIDS care. “I didn’t feel like I could specialize in taking care of HIV-positive patients while also thinking about having to deal with that as my own personal fate,” he recalls.

By the time Dr. Beil became chief resident in the social medicine program at Montefiore in 1996, the outlook for AIDS patients had changed dramatically. Effective drug combinations dubbed “highly active antiretroviral therapy” had been introduced and were performing miracles. “It was the most amazing thing any of us will ever experience,” says Dr. Beil. “People on the verge of dying were recovering their health within months. It’s really hard to experience something like that with patients and not want to do that for the rest of your life.” And so he has.

In 2001, Dr. Beil became the medical director of the Center’s Implementing Clinical Excellence & Restoring Opportunity (CICERO) program, which serves more than 1,000 HIV-positive patients at Montefiore sites throughout the Bronx. Over the next two decades, Dr. Beil, who is also an Assistant Professor of Medicine at Einstein, would make it his mission to expand healthcare to lesbian, gay, bisexual, transgender and queer (LGBTQ) individuals.

Those efforts culminated in the TransWellness Centers at Montefiore Einstein, an initiative that Dr. Beil directs. It provides comprehensive healthcare to people whose gender does not match their sex assigned at birth. (Find out more about LGBTQ health education, research and clinical care at Montefiore Einstein here.)

The acceptance Dr. Beil found at Montefiore Einstein is what motivated him to create a more informed, welcoming environment for others. “I found a community at Einstein and Montefiore of gay and lesbian residents and faculty,” he says. “That really set the stage for a career working toward improved access to quality healthcare for LGBTQ folks.”

We caught up with Dr. Beil to discuss how far care for LGBTQ individuals has come in the past 25 years and what unmet needs remain.

When I was coming of age in the 1990s, the gains for LGBTQ equality centered on white, professional, cisgender [those whose birth sex aligns with their sense of personal identity] gay men and lesbians — gains that didn’t really help the people in the Bronx I was caring for, who were largely Black and Latinx. The Bronx was still a dangerous place to be an out queer person. A lot has changed to make this borough a more hospitable place for queer folks, particularly the people of color who make up the majority of Bronx residents. I certainly don’t take credit for that transformation, but I feel that my work as a practitioner and the organizations I’ve worked with have played a role in helping create that reality.

When I first got to the Bronx, not many practitioners were taking care of transgender folks. So I found people in New York City who mentored me, and I learned how to do it. Years later, the medical societies started to make it clear that transgender healthcare was mainstream healthcare — that all transgender and nonbinary people had a right to their gender identity and to seek gender-affirming care. It was a huge shift, and it happened over the course of about 10 years, from around 2005 to 2015.

About eight years ago I started pulling together a group of people with an interest in this work — surgeons, primary-care physicians, researchers, endocrinologists and more — to form the Transgender Health Working Group. We met regularly to figure out how to improve Montefiore’s ability to offer comprehensive care to trans folks. At the same time, from senior management on down, the institution was interested in addressing the vast unmet healthcare needs of the trans community in the Bronx. Those efforts coalesced into the TransWellness Centers at Montefiore Einstein.

Some of my colleagues and I get an increasing number of hours during the course of students’ medical education to lecture on LGBTQ health, and we also teach during residency. Most providers practicing medicine today did not receive much — if any — training in sexual- or gender-minority care. Not only do we need to teach future physicians about sexuality, gender and identity; we also need to retrospectively educate healthcare practitioners who never received that training.

One of the advancements I’m most excited about is the Montefiore Sexual and Gender Minority Grand Rounds, which we’ve been able to provide due to some funding from the Bronx Community Health Network. We’ve been doing this for a year and have received very positive feedback. With the pandemic, we’ve delivered these lectures over Zoom videoconferencing, and honestly, that has made it possible to build a wider audience. It’s exciting to be able to dive deeper into the healthcare needs of our vulnerable population and be able to deliver information to a multidisciplinary audience throughout Montefiore Einstein.

A lot of the HIV work I’ve done at Montefiore has been funded through government support, but not transgender care. Similarly, many of the efforts I’ve advanced with community-based organizations have been through a mix of philanthropic and government grants, though a lot of those programs have aimed at treating and preventing HIV — with transgender and gender nonbinary [TGNB] work as a product, but not a goal.

My hope is that we can increase funding for hospital-based TGNB care. I think there’s a perception that, because gender-affirming care involves surgery, the programs then pay for themselves. The reality is that launching a comprehensive gender-affirming program takes a very significant investment well before there are reasonable amounts of collections.

A smaller effort that we would like to get funding for is a micro grant program for electrolysis hair removal for TGNB patients. Electrolysis is exceedingly expensive and rarely covered. Financial support would increase the speed of their transitions. A more limited philanthropic grant could make a huge impact in individual lives.

The work we’ve done through the TransWellness Centers is all on our own time and without any additional financial support from outside Montefiore. With funding, we could do so much more to build up the program for our patients. There’s a saying that “support begets more support.” We need staff to write grants, more clinicians to provide care and a patient navigator to help guide people through the system. We need support to develop community partnerships and to get the word out about the terrific work we’re doing. That capacity-building progress would be huge for our mission.

The TransWellness Centers encompass multiple centers of care for transgender people throughout Montefiore. I think it would be a tremendous step forward — for Einstein, Montefiore and the Bronx’s TGNB community — to have a single location where people could go to receive comprehensive care. Centers like that take quite a bit of funding for medical staff, administrators, clerical staff and operating costs like rent. It’s no small undertaking.