36 minute read
UIHC LGbTQ Clinic
Changing Medicine
Through specialized care, UI’s LGBTQ Clinic has saved countless lives in its first decade.
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by aDrIa CarPeNTer
When Dr. Nicole Nisly met her first transgender patient, she didn’t know what to say. It’s common among healthcare providers. What name should I use? How should I refer to them? Should I ask? Her patient was a trans woman who had transitioned 10 years prior, and Nisly could feel the tension in the air. She was unprepared.
For trans people, that unease is instantly recognizable, and it comes in different flavors, ranging from well-intentioned curiosity to outright disgust. Around a third of trans people reported having at least one negative encounter with a healthcare provider because they were trans, including verbal harassment, refusal of treatment or having to teach their provider about trans people to receive care. A fourth said they didn’t see a doctor when needed because of fear of mistreatment, a survey by the National Center for Trans Equality (NCTE) found.
“We’ve had a few providers that just say, ‘We’re not going to take care of an LGBTQ patient,’” said Bridgette Hintermeister, a registered nurse at LGBTQ Clinic at the University of Iowa Hospitals and Clinics (UIHC). “That is one of the areas of discrimination that we see. They don’t feel comfortable, and they don’t want to learn.”
But Nisly resolved that next time, she’d be prepared. In November 2011, she went to a seminar led by a student group called TransCollaborations. The group, consisting of mostly gender nonconforming people, shared their stories about interacting with the healthcare community.
The students said that hospitals were often inhospitable towards them. Between the lack of properly trained physicians to staff that didn’t
Timeline of Medicaid bans and lawsuits in Iowa
Mika Covington called it “an emotional day” when a judge ruled last year Iowa couldn’t prevent Medicaid from paying for the genderaffirming surgery she needed. The path to that legal victory for Covington and all transgender Iowans started 14 years earlier.
March 2007
The state legislature, with both chambers controlled by Democrats, passes a bill amending the Iowa Civil Rights Act (ICRA) to prohibit discrimination “based upon a person’s sexual orientation or gender identity.” Gov. Chet Culver signs it into law.
ACLU of Iowa
August 2017
Jesse Vroegh, a transgender man and former Iowa Department of Corrections employee, sues IDOC for refusing to make reasonable accommodations for him as he transitioned genders. It’s the first lawsuit to rely on the ICRA’s gender identity protection.
use the correct name or pronouns, to the general pricks and thorns of an unequipped healthcare system, they had to regularly out themselves just to find a clinic willing to help them.
While listening to their stories, Nisly, then the chief diversity officer for the University of Iowa, thought about her own discomfort and lack of
By Paul Brennan
September 2017
Carol Ann Beal and EerieAnna Good sue to overturn the state regulation banning the use of Medicaid funds for gender-affirming procedures prescribed by their doctors. Vroegh, Beal and Good all receive legal support from the ACLU of Iowa.
June 2018
Polk County District Court Judge Arthur Gamble rules in favor of Beal and Good,
training.
“There was a great opportunity to kind of really transform the healthcare based on their feedback, and I felt like we needed to do something,” she said.
At the seminar, she met Dr. Katie Imborek, who was finishing her residency at UI. Imborek
finding the state’s ban on the use of Medicaid funds violates the ICRA and the Iowa Constitution guarantee of equal protection. The Reynolds administration appeals the decision.
February 2019
Vroegh wins his case. The jury finds the state engaged in illegal discrimination and awards him damages and legal fees.
March 2019
The Iowa Supreme Court upholds the lower court decision in Beal’s and Good’s case on grounds the state regulation violates the ICRA. The justices don’t address the constitutional issue. The Divine Non-Binary, 6’10” x 3’2” pastel, 2020; The DivineTransfeminine, 6’10” x 3’2” pastel, 2020; The Divine Transmasculine, 6’10” x 3’2” pastel, 2020, by Charlie Esker
had founded a medical student LGBTQ group. Together they began work on what eventually became the LGBTQ Clinic.
Beginning as a one-night-a-week service, the LGBTQ Clinic now serves between 13,000 and 15,000 people, around 70 percent of which are transgender or gender nonconforming patients, Nisly estimated.
The clinic provides treatment for chronic diseases including depression and anxiety, contraceptives, HIV testing and prevention, immunizations, family medicine, internal medicine, obstetrics and gynecology, urology, dermatology, urgent care and sexually transmitted infection (STI) testing and treatment.
For trans patients specifically, the clinic offers hormone replacement therapy (HRT), laser hair removal, physical therapy, social work, speech therapy and gender-affirming surgeries. Those include bottom surgeries like zero- or full-depth vaginoplasty (the construction or repair of a vagina), orchiectomy (removal of testicles), hysterectomy (removal of the uterus), oophorectomy (removal of ovaries); top surgeries, such as breast augmentation or masculine chest reconstruction; and other surgeries including facial feminization and tracheal shaves.
The clinic also has pediatric endocrinologists and family medicine physicians who see transgender and gender nonconforming children and adolescents, and can provide puberty blockers.
“We’re here to create a welcoming safe space, where people can thrive and get good healthcare,” Nisly said.
Charlie Esker is one of Nisly’s patients. Originally from Cedar Rapids, Esker majored in integrated studio art and minored in psychology
40% of trans people have attempted suicide in their lifetime
46% have been verbally harassed
9% have been physically attacked
30% have experienced homelessness in their lifetime
77% have faced discrimination in K-12 education
27% were fired, denied a promotion or not hired because of their gender identity or expression
47 trans and gender nonconforming people were killed in 2021
at Iowa State University. They want to pursue an art career, working mostly with acrylic paints and chalk pastels, but they could see a future in education.
“I would consider myself an artist,” they said, “That’s my passion.”
In junior year of college, Esker realized that they were nonbinary.
“I identify as nonbinary, but definitely more on the femme side,” they said. “I definitely present feminine all the time. I mean, except maybe when
ACLU of Iowa
May 2019
Republicans in the Iowa House and Senate push through a new law reinstituting the ban on the use of Medicaid funds. Gov. Kim Reynolds signs it. The ACLU of Iowa files a lawsuit on behalf of two trangender Medicaid patients, Mika Covington and Aiden Vasquez, whose doctors have prescribed gender-affirming procedures.
August 2020
The Iowa Court of Appeals dismisses the case because the state hasn’t rejected Covington’s and Vasquez’s Medicaid applications yet.
April 2021
The ACLU of Iowa files a new lawsuit on behalf of Covington and Vasquez, after the state rejects their applications.
November 2021
Polk County District Court Judge William Kelly rules in favor of Covington and Vasquez, and issues a preliminary injunction against the 2019 law. Kelly finds the state presented “no facts” to justify its ban on the use of Medicaid funds for gender-affirming procedures.
I wake up right in the morning, or go to the gym, or throw on sweatpants when I’m really lazy.”
Through their art, Esker is re-illustrating how we perceive trans people. In college, they created “larger than life” portraits of trans bodies using roofing paper and chalk pastels. They wanted to counter the stereotypical portrayal of trans bodies as inherently sexual, or conversely gross and disgusting.
“It’s really just a celebration of trans bodies portrayed in a way that is divine,” they said.
Esker wants to take their transition slow. They came out four years ago but didn’t consider medically transitioning until two years ago. They have their third appointment with Nisly this month.
Originally, they visited a clinic in Ames in 2021 to start transitioning. But the process there was “rushed.” The provider didn’t ask about Esker’s transition goals and didn’t provide many options or information.
After graduation, they moved back to Cedar Rapids to care for their grandmother, who has Alzheimer’s. Instead of continuing care at the Ames Clinic, they came to the LGBTQ Clinic.
“I was given a lot more resources, like physical packets of information on how to legally change your name, how to change documents like driver’s license, how to advocate for yourself in the workplace,” they said. “A lot of those things come into holistic care for people, especially for trans people. And so the difference from the Ames clinic to the Iowa City clinic was like night and day.”
Simple courtesies, like asking for correct names and pronouns, came as a relief. Esker talked with Nisly about what feminizing effects they wanted from HRT, the timeline for physical changes and regular blood work.
“My goal is to just be a little bit more happy in terms of my, like, physical outward appearance,” they said. “It’s the main reason I sought trans healthcare.”
After their conversation, Nisly prescribed them estradiol patches. The Ames clinic never told Esker that patches, instead of oral medication, was even an option. In three months, Nisly will check their hormone levels, and Esker will decide to increase or decrease the dosage, or keep the levels constant.
“She was amazing. Like the clinic itself there, sitting in the lobby, just the feeling was so much different than the Ames one,” they said.
Building a new LGBTQ Clinic, the first of its kind in Iowa, took a year’s worth of planning. Nisly approached then-UI President Sally Mason with a plan and received her full support. She reached out to deans and department chairs, fellow colleagues and most importantly, to the LGBTQ community itself.
“We realized very quickly that, you know,
Lucy Suarez
When Lucy Suarez decided to transition,
the metalhead musician made the call to keep her voice as it was.
“Obviously I still kept the low voice,” she said. “I can rock a baritone. … I know where [my voice] naturally resonates and I stick to it.”
She studied composition at the University of Northern Iowa, and she can play guitar, bass, saxophone, trombone, a “little bit of percussion and a little bit of piano,” in addition to being a vocalist. She’s made her own music independently, played in a Christian band (“when I was still Catholic,” she says) and a bar band. But recently, she decided that what she really wanted to pursue is video game design.
“I got fed up with settling for what was expected of me,” she said of the radicalseeming switch to a discipline that she has always been intrigued by, but never felt confident enough to attempt.
“I got paid $1,000 to write a piece for my high school concert band,” Suarez explained. “This happened about a year ago, because it was supposed to be kind of a tribute to all those who suffered during COVID, during quarantine.
courtesy of Lucy Suarez
being a physician is not enough of a tool for you to create something like that,” Nisly said. “We need, really, the patients’ input and their lived experiences to help frame what a clinic should be like.”
They created focus groups of LGBTQ pateints and reached out to national LGBTQ groups, asking questions like:
What would your ideal clinic for LGBTQidentified people look like? Help us imagine a
program where you would feel safe and comfortable participating.
What unique services and programs are lacking at ours and other typical medical institution? What do you need for your health care that we do not currently offer?
What are the barriers to your care at our institution? How would you change or remove them, if you had the power and resources?
“It became clear that it was not just medical care, but we really needed structural change. And we also needed some help from other professions,” Nisly said. “We begin using our connections to kind of create basically a team, you know, a little village around our concept of trying to develop the LGBTQ Clinic.”
The clinic looks at patients holistically, addressing their mental and social needs as well as their physical ones. While the clinic is open to everyone in the LGBTQ community, trans people face more barriers to healthcare, so they designed the clinic around those needs. For example, around 40 percent of trans people have attempted suicide in their lifetime—nearly nine times the national rate in the U.S. of 4.6 percent, the NCTE survey found.
This may be because 40 percent had neutral or unsupportive families (which increases the likelihood of suicide); 47 percent had been sexually assaulted in their lifetime; 46 percent had been verbally harassed; 9 percent had been physically attacked; 30 percent have experienced homelessness at some point in their lifetime; 77 percent have faced discrimination in K-12 education; 15 percent were unemployed (three times higher than the national rate); 27 percent were fired,
denied a promotion or not hired because of the gender identity or expression; 58 percent who interacted with law enforcement experienced mistreatment; and so on. For BIPOC trans people and those with disabilities, these numbers increase. And Republican state lawmakers perpetually pursue anti-trans legislation. The Iowa Civil Rights Commission received 30 complaints relating to gender identity in FY 2020, according to their annual report. Nationwide, 227 people were victims of gender identity hate crimes in 2019, the Federal Bureau “THEy TOLD ME THaT, ‘I HaVE My SUICIDE of Investigation shows. In 2021, at least 47 trans PLaN HErE, aND I’M rIPPING IT UP bECaUSE and gender nonconforming people were killed, I HaVE HOPE.’ SO THaT WaS aMaZING. THaT the deadliest year so far according to the Human Rights Campaign. WaS SOMETHING THaT STayED WITH ME Early in the clinic’s history, Nisly had a patient aLL THOSE yEarS.” —DR. NICOLE NISLY who came to the appointment with a suicide plan in their purse. “The patient I remember was very nervous, and in the beginning I noticed that our patients often were. They looked scared, or they were crying, and they were very nervous,” she said. “I think their previous encounter with healthcare had been so negative that it informed how they came to clinics.” After the appointment, the patient told Nisly about what was in their purse. “They told me that, ‘I have my suicide plan here, and I’m ripping it up because I have hope.’
… I decided to use that money to purchase computer parts to learn how to build my own computer, and then I downloaded everything I could that would help me learn programming.”
It’s all part of a drastic reinvention of self, spurred, she says, by her transition.
“My entire transition has been about redefining my authenticity, in so many more ways than just, ‘Am I a woman?’ It has prompted me to reexamine how I view relationships, how I view hobbies, how I view work, how I interact with the general public, how I interact with pets—everything. Because a lot of me pretransition was what others expected, or what I believed others expected.”
She was particularly worried about the impact the knowledge would have on her father. Her only siblings are sisters, and she’d always taken after her father growing up.
“I wanted to make sure he understood that he wasn’t losing a son, but he also wasn’t quite gaining a daughter, because it was still me.”
“We went out to Buffalo Wild Wings and had that conversation,” she recalls. “‘Hey dad. Um, I know you don’t really like labels’ (he grew up in the ’80s and so he just has a thing against it; ‘Why does everything have to be labeled?’). So I was like, ‘I know you’re not really a big fan of labels, but labels help me talk about what I’m going through. So here’s what it is.’ I just kinda laid it out for him. And at the end of the entire thing, he just kinda paused for a moment, then he just took my hand, looked me in the eye and said, ‘I just want you to be happy.’”
Suarez acknowledges that she is “one of the lucky ones” in terms of her family’s reaction.
“While it took a little bit of prompting, and they still mess up pronouns and such, occasionally, my entire family has really taken to it very well. I have one estranged aunt who has decided that I made a mistake. I don’t talk to her much, and I don’t honestly care that she exists.”
The final decision to pursue transition came after Suarez’s partner dressed her in drag one night. “I was crying,” she said, “because I felt like I was seeing the woman I knew on the inside.”
“I was in therapy for damn near half a year before [transitioning] was even considered. I wanted to make sure that I did it as close to the smart way as possible. Because there is no right way to transition. But there is a smart way (or a few).”
Now that she is out, she finds gender euphoria simply in socializing as a woman: hanging out with women, being treated “like one of the other women.” She never felt comfortable around men, she said, but didn’t understand why until she transitioned. And she loves when she’s correctly gendered in public without having to “do anything”—“It’s kind of annoying being a trans person who also believes that bras are lies and makeup is useless!,” she says with a laugh.
Ultimately, she finds that satisfaction hinges on who you surround yourself with—the network of support you build around yourself.
“The more time, compassion, patience and effort you put into surrounding yourself with highly qualified professionals and highly supportive, compassionate people, the better off your transition will be in the long run,” Suarez said. “The more you learn to let go of toxic preconceptions, such as (I hate to say this) the idea that if someone is your family, it means they’re always right … You have to let go of the preconception that family is the strongest bond. Chosen family is the strongest bond.”
By Genevieve Trainor
So that was amazing. That was something that stayed with me all those years,” she said.
To treat patients holistically, Nisly and Imborek began building a network by contacting people from other medical departments or other professions. They talked with Professor Jacob Priest at the College of Education, and he created a clinic that provides free mental health support to LGBTQ patients at no cost. The clinic provides care including letters of support for HRT and gender affirming surgeries, and support for families.
They contacted the Information Technology Services (ITS) department to change the online system to provide more genders beyond man and woman, to create an option for a preferred name, and so on.
They met with general counsel for UIHC to create a policy that requires use of an individual’s preferred name. In cooperation with the President’s Office, they implemented a bathroom program, so that single bathrooms on campus became gender neutral.
For trans patients, they created new normative data, which establishes a baseline distribution of results for a particular population. They changed UIHC policy so when trans patients had to share a room with another patient, that room matched their gender identity instead of their legal gender.
“Everybody really needs to create a welcoming space, and I think it has become a cultural change and shift that has many, many, many, many people that were part of that,” Nisly said. “It took an entire village.”
The LGBTQ Clinic continued to expand, partnering with other departments at UIHC, like urology, to provide gender-affirming surgeries. Other clinics formed, like the HIV pre-exposure prophylaxis clinic and the anal dysplasia clinic.
During these institutional changes, the team
Oliver Wenman
Oliver Wenman says, leaning into his laptop camera during our conversation over Google Meet.
“Being able to hear my voice and not cringe at it. Being at a public pool just in swim trunks, and being able to just feel the sun on me.” He smiles with satisfaction. “My gender euphoria comes from those aspects that allow me to be me.”
Wenman has been on testosterone for three and a half years. When he looks back at the YouTube channel that he started at the beginning of his transition journey, he can barely recognize his voice. And he’s glad of that.
“I really enjoy all of the effects that have been happening with testosterone,” he said. “I very much am happy, and really grateful that I did decide to be more true to myself.”
Like many trans folk, Wenman notes that there was “a lot of foreshadowing” when he looks back at his life pre-transition. He notes, for example, that while his voice has deepened, his speech cadences are the same—but that even in a higher register, his pattern of speaking had always been somewhat more masculine.
And he remembers trying to come out somewhat gently and subtly to his mother, only to be met with not just acceptance, but familiarity.
“‘I don’t know if you’ve noticed, but I’ve been dressing more masculine lately,’” he recalls telling her. “And she goes, ‘I have two sons; I know.’”
Then one day, when looking for his passport in the household safe, he happened on his mom’s will. “She wrote it back in 2010, and she actually
“I just felt like the only way I could be accepted was if I looked hyperfeminine. It was me projecting, that’s what it was—it was me projecting that the only way that anybody would accept me was if I looked hyperfeminine.”
He “broke and cracked and constantly dislocated ribs” trying to achieve hyperfemininity through corseting, and that hourglass shape is now permanent, even as his body changes.
“Weird silver lining is it makes me look more like an anime character,” he says with a rueful laugh.
Wenman, who is a performer in many capacities, has done burlesque since before his transition, now frequently with his group Knights of the Round Pasties. He explores a wide variety
has a note in the addendum that all genders and pronouns are just as valid as any other pronouns or genders that may not be listed. My mom knew back in 2010—holy crap!”
His own path to understanding was less direct.
“I could tell that something was off, but I couldn’t put my finger on it. And it wasn’t until I did drag for the first time that I saw my reflection and went, ‘Oooohhhh, that’s what that is.’”
Wenman remembers pushing himself toward hyper-femininity when he was younger, in an attempt to make sense of the confusion that he didn’t yet know to name gender dysphoria. of characters, and that broadness is anchored in feeling confident in who he is day-to-day.
“Performing a gender that is outside of my gender is kind of the thing like, ‘Oooh, I’m a superspy; nobody will know, muahahahaha!’” he said, with a hint of glee.
Last fall, he performed the role of Frankenfurter for the Rocky Horror Picture Show screening at NewBo Market.
“Oh my god! It was so great to be a trans man costuming as a natal male that was in drag!” he said. “It was great. … Some people were like, ‘I’m jealous that your ass looks better in those Spanx than mine does,’ and back in my brain, I’m like, ‘Because I have experience in heels.’”
“Instead of feeling like I’m not being true to my gender,” he said, “it feels like I’m an excellent showman.”
“I do the brightly colored hair; I still like to wear makeup, because, well, I’m a performer! I like that situating of oneself. But when I wake up in the morning, I can just say, ‘Yeah. Cool.’ I don’t need to spend hours putting on makeup to look as feminine as possible, to be OK with it, because at that point, it was putting on a costume, and I didn’t realize that.”
Wenman acknowledges that the path to self-integrity can be a tricky one to walk.
“I was worried that I would not be man enough,” he remembers. “Especially because I’d devoted so much of my life to being feminine, I was like, ‘Do I have to just learn a whole other thing?’ I realized what it was: I didn’t feel comfortable being a toxic man, I didn’t feel comfortable with toxic masculinity. So I was afraid I wouldn’t be man enough.”
But he knows now that isn’t the case.
“Any man. Trans man, any man—you are man enough. If you identify as a man, you are man enough. … No matter how you dress, no matter how your hand gestures are … You are. I am. … I may not have started transitioning without that realization.”
courtesy of Oliver Wenman
By Genevieve Trainor
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often had to justify the time and resources spent in service of a minority population.
Since the United States Census Bureau does not ask about sexual orientation or gender identity, it’s difficult to know how many LGBTQ people live in the country. The Williams Institute estimated there are 1.3 million trans people in the U.S., with nearly 250,000 living in the Midwest and 7,400 in Iowa. They estimate there are 13 million LGBTQ people living in the U.S. with 106,000 in Iowa. Many patients drive hours, or come from adjacent states, to visit the LGBTQ Clinic, Nisly said.
The team explained that both LGBTQ and cis, straight patients generally appreciated questions about sexual orientation, behavior, gender identity, and the option for preferred names.
“In many occasions, we learned how universally diverse sexuality is, regardless of one’s identity as straight or LGB. If we had chosen to stereotype patients based on presumed identity and withheld the expanded questionnaires, many of this important health care information would have been missed,” the team wrote in an article published in the Clinical Obstetrics and Gynecology journal in 2018.
Nisly also called Professor Len Sandler at the College of Law. He’d previously worked with her on disability issues. Sandler has always represented marginalized people, from abused and neglected adolescents to migrant workers. He came to Iowa to open a law clinic for people with HIV/ AIDS.
“I also grew up in a family that always cherished helping people. You do good. You do justice,” he said. “Our job was to put us out of business.”
When Nisly calls, Sandler knows to ask what she wants, by when and in what form. “Nicole is somebody you don’t say no to,” he said. “She’s a ferocious advocate. She’s just a lightning rod for people.” She said that her trans patients face complex, expensive and often unnecessary legal hurdles while changing their identity. Wouldn’t it be nice if there was a law clinic that helped trans people change their legal name, change the gender on their driver’s license, birth certificate and passport, and update their Social
“I aLSO GrEW UP IN a FaMILy THaT aLWayS CHErISHED HELPING PEOPLE. yOU DO GOOD. yOU DO JUSTICE. OUr JOb WaS TO PUT US OUT OF bUSINESS.” —LEN SANDLER
Madeline Trainor
courtesy of Madeline Trainor
Before being approved to receive genderaffirming care
at the University of Iowa’s LGBTQ Clinic last year, Madeline Trainor was asked to write down her thoughts on gender. So she did, coming to her next appointment with a 13-page personal essay.
“My therapist cut me off at page seven,” Maddy said with a chuckle. “She’s like, ‘OK, well, when are you going to the clinic? This is gender dysphoria.’”
“I’d been thinking about this for a long time— 30, 40 years at that point.”
Born on the East Coast, Maddy’s family moved to the Cedar Rapids area when she was 4. She wouldn’t really know she was a trans woman until adulthood, but she’d felt it all her life.
There were few, if any, positive trans characters onscreen when she was coming up in the ‘80s and ‘90s; you either got a homicidal Angela Baker in Sleepaway Camp, the tragic femme fatale Dil in The Crying Game, or a big joke, like Monty Python’s “The Lumberjack Song.”
Adults seemed to know all these unspoken rules about gender, and young Maddy would consistently find herself brushing up against them. She’d earn odd looks for asking to start the board game Life with a pink peg in her car piece, or wondering why she couldn’t join the Girl Scouts.
A theater major and fan of rock bands, video games and comic books, Maddy found it easier to don graphic T-shirts—“When the Marvel movies came out, I finally looked cool.”—than face the conundrum of shopping in either the men’s or women’s section. Given the choice, she’d always rather play as Princess Peach than Mario.
“I was so dissociated from myself,” she said. “I would look in the mirror and not see anything.”
She met her future spouse, Genevieve (Little Village’s publisher), at a poetry slam in Cedar Rapids in the early 2000s. They’ve been together since 2007, raising Genevieve’s two older children and welcoming their own daughter in 2017.
Years of reflection and chatting with LGBTQ folks online helped her understand that she was trans, but she still worried about coming out so late in life—how transitioning might affect her body, the healthcare costs and how it would affect her family. But after nearly a year in lockdown due to COVID-19, she couldn’t imagine reentering the world the way she’d left it.
“Am I gonna buy boy clothes on Amazon? Am I gonna put myself through that again? Or am I just going to pull these skirts out that I already bought on the sly at Goodwill?” she wondered. “Why am I hiding? Like, it’s the end of the world. Why am I going to spend the next half of my life pretending?”
“I was like, OK, alright, I guess I’m doing this. I guess I’m going to Trader Joe’s in a fucking skirt. And it was really kind of awkward and scary, and I felt exposed, but every week it became easier.”
She made an appointment with a therapist, received her diagnosis of gender dysphoria, signed an informed consent form, met with an endocrinologist and other specialists, and began her first year of hormone replacement therapy (HRT).
“Definitely the first thing I noticed is my thighs are kind of bigger and less dense,” she said. “My muscles are softer and sort of curvier.”
She joined a transfemme voice-chat room on Twitter, where members can “kick out the transphobes” and discuss healthcare, tech, sex, kink and other issues important to them.
“Just having trans women in the room, it’s a different feel, right? Because you can feel safe to share anything. … There are people who are homeless, there’s sex workers, there’s journalists,
Security information?
In 2013, Sandler created the Rainbow Health Clinic. UI law students, under his supervision, help patients at the LGBTQ Clinic traverse the legal landscape of healthcare, transportation, estate planning and so on.
“We provide that service, and it’s no cost. We don’t charge our clients,” he said. “Basically, free lawyers.”
The law clinic also helps fight discriminatory bills, laws or policies at the state level, assisting advocacy organizations and litigators like the American Civil Liberties Union in drafting proposed legislation and producing a self-help guide to changing legal identity documents.
One roadblock they encountered was the Iowa Department of Public Health (IDPH), which required surgery as a precondition to changing an individual’s legal gender on birth certificates, driver’s licenses and other documents.
By Emma McClatchey
there’s autistic [folks], people from all walks of life and different realities who all happened to be trans.”
“We all have this sort of bond of marginalization, as cliche and corny as that sounds.”
“Everything has been a milestone” this first year: Her first Mother’s Day as “Maddy Momma.” Her first Halloween in a sexy costume (she and Genevieve dressed up as Poison Ivy and Harley Quinn, respectively). Buying a house in Iowa City just in time to play host and matriarch at Thanksgiving, taking over the cooking reins from her mother for the first time. Finding a stocking with her deadname on it while putting up Christmas decorations, prompting her family to run to CVS and buy a new one, decorating it “Madeline.”
Sure, it can be hard to find privacy so she can “learn to girl” when a 4-year-old is running around the house. But “my family has been 100 percent supportive and I know that I’m lucky there,” she said. “Not everybody has that.”
She looks forward to bigger breasts, a rounder butt. Six months into hormone therapy, she decided for certain she wants a vaginoplasty, often referred to as bottom surgery.
“Once the estrogen started changing my body it was like clear what I wanted my body to be,” Maddy said.
“You have to do a lot of soul searching and be ready to make big decisions about what you want out of this. Don’t let other people pressure you into what they think is right, because there’s no right way to be trans.”
Only a fourth of trans people have had a transition-related surgery, the NCTE reported. The majority of trans people want a surgical procedure, but barriers remain. Fifty-five percent were denied insurance coverage for surgery, 42 percent said their insurance only covered some procedures and 21 percent had coverage for surgery but no providers in their network. A fourth were even denied HRT.
In practice, this policy meant that many trans Iowans couldn’t change their legal gender, despite medically and/or socially transitioning. But the law clinic found that IDPH were not following the letter of the law. To amend a birth certificate, Iowa Code requires a notarized affidavit from a doctor or surgeon stating that an individual’s sex designation has been changed by reason of surgery “or other treatment.”
“After we found that out, then it was easier, and we persuaded the powers that be to make sure that people can get their gender changed on a birth certificate, and then on our passports, driver’s license, Social Security, as well,” Sandler said.
The Iowa Civil Rights Act (ICRA) protects people against discrimination based on sexual orientation and gender identity. While the Republican-led legislature has repeatedly tried to undermine those protections, these attempts have failed, so far.
“When I talk with people around the country, a lot of them are fighting to get laws that Iowa already has, protections that Iowa already has, state civil rights laws and local civil rights laws,” Sandler said. Iowa may not be a blue state, “but we are, I hate to say, progressive on this issue because we are not known as a progressive state any longer.”
“With regard to coverage, Iowa is really lightyears ahead of many states, and in large part because of Nicole and the clinic, and the network they have created around the state,” he continued. “There are many people in the state who still do not accept the concept of gender identity. And we’ll keep fighting bills.”
Sandler said the Rainbow Health Clinic will keep defending against anti-trans legislation in Iowa, including national organizations that create prepackaged bills to ensure state governments don’t support or protect people.
“Unfortunately, because our client community faces different barriers, they need a solution. And if we can do it individually, we do it individually or represent them. If the law doesn’t help them, then we work to change the law and policy,” Sandler said. “But everything starts with Nicole saying, ‘Hello Len, can your students do this? How about this?’”
Iowa’s homegrown bigotry scares Esker, even though they’ve found a pocket of accepting queer friends in Ames. They aren’t perceived as a cisgender woman but also don’t present as a cis man, which makes for uncomfortable encounters in day-to-day life, including job interviews.
“It’s weird to navigate those spaces, especially as somebody who doesn’t present fully femme,” they said. “The queer clinic in Iowa City feels like a haven. It seems like when I’m in there, none of those factors will affect me.”
In a monumental victory for trans Iowans, the Iowa Supreme Court ruled against a state regulation prohibiting Medicaid from covering medically necessary gender-affirming procedures in November 2021, since the policy violated the ICRA.
“We’re working really, really hard to provide access for our Medicaid patients to get their gender-affirming surgeries, but they had to wait years for that,” Nisly said. “To me, that’s a lot of suffering that is unnecessary. And for the legislators,
and laws understand how important those surgeries are to support people in their transition. And it causes suffering, and it is really painful for me to see,” Nisly said. Hintermeister, a nurse at the LGBTQ Clinic, said they’re currently working through a backlog of patients, getting them letters of support, scheduling surgeries, and so on. The clinic, she said, is helping give patients a voice, so they can advocate for themselves in all areas of their lives. Hintermeister previously worked in the emergency room for 10 years. Moving to the LGBTQ Clinic was a “learning curve,” but the essential elements of the job never changed. “Taking care of the actual patient is not any different than taking care of any other patient, you know. You want to respect them,” she said. The clinic also helps educate medical providers about treating LGBTQ people. For example, the team has presented on the current restrictions that prevent men who have sex with other men from donating blood. Along with other team members, Hintermeister helps educate nursing staff and students, so “TraNS PEOPLE JUST WaNT TO bE HaPPy that everyone is equipped to LIKE EVErybODy ELSE. HaVING aCCESS TO treat an LGBTQ person. QUEEr CLINICS, ESPECIaLLy THE ONE IN “Our main goal is to not have LGBTQ clinics. And IOWa CITy THaT IS MaDE FOr US aND by US, that all providers—nurses, IT’S rEaLLy IMPOrTaNT.” —CHARLIE ESKER physicians and surgeons— all feel comfortable and empowered to take care of the and those that are responsible for those decisions, population, just as they would for elderly and kids I don’t think they understand the human scope and whatnot,” she said. and the impact on people.” Hintermeister has worked at the clinic for al-
Nisly worries about having access to immedi- most three years and has never looked back. ate care. At the moment, new patients may have “It’s one of my most favorite jobs that I’ve had to wait between one and three months for an ever, and the absolute most rewarding. Teaching appointment, but those in crisis can get appoint- a brand new patient how to do their own testosterments sooner. one injections, or how to apply estrogen patches,
“I don’t like for my patients to wait three and they start to cry, and they’re so happy about months to be seen. I really don’t. In particular, it,” she said. “Like seriously, it’s the most reif you’re looking for a gender transition, I really warding thing I’ve ever done. It’s so awesome to would like for things to be more immediate,” she see that.” said. “There is a high suicide risk in the commu- On Tuesdays and Thursdays, the clinic is open nity. People are not supported or have access to until 9 p.m. to help manage the backlog and allow care. So that is my personal biggest worry.” newer patients to come at a time when there are
Even with the advancements made in the state, fewer people. On those days, Nisly is physically barriers remain. Iowa does not have private health tired and exhausted, but the experiences with her insurance nondiscrimination laws or trans inclu- patients keep her energized. sive benefits for state employees. The state hasn’t “We have these amazing, lovely encounters. banned health insurance providers from exclud- They’re so meaningful, and so at the end of the ing trans-specific care or banned conversion day, instead of feeling exhausted, I feel like my therapy. Oftentimes, providers will deem transi- heart is full,” she said. tion-related surgeries like breast augmentation or Nisly remembers working with young adults facial feminization as not medically necessary. just starting their gender transition. The parents
“I really hate that it’s limited in that way. I were concerned and scared. Years later, the same don’t think people that made those regulations parents would tell her how much happier their
child is and that transitioning was the best thing to happen to them.
She loves getting to know her patients over the course of their life. She’ll notice mood changes in her pre-transition trans patients as they develop over the years.
“When they come back a couple years later, when you see sort of the transition fully realized, you know people are glowing, just happy,” she said.
Many of her residents and students have decided to dedicate their professional lives to LGBTQ healthcare because they felt it was the most meaningful experience of their career. Sandler said his law students have often done the same.
“My granddaughter is going, ‘What’s the big deal? Why are people worried about gender identity or sexual orientation or who people marry?’” he said. “I’ve seen in my students where they’re going, ‘Why is this an issue? Why has it happened?’ So that’s what I hope to do, pass it along, and each generation gets better.”
Esker believes that the LGBTQ Clinic provides a vital service for the trans community throughout the region. Cis people routinely have access to gender-affirming healthcare, but without the structural barriers like psychological evaluations and insurance regulations, they said.
“Trans people just want to be happy like everybody else, and I think that having access to places like queer clinics, especially the one in Iowa City that is made for us and by us, it’s really important for trans people to have. It’s lifesaving care for a lot of people,” they said.
Nisly still treats her first trans patient, but now, her initial unease is gone.
“It’s very difficult for me to even relate to how I felt back then,” she said. “The trans community is such an important community in my practice. And I’ve gotten to know them so well over so many years, and so I cannot see the patient in any way other than who they are.”
Her current ease was a skill that she learned from her patients, she said. And through the LGBTQ Clinic, Nisly and Imborek use that experience to educate other healthcare providers.
“So many people have been part of this making this possible and making this happen, including the trans community and the LGBTQ community,” Nisly said. “I think it really shows that people can get together, and radically change and transform healthcare into a much more human and welcome space.”
Adria Carpenter is a multimedia journalist for Little Village. There’s so much more she wanted to write about, but she hopes this brief story will suffice.
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