When Dalena SpiritSong goes in for her annual health checkup, she needs something most women do not: a prostate exam.
As a transgender woman who began taking hormones in 2001 to make the transition from male to female, the 67-year-old Corvallis resident still needs the exam recommended for men that age.
Her transition forces her to navigate a health care world still learning how to serve transgender patients, as well as those who are gay, lesbian, bisexual, questioning or intersex.
Shifting public health perspectives acknowledge the unique needs and concerns, both physical and mental, of the LGBT community. HIV and AIDS -- which still affects gay men disproportionately but is often a manageable disease -- is no longer the major health concern for the diverse community. As people continue to live longer and well, chronic disease, mental illness and general wellness have become the new focus for organizations, physicians and public health officials serving gay, bisexual and transgender patients.
In Oregon, the community's health choices vary by region. While the Portland metro area has a plethora of agencies and services, as well as gay- and transgender-friendly doctors, rural parts of the state do not offer the same options.
Local efforts mirror a national trend of recognizing needs, says Hector Vargas, executive director of the Gay & Lesbian Medical Association.
"I think what's happening in Portland and in other places is a result of all of these efforts that have been happening nationwide," Vargas says, "to not only educate the health care providers about disparities that affect the LGBT community, but also to educate LGBT individuals and patients so that they can be empowered" to discuss health inequities with their doctors.
That is tougher to do in a smaller community because the resources aren't always there, SpiritSong says.
"At least in the Corvallis area, there's not a lot of knowledge about trans issues," SpiritSong says. "Those who have been transitioned or are in transition need to go down to Eugene or Portland."
Local health departments have taken notice as the community has grown and the medical community has awakened to the numbers. In Oregon and Washington, 3 percent of females and 2 percent of males identify as gay, bisexual or lesbian, according to the latest data, combined numbers from 2003-06 from those states. Portland has a larger population, but no precise numbers are known.
Multnomah and Benton counties both surveyed the LGBT community in 2009 to assess discrimination and harassment, overall physical and mental health, access to medical care and substance abuse. Some risk factors mirrored the general population, while responses suggested higher rates of depression, anxiety and post-traumatic stress, as well as more experiences of violence.
The two counties plan to address access and equity barriers. For example, last month, Benton County Health Department offered transgender health training in Corvallis for its staff and will do a similar session in March with medical professionals in the 82,600-person county.
"Being a rural community, even though there are services and there are a lot of people that are really comfortable, there's a lot of fear and anxiety and concern," says Tatiana Dierwechter, Benton County health promotions program manager. "And sometimes it doesn't feel as safe for people to have these conversations."
Multnomah County's survey focused on LGBT health in general in the metro region. More than 840 residents of Multnomah, Clackamas, Washington and Clark counties responded.
Kim Toevs, manager of the STD, HIV, Hepatitis C Program at the Multnomah County Health Department, says they asked, "What kinds of policies do we need to change? We're trying to look upstream like what are the actual things that cause this poor health to happen?"
"Bigger health issues"
"There are arguably at this point in 2011 bigger health issues for the LGBTQI community than just HIV," Lewis says. He added, "Health is bigger than just one problem, which is no way intended to belittle the national and global impact of AIDS."
Other organizations and agencies formed to help with other health needs. In Portland, where the concentration of such agencies is the greatest in the state, LGBT-friendly nonprofits and social-oriented groups serve the transgender community.
Marc LeJeune, a behavioral health services administrator for the Outside In Clinic in Portland, says the nonprofit started a monthly transgender clinic eight years ago for patients to see transgender-friendly health professionals who understand their unique needs.
LeJeune, a transgender man, says health access for transgender people is not as far along as for gay and lesbian patients.
The emerging visibility is what SpiritSong sees, too.
"We're the new kids on the block," says SpiritSong, who also served as a panelist for Benton County's transgender training. "Transgender didn't even become a term until the '90s."
"People in medical school actually don't get a lot of training on how to talk about someone's sexual health," says Toevs, manager of the STD, HIV, Hepatitis C Program in Multnomah County. "What kinds of sex have you had? How can I help you make some safer choices? For a lot of health care providers those can be uncomfortable (conversations) for people to have."
This year, Multnomah and Benton counties launch their first major efforts since gathering survey data.
Multnomah County's health department formed a coalition with other agencies including the Cascade AIDS Project, Quest Center for Integrative Health, Basic Rights Oregon, Outside In and the Q Center. The coalition has applied for a grant to continue its research and outreach.
A coalition in Benton County will continue to look at key areas including mental health, substance abuse and sexual health.
Dierwechter, the Benton County health promotions manager, says through the surveys the county learned all kinds of information, including that some people are not willing to exercise in public places.
"Corvallis is known for being a very progressive, liberal community, but being gay or lesbian is a risk factor for being targeted in a public setting," she says. "How do you make gyms and public places more safe?"
The training in Benton County took a year to implement because of lack of funding, Dierwechter says, and it's just the first step.
"If we can train and support our clinicians to do a better job, we hope that has a ripple effect on the rest of the medical community as well, not to mention the people who are their patients," she says.
SpiritSong, the transgender advocate, says that while she struggled with depression and alcoholism as she came to terms with her gender, she says she was lucky to have loved ones to help her. Other people struggle alone.
"I learned to advocate for myself," SpiritSong says. "A lot of people who are just beginning don't know how to do that."
-- Melissa Navas