Alex and Jess Welker sat on a plush tan couch in their McCandless home and recounted their first date. The two tell the story together, going back and forth with details of their earliest interaction.
“We did it the other way around--we did go to a movie first and then went out to dinner and then hung out and went to WalMart, actually,” Jess said. “He said he needed litter.”
“And cat food,” Alex added. "Cats needed to eat.”
Near the fireplace, their 13-year-old cat Puss slinks under a three-paneled framed picture of the couple. They met online in 2005, got married in 2012, and married again in 2015. The second time, Alex said his vows as a man.
“We wanted to make sure all the legal stuff was done,” he said. “I wanted to get married as Alex, not as Jennifer.”
Alex identifies as transgender, meaning he was born biologically female and has medically transitioned to become male.
“When I finally figured out that transgender is who I am, it was liberating,” he said.
Before he started transitioning, Alex flew home to Nebraska to tell his mother. He wrote a speech on his phone, complete with bullet points, and prepared to deliver it. But, he said, just as he was getting to the part about identifying as transgender, she cut him off and surprised him.
“She said, ‘Wait--are you going to change your body to match your mind?’ And I wasn’t prepared for that,” he said. “She was excited, and I wasn’t prepared for that.”
But by far his biggest advocate, Alex said, is his wife. Jess said she never hesitated to support him when he decided to transition.
“It was absolute certainty to for me that I wasn’t going anywhere,” Jess said. “He’s a good person and loves people and cares about people and loves me in a way that I never expected I would find. To me, that was everything.”
In early 2014, Alex took the first step in his transition and began hormone replacement therapy at a local clinic. But he said he didn’t feel comfortable during his visits.
“In Pittsburgh, in 2014, I felt like I was treated like a science experiment,” he said.
He said providers in Pittsburgh at the time weren’t confident about how much testosterone to give him, and eventually, he decided to start receiving medical care elsewhere at the Mazzoni Center in Philadelphia. But it bothered him that he had to drive all the way across the state.
“Pittsburgh is up there on the list for good doctors and cancer treatments and, you know, pretty much if you need it, it can be done in Pittsburgh, or that’s what most people think,” he said. “Except when you’re transgender.”
Pittsburgh received high marks for LGBT-friendly policies, according to the Human Rights Campaign, but not all members of the community feel the city has enough resources.
For his gender reassignment surgeries, Alex traveled to Cleveland and Texas, but not every local transgender person can afford that luxury, he said.
“You’ve got to travel, you’ve got to get accommodations, you’ve got to pay for food, you’ve got to get a rental car,” he said. “If there are complications, you have to go back to those cities.”
Friendly and competent
For transgender people, quality care goes beyond finding the right place to get your gender affirmation surgeries or hormones. It’s about feeling safe with doctors and knowing that even for a quick visit, the staff will help the transgender patient feel at home.
Pittsburgh therapist Bob Moore counsels LGBT clients and is part of a group practice called the Center for Relational Change. He said providers should be friendly and competent. Friendly, he said, in the sense that the provider is welcoming and accepting; and competent in that they’re trained specifically in the world of LGBT care and know to ask for preferred names and pronouns.
“It’s more of a well-rounded view of what that experience for that client has been,” Moore said.
"Friendly and competent" also includes paperwork, he said. Is there a box on intake forms other than male or female? Is staff trained to understand nontraditional family structures? Do they know how hormone treatment may interact with other prescriptions?
In Pittsburgh, the PERSAD Center in Lawrenceville works to provide a safe space for LGBT residents who may feel isolated from other facilities to receive mental health counseling and other resources.
“People come to us because we have particular competencies that are important for the populations we serve,” said executive director Betty Hill. “It’s more comfortable to be here than it is to be somewhere else and kind of have to translate yourself and your relationships.”
Moore said this systematic bias within health care systems is exacerbated by the lack of an anti-discrimination policy in Pennsylvania.
Moore said he’s had clients tell him they’ve withheld information from medical providers because they perceive a bias against them. The left-leaning public policy research organization Center for American Progress reported in January that 29 percent of transgender people had been turned away from a health care provider because of their “real or perceived gender identity.”
He said discrimination laws would not only lower a barrier for LGBT people to health care, but also help in access to housing and employment.
“State protections would be a lovely thing,” Moore said. “I just don’t see it happening anytime soon.”
Health care providers said they’re trying to add more transgender-specific care. Most of the hospital systems around the region have resources for LGBT people, including Allegheny Health Network (AHN) and the University of Pittsburgh Medical Center (UPMC).
Gerald Montano, a pediatrician at Children’s Hospital of Pittsburgh in the Gender and Sexual Development Program, said since the clinic opened about a decade ago, they’ve offered a range of mental health and medical services for patients up to 26 years of age.
“We offer pubital blocks and cross-sex hormones,” Montano said. “And if there are any social services they need in terms of finding a therapist outside the city proper and finding some resources that could help these individuals navigate through their lives, which can be quiet complicated.”
Looking ahead, Montano said he’d like to see an established network of city resources made available to patients so they can streamline their own care.
“So hopefully by being active and trying to connect ourselves to these other places that provide services, our patients could have a variety of options when choosing a provider that’s right for them,” he said.
Stuart Fisk, director of the Center for Inclusion Health at AHN, said he’s not aware of anywhere in southwestern Pennsylvania for transgender people to get genital reassignment, or bottom surgery. Patients can get breast augmentation or reduction, known as top surgery, at both UPMC and AHN hospitals.
“The specialty surgical knowledge and experience that’s needed to do genital reassignment surgery, I just don’t think there are a lot of people around that are trying that,” Fisk said. “The demand has been low because of the hidden nature of the transgender population.”
Similar to Welker's experience, Fisk said many of the transgender patients he’s worked with end up traveling outside the Pittsburgh area for their surgeries.
“I certainly think there is clearly a regional market that could be tapped and I’m hoping we can begin to look at the financial feasibility of developing that for people in the southwest Pennsylvania area,” he said.
Fisk and other LGBT health care advocates echoed Welker’s need for safe spaces and inclusive clinics. That could mean that health centers put a rainbow flag in their window or advertise. He said competent care is something that needs to be taught in the medical community.
“So medical students, residents, nursing students, all kinds of people [need] to work with populations they’re not comfortable working with, necessarily,” he said.
Central Outreach Wellness Center on the North Shore and in Washington, Pa. serve about 4,000 patients, according to founder Stacy Lane. The center opened in 2015 and offers a spectrum of care.
In 2016, the Pennsylvania Department of Health and Human Services announced that gender affirmation surgeries would be covered for Medicaid patients in the state. It’s also a little easier for people to change their gender on official documents.
Welker said he’s glad that Pittsburgh is starting to recognize some of the divides between the city and the transgender community. He’s part of a group that speaks with new officers of the Pittsburgh Police Department about transgender-related issues, such as drivers presenting themselves a different way than they might look on their official ID.
He's is also starting an organization called Live Overt, that brings people together online to talk about their identity struggles and provides support for members of the transgender community.
*This post was updated to include services offered by the Central Outreach Wellness Center.