eing transgender is more than a medical condition; it is an aspect of human lives. That said, transgender people have, by their nature, special healthcare needs.

Since 2014, when TIME magazine signaled a “Transgender Tipping Point,” the number of Americans who say they know a transgender person has grown from 9 percent to 44 percent (plus 20 percent who know someone who is gender nonbinary), according to a Pew Research Center survey. The population who themselves identify as a gender other than one assigned at birth remains about 0.5 percent, yet that fraction is more visible.

“People did not talk about gender and gender diversity” a decade ago, says Lynn Murphy, operations director for Identity Health Clinic in Anchorage, “and now the young kids have role models, they have people they can look up to, so they feel safer by coming out as gender diverse.”

Identity started in 1977 to advocate for the LGBTQ community in Anchorage. The nonprofit acquired a healthcare branch in 2020 by absorbing Full Spectrum Health, established in 2017 by Tracey Wiese, a doctor of nursing practice. “At the time, I was the only clinic in Alaska that was openly marketing to the queer community,” Wiese recalls. “I had friends who were in my kitchen crying because they couldn’t find providers to prescribe hormones.”

Full Spectrum Health was renting space in the same Midtown building as Identity, but after a couple of years Wiese realized she couldn’t stand alone. “I’m not a business person, so I kind of opened out of passion, which is not always a good foundation to start a for-profit business,” she says. With at least half of her patients covered by Medicaid, the clinic’s books looked more like a nonprofit. Wiese, who was already on the board of Identity, offered to let the group take over.

Gender-affirming care has likewise been added to the services offered at Chena Health in Fairbanks, which began as an OB/GYN clinic in 2006. “It’s certainly become more of a part of family medicine practice,” says founder Dr. Ellie Hogenson. “I think as the number transgender individuals grows, people are going to have to know how to appropriately treat them.”

Hogenson is not just a provider of healthcare for transgender patients; she’s a seeker on behalf of her daughter. “It was kind of a strange coincidence because I was doing transgender medicine for years, and then she came out about three years ago,” Hogenson says. “She was definitely a little girl, and I didn’t recognize it, I think.”

A social work intern at Identity is definitely a middle-aged guy: full beard, hair thinning on top, a little soft around the middle. However, Vincent Feuilles (pronounced fo-yay) is shorter than the average male, and his hands are smoother than his side gig as a leathercrafter might suggest. That’s because Feuilles had to become himself.

“Trans guys, we’ve got it a little easier because we just look young,” he explains.

Tracey Wiese (second from right) leads a discussion during a 2021 visit to Identity Health Clinic from Anna Dietderich (in purple), a legislative assistant to US Senator Lisa Murkowski.

Identity, Inc.

In 2020, Tracey Wiese (left) handed over her Full Spectrum Health clinic to Identity Inc., largely thanks to Joey Agloinga-Keeney, then the nonprofit’s co-chair, arranging the purchase.

Identity, Inc.

Feuilles came out in 1991 while living in Seattle but couldn’t find transgender peers or other support. “There were no doctors who would talk to you if you were trans, anything like that. If there was, it was kept extremely quiet,” he says.

He moved to Alaska in 2008 and was able to find a gynecologist in Fairbanks for hormone therapy. “He was like, ‘Okay, I don’t know a lot about it, but let me do the research,” Feuilles recalls. He now uses a daily Androderm patch, the same testosterone prescribed for cis men with low-functioning gonads.

After moving to the Matanuska-Susitna Borough, Feuilles needed a new doctor to maintain his medications. “I had to educate him on, ‘These are where the levels should be. Look, here’s this and this and this.’ Which is what a lot of trans folks go through,” he says.

Feuilles notes that not every transgender person has body dysphoria that requires medical treatment. What every transgender person needs, as surely as anyone else, is ordinary medical care, and that service is not always easy to find.

“There’s some pretty horrible stories out there for trans individuals trying to seek medical care, getting rejected, turned away,” says Hogenson, “not just for trans care but patients that are there for an annual exam.”

Identity’s website lists Hogenson as a trans-friendly provider, and she says that’s because she serves patients without judgment while having the knowledge to care for them.

Feuilles says, “A lot of folks will find a doctor who’s really good but maybe just doesn’t have the knowledge of trans healthcare, so they spend a lot of time educating, which is really difficult because you’re supposed to be the patient.”

One resource to connect patients with gender-affirming providers is QueerDoc, a website created by Crystal Beal, a Seattle-based doctor on staff at Identity Health Clinic. In addition to facilitating telehealth services, Beal’s website aims to increase the availability of in-person care by training healthcare professionals and other organizations.

It’s the kind of training Hogenson says most doctors never get. “In residency it wasn’t anything that was even discussed,” she says. “This is something that I’ve sought out educational opportunities after training.” Hogenson points to guidelines published by the Endocrine Society and the World Professional Association for Transgender Health.

Trans-friendly providers ask questions, assess patients, and order labs in a slightly different way, Wiese explains. “These are competencies that come from several professional organizations,” she says. “We offer that in a way that’s gonna look different if you go down the street.”

Those competencies extend to all staff interactions. “Somebody who understands them, somebody who calls them by their right pronoun, is able to use their name, not their deadname,” Murphy says.

A transgender patient might find a friendly practitioner anywhere for routine medical needs. For transgender-specific services, though, options in Alaska are slim to none.

Recognizing a mismatch between assigned gender and internally perceived gender sends a person on a transformational journey. “Some people come in wondering if they’re trans, wondering if what they’re feeling is gender dysphoria, and for that individual—just like any human coming in with some kind of identity or existential question—it would be therapy with a competent, trained provider,” Wiese says.

Counseling is a major part of Identity Health Clinic’s offerings. Wiese finds herself treating not just gender dysphoria but also the syndrome that comes with living as a marginalized minority. “It looks like you have PTSD, even if you don’t have any other trauma, because your body is so used to coping with daily stress and fear,” Wiese says.

Feuilles observes that social marginalization leads to economic disadvantage among the trans community, which is why most clients receive assistance from Medicare or Medicaid. Thus, Feuilles chose the field of social work, which is more accessible to Medicaid billing codes than psychological counseling.

During his internship while finishing a Master of Social Work degree, Feuilles is also a contractor at Identity Health Clinic through his peer-to-peer consulting service, Authentic Beginnings. He mainly assists clients with changing their names and gender markers. Any lawyer’s office can do it, but Feuilles (although not a lawyer) is a specialist. “Usually, attorneys will charge quite a bit more,” he says. “As far as the gender marker change, I am the only one in Alaska who has paperwork for submitting a gender marker change into the court system.”

Legal recognition is the third of four steps that Feuilles counts along a transgender journey, after the internal transition and social expression. The last step is medical intervention.

Since June 2021, state Medicaid funds have partially covered hormone therapy and gender-affirming surgery. That month, the Alaska Department of Health and Social Services settled a lawsuit challenging a decade-old policy against such coverage.

Patients without Medicaid or other insurance can still find help at Anchorage Neighborhood Health Center (ANHC). “We have a sliding scale for uninsured patients at ANHC to make sure that anyone who needs care (gender affirming or otherwise) can get it,” says the center’s chief medical officer, Dr. Rachel Samuelson.

One of ANHC’s former physicians is out of state for the moment, upgrading her skills. Massachusetts General Hospital has a special program in transgender health, so Dr. Rachael Carricaburu is finishing her internal medicine residency in Boston. “I know the gaps in care that exist for people in Alaska, and I continue to seek training to fill those gaps. Transgender medicine is just one of those things,” Carricaburu says.

Surgery, in particular, is in short supply. The last doctor in Alaska doing “top surgery” for trans men died a year ago, according to Feuilles.

“There are plastic surgeons in Anchorage who will do breast augmentation, but only for cisgender women,” Feuilles says, “and the surgeries are different, too. For a trans man, people want to say it’s just a mastectomy, but it’s not.”

Although billed the same as a mastectomy, top surgery requires reconstruction to create a male chest contour. “While some of the techniques might be similar, the procedures [are different] to do the scar tissue in a certain way, to perhaps graft nipples,” Wiese explains. “There’s a joke out there that some surgeons do designer nipples.”

The only other surgery available in Alaska is orchiectomy, or removal of the testicles. All other “bottom surgery,” as well as facial and vocal surgery, must be sought out of state. Medicaid pays for travel, but Wiese says convincing surgeons to accept Medicaid is a hard sell when a $10,000 procedure might only get $1,600, a rate she calls “abysmal.”

Renderings show the new lobby (above) and wheelchair lift in the stairwell (below) at Identity Health Clinic in Midtown Anchorage, part of an ongoing expansion project.

Determine Design

As the stigma around gender diversity fades, Hogenson expects to see more demand for gender-affirming services, and providers will rise to meet it. “There are more and more providers in Fairbanks that are feeling comfortable providing these services,” Hogenson says.

Identity Health Clinic has been seeing more than twenty requests for new patients each week. “Patients keep coming, and we are still working to meet the need,” Wiese says.

The clinic is about to double its size, thanks to $300,000 of federal stimulus money through the Municipality of Anchorage, matched by donations. The 1,000 square-foot expansion adds two exam rooms, two more offices, a training room, a waiting room, and an accessible ramp for the front door and a wheelchair lift to the second floor.

The expansion is meant to alleviate constraints that disrupt patient care. “Any medical clinic is limited in profit by space,” Wiese says. “You can only have so many folks going at one time, and you need more providers to support more staff.”

Those providers don’t necessarily have to be within Identity’s walls. “We want to put ourselves out of business. If we didn’t have to have a health clinic—and our community was well—that’d be great because that would be a signal to us that we had done our job,” Wiese says. “But we’re not there.”