Transgender care – top-notch medicine with big dose of kindness

Mal Foust was born in a small, conservative Nebraska town. He was identified as a girl, but always felt like a boy. Now, after a lifetime of slights, Mal and other transgender patients receive sensitive medical care at a unique clinic designed just for them.
September 25th, 2018

In photos from childhood, Mal Foust wears short hair, baseball hats, jeans and T-shirts.

Looking back, it seems obvious that Foust was a boy.

Mal Foust at age 5 sits on his front steps. He was born a girl, but looks very much like a boy in this picture.
Mal Foust at age 5. Mal was born a girl, but always felt he was a boy. Photo courtesy of Mal Foust.

But, he had been born in a small, conservative town in Nebraska and was identified as a girl. Few residents ever had heard of transgender people. So, even though Foust knew he was different, he didn’t have the words or concepts to explain that his body didn’t match what he felt in his mind and his soul.

UCHealth Integrated Transgender Program

Services include:

  • Gender-affirming hormone therapy
  • Primary care
  • Mental health care
  • Sexual health and screening for sexually-transmitted infections
  • Surgical and dermatologic care
  • Fertility preservation

Program coordinator: Keily Fisher

Call 720-848-2650 with questions or to schedule a visit.

Many years later, after countless cruel incidents and years of introspection, Foust has transitioned to the male he always knew he was.

And finally, after years of insensitive medical care, he is grateful to be a patient in one of only a handful of multidisciplinary clinics in the U.S. designed specifically for transgender adults, the UCHealth Integrated Transgender Program at the Anschutz Medical Campus.

During a recent hysterectomy surgery to help tame conflicting hormones in Foust’s body, his doctor, Tricia Huguelet, made sure every member of the team fully embraced and respected Foust.

Then Huguelet had a surprise for her patient.

A copule poses for a photo. They were flannel shirts. On the left is a woman. On the right is Mal Foust, a transgender male. He's got a scruffy beard and is much taller than his partner.
Mal Foust, right, with his partner, Jess Wheeler. Mal was born a girl, but always knew he was a male. He transitioned as an adult and now receives care through a unique UCHealth program for transgender people. Photo courtesy of Mal Foust.

As the team wheeled Foust in for surgery, music from the recent movie, The Greatest Showman, filled the room. And the lyrics of This is Me said everything.

In the film, showman P.T. Barnum gathers people whom society has rejected — a bearded lady, an albino man, an unusually tall person, a brother and sister of color — and brings all of them out of darkness into a show.

This is Me is a proud anthem of self-acceptance. The bearded lady describes her evolution from shame to freedom.

The song begins with sadness: “No one will ever love you as you are.”

Then she belts out her truth:

“I am brave. I am bruised.
I am who I’m meant to be…

I’m not scared to be seen.
I make no apologies.

This is me.”

Foust wept as he heard the song.

In a pre-op appointment, he had told Huguelet about a chance meeting on a plane with Keala Settle, the actor who plays the bearded lady.

Foust had told Settle about his journey and how much he connected with her character. Later, on that morning in the operating room, Foust was overjoyed to have a team of medical providers who treated him so kindly.

For years, he had suffered countless slights in medical settings and in life.

Finally, Foust could be himself.

No words to explain gender mismatch

Foust had grown up as Mallory Ann Foust, the youngest of three kids who lived in a small town in western Nebraska.

He remembers being about 6 and seeing his mom put some bras away.

“What’s that?” Foust asked.

“It’s a bra. You’re going to wear one when you get older,” Foust’s mother said.

“No, I won’t,” Foust replied.

“What are you going to do?” his mom asked.

“I’ll cut them off,” Foust said of his breasts.

A teen sits in the cab of a large orange tractor. Mal Foust looks male and wears a ball cap, jeans and T-shirt. But he had been born a girl.
Mal Foust grew up in Nebraska as Mallory Ann. He always felt he was a boy, but had never heard of transgender people. Photo courtesy of Mal Foust.

“I always felt like I should have been born a boy. But I didn’t know how to put it into words. I didn’t even know what transgender was,” he said. “All I knew was I couldn’t talk about it.”

That lesson was seared in his brain when a girl in his town came out as bisexual in high school.

“People threw bricks through the window at her home,” Foust said.

As a survival strategy, Foust kept quiet and thought, “When I leave and go to college, it will be better.”

Foust loved sports and played basketball in college in Nebraska, then later transferred to University of Colorado at Denver, where he earned his Bachelor’s degree.

At 19, Foust wrote a letter to his parents and brother and sister, coming out as a lesbian.

“But I didn’t fully commit to it. I said, ‘I’m gay, but I think it’s just a phase,’” Foust, now 32, recalled with a laugh.

He later performed as a drag king and, when he put on fake facial hair and a chest binder that flattened his breasts, he felt all the more himself. Later, after a move to Los Angeles, he asked a friend about scars on his chest.

“I’m transgender,” the friend replied.

“That’s when it clicked,” Foust said.

He finally had a word to describe what he’d been feeling all his life.

Transgender people struggle to get medical care

Foust moved back to Denver and started using male pronouns in 2013. Even then, however, he felt a great deal of conflict about fully transitioning. It’s common for trans people to feel stigma, even within the LGBTQ community.

Foust no longer felt he fit in among lesbians.  And he was fearful of losing a relationship with his grandparents, with whom he’d been very close all his life.

“I panicked. I thought, ‘If I go through with this, am I going to lose my family? Am I going to lose my job? Am I going to lose my friends?’”

Getting adequate health care also was a struggle, as it is for many transgender people. They suffer higher rates of depression and suicide than non-trans people, along with greater substance use problems, according to studies on transgender health from the LGBTQ advocacy group, One Colorado.

Even getting adequate primary care can be a struggle for transgender people.

Foust experienced that first hand. Even though he had health insurance and the psychological approval he needed to begin transitioning, he struggled to find a doctor who could give him male hormones.

“I had been paying for medical insurance my entire adult life. Now that I actually needed to use it, I couldn’t find anybody who would actually see me,” Foust said.

Eventually, Foust found a women’s clinic in Boulder where he could start hormones. He began taking them on March 18, 2014 — a day he now calls his “boy birthday.”

Excited at first, Foust soon faced the kind of insults that undercut many trans people on a daily basis.

He worked as a paramedic at the ER at UCHealth University of Colorado Hospital and co-workers there were quite supportive. But, a trip to the pharmacy to get testosterone for the first time was devastating.

“I was so pumped and it was short-lived. I was sitting there waiting. The pharmacist saw that the hormones were for ‘gender identity disorder’ and said, ‘Great, we’re prescribing hormones now for psych problems.’”

“The wind was taken out of my sails,” Foust said.

Along with enduring regular taunts, Foust said he never knows for sure if his health insurance will cover his hormones.

“There’s a lot of anxiety,” Foust said.

Finally, patient-centered transgender care

Now, thanks to the new Integrated Transgender Program, care for Foust and others has improved dramatically.

Not only do transgender patients get to see a team of people all of whom understand how to properly care for them, but the highly educated providers put patients at the center of the care.

Instead of having to schedule multiple separate visits with various doctors on different days, trans patients can come from near and far and see all their providers on a single afternoon.

Four doctors pose. They include three women and a man. All provide care for UCHealth's Transgender Program.
The UCHeath Integrated Transgender Program puts patients at the center of care. Several doctors come together twice a month so transgender patients can see the specialists they need all in one afternoon. The doctors include (left to right) Rita Lee (internal medicine), Tricia Huguelet, (gynecology), Micol Rothman (endocrinology) and Robert Davies (psychiatry).

Twice a month, the medical team gathers in the UCHealth Endocrinology Clinic at the Anschutz Medical Center and patients can see whomever they need: a primary care provider, an endocrinologist, a gynecologist, a psychiatrist and a plastic surgeon.

Since many transgender people have experienced discrimination in health settings in the past, clinic workers from front desk workers to medical assistants and doctors have put respect and trust at the heart of the clinic. The setting is gender neutral. Pronouns matter. Everyone on the team knows to ask patients how they wish to be addressed.

Then the team aims to deliver seamless, high quality care.

Services include:

  • Gender-affirming hormone therapy
  • Primary care
  • Mental health care
  • Sexual health and screening for sexually-transmitted infections
  • Surgical and dermatologic care
  • Fertility preservation

Dr. Micol Rothman hatched the idea for the clinic with colleagues a couple of years ago, then she and her co-founders opened it a year ago.

“Transgender health is one of these areas of medicine where a team approach is crucial. During transition, there are so many things going on: hormonal and psychological and dermatological issues,” said Rothman, who is a UCHealth endocrinologist and an associate professor for the University of Colorado School of Medicine. “Having everyone on one team thinking about challenges together is key.”

Headshot of Dr. Micol Rothman.
Dr. Micol Rothman.

The logistics of getting several specialists together are complicated. But Rothman and her fellow providers wanted to make life easier for transgender patients and be able to collaborate in real time.

“We’ve had really positive feedback. Patients appreciate the multidisciplinary approach and like the nitty gritty of having multiple appointments in one day at the same time. That means less time off of work and streamlined care,” Rothman said.

Sometimes she and fellow providers will spend time together with patients, which is unusual for doctors in different disciplines.

Dr. Robert Davies, our psychiatrist, and I will go in and take a psychiatric and medical history together. He will make the diagnosis of gender dysphoria and I will talk about what to expect from hormone therapy,” Rothman said.

Of course, hormone treatments can affect a patient’s mental health, so cooperation in real time can be invaluable.

“We’re both right there. It’s great for patients,” Rothman said. “And we’ve both gained a lot from each other.”

Transition can be one of the most vulnerable times

Davies got to know Rothman after he helped create the Imagine Clinic for LGBTQ mental health.

“We were being flooded with transgender patients when we opened the doors. Their access to care is so poor,” said Davies, who is also an associate professor and vice-chair of education in the University of Colorado School of Medicine’s psychiatry department.

And the mental health needs are great.

“Upwards of 60 percent of trans individuals have been suicidal at some point. While those rates go down after transition, they don’t totally go away. They’re still elevated because they still face discrimination, stressors and violence out in the world, just as they did before,” Davies said.

Headshot of Dr. Robert Davies
Dr. Robert Davies.

“A particularly vulnerable stage is when you’re starting transition. You may be presenting as your identified gender,” said Davies. “But, physically, you may not have had changes yet. There’s this difficult phase that people go through. It’s also a time when they may get very discouraged and think, ‘I’m never going to look like who I feel I am.’ It can be a slow process for people.”

Health insurance plans — both public and private — are covering more care for transgender patients, but in order to proceed with hormones and surgeries, patients need approval from a mental health expert. The Integrated Transgender Program brings all that care together under one roof.

“We see people at all stages of the process. Some are still using the names and pronouns of the sex they were assigned at birth and are starting the process. We see others who transitioned years ago,” Davies said.

Some patients received poor care in the past that is harming them now.

“We see people who overused hormones in order to get faster results,” Davies said.

Psychologically, it’s understandable that once patients decide they want to transition, they want quick results. But higher doses of hormones do not lead to faster physical changes, Davies said.

“There’s this desire to have changes occur as fast as possible and as dramatically as possible. Some of that may be unrealistic,” Davies said.

The gift of acceptance

As trans patients navigate a tough path both physically and emotionally, Dr. Tricia Huguelet, who is a gynecologist and a fellow co-founder of the trans clinic, thinks the greatest gifts she can give trans patients are respect, kindness and acceptance.

Headshot of Dr. Tricia Huguelet
Dr. Tricia Huguelet.

She first started seeing trans men on her own about seven years ago. Through word of mouth, more came to see her. It wasn’t always easy for them to come to her.

“They come to my office with such fear. They are men coming to what is traditionally a women’s care area,” Huguelet said.

Despite Huguelet’s efforts to ensure that her patients were greeted properly, some were told they were in the wrong place.

Huguelet loves that the trans clinic provides excellent, integrated care and serves as a refuge for many, like Foust, who have suffered in the past.

“If I can be one positive person in their life, to help them feel good about themselves and to be happy and feel loved, that’s great. That’s what I love about what I do,” she said.

More research key

Along with the clinical care, the team is conducting much needed research. Relatively little is known about the impacts of gender-affirming hormones on long-term transgender health and trans people face some unique health challenges.

For instance, doctors have to be careful about how much testosterone they give trans males who are living at higher altitude because the hormones can affect red blood cell counts.

And some trans females face risks of blood clots if they take too much estrogen or if they smoke.

“Additionally, the long-term impact of hormone therapy beginning in puberty on future fertility and egg and sperm quality is still unknown,” said Huguelet, who is also an Associate Professor of obstetrics and gynecology at the University of Colorado School of Medicine.

“It’s all very complex and there’s so little research,” she said.

headshot of Dr. Sean Iwamoto
Dr. Sean Iwamoto

 

That’s where Dr. Sean Iwamoto, another one of the co-founders of the Transgender Program, steps in. He’s a UCHealth and Rocky Mountain Regional VA Medical Center endocrinologist and an instructor for the University of Colorado School of Medicine. He will be conducting research on a variety of trans-health topics from obesity and bone density to cardiovascular health, side effects from hormones and the outlook for trans people as they age. The Center for Women’s Health Research will be funding the research.

“We have a lot of research showing the mental health benefits of treating people with gender dysphoria,” Iwamoto said.

But, he said, it’s not clear how hormones will affect trans people down the road.

“What can we expect for older patients?” Iwamoto said. “Are we supposed to lower the doses of hormones? We don’t know yet. We need more data. And what should we do if a trans woman is at risk for clots and cardiovascular disease?”

Over time, with significantly more research, answers should become more clear, Iwamoto and others say.

Estrogen and testosterone ‘battling it out’

For Foust, life has gotten easier thanks to sensitive medical care and an incredibly supportive partner, who eagerly attends medical appointments with him and serves as a bridge to his family.

Jessica Wheeler is also 32. She met Foust before he transitioned. The two built a relationship first as friends, working together in the University of Colorado ER, where she’s a nurse.

Foust and Wheeler started dating two years ago and now share a home and a puppy named Indie.

“Mal singlehandedly educated the entire Emergency Department,” Wheeler said, curled up on a couch in their living room.

A couple poses with their dog in the middle.
Mal Foust, left, and Jess Wheeler with their puppy, Indie. Photo courtesy of Mal Foust.

“I’m an open book,” Foust said. “I talk a lot about being transgender. I feel it’s the only way to normalize it.”

Especially in health care settings, he presses everyone to become much more knowledgeable.

“The health care community doesn’t know anything about transgender health. This should be taught. That’s why trans people don’t come in for health care. They feel they have to educate providers. Or they feel like they’re going to deal with discrimination,” Foust said.

The medical journey can be incredibly difficult. Before opting for a hysterectomy, Foust was dealing with hot flashes, bleeding, acne and mood swings. When he started taking testosterone, his body swelled. He gained 30 pounds and a lot of water weight.

“My body was doing weird things and I felt really anxious,” he said. “Your estrogen and testosterone are battling it out. Then you’re changing on the outside and everyone feels free to give you opinions,” Foust said.

“With these emotional swings, you’re just trying to hang on for the ride,” said Wheeler, who helps bring calm when chaos is swirling.

The power of support

And that’s when good doctors are key.

For Foust, seeing Rothman was a breath of fresh air. Finally, he found a provider who was knowledgeable and cared about his story and his views on improving care.

“She sat me down and asked me medical questions, but also about my experiences. She wanted to know if I had suggestions for making the care better,” Foust said.

In addition to improved medical care, Foust also has found greater acceptance within his family.

He finally decided that he had to come out as transgender to his family. He had started testosterone about a month earlier and knew they’d see the physical change.

Foust sent an email so his family would have time to digest the news before responding.

His mom sent back a kind note.

“You’re my kid and I love you,” she wrote.

What made her sad was the thought of Foust’s voice changing.

Foust said he has never discussed his identity with his dad, who still introduces him as his daughter.

‘They saw me as a person’

Foust’s grandparents died in recent years, his grandfather in 2014 and his grandmother two years later. Foust and Wheeler teamed up to help provide hospice care for his grandmother in her final days. While he and his grandmother never discussed his transition — and Foust regrets not talking about it directly — he thinks she was trying to give him tacit acceptance, albeit in a roundabout way.

About two months before his grandmother passed away at 88, Foust had appeared on the cover of The Denver Post in a story about transgender people. In one photo, Foust is working out without a shirt. He shows his scars from top surgery. Because insurance didn’t cover the surgery, Foust had to pay more than $10,000 out of pocket and traveled to Florida for the surgery.

When he visited his grandmother, she had a copy of the paper.

“She said, ‘Do you know this guy? He’s cute. He looks nice. You should be friends with him.’”

Perhaps it was her way of giving Foust her blessing.

“I took care of her and she had a pretty painful passing. In hindsight, even when my appearance started changing, she never made me feel any different. I was very lucky,” he said.

Another key moment came when Foust changed his name. In his new job as a flight attendant, Foust has had to contend with some confusion because flight manifests list the name of each crewmember.

It got old explaining that he was Mallory Ann.

So, in April, he decided to formally change his name and sought support from his mother.

“I said, ‘Mom, it’s really hard at work. I need to change my middle name. You’re my mom and you named me. I’d like you to help pick my name.’”

They settled on Andrew. Foust’s mom found symbolism for each letter. She liked that Andrew started like Ann. The “d” was like Debbie, him mom’s name. The “r” was for a letter he gave up at the end of Mallory. And she and liked that it ended with a “w.”

“W is for Jess Wheeler,” Foust’s mom said, a warm embrace for the woman who has helped Foust through his journey.

The positive moments can’t erase all the ugly ones in the past, but kindness goes a long way. When Foust is down, he can think back to the day in the spring when a surgical team made big difference in his life.

“They saw me as a person,” Foust said.

And they had a simple message: “We’re all rooting for you.”

Then, they turned up the volume on a powerful song:

“When the sharpest words want to cut me down,
I’m going to send a flood, going to drown them out.

This is brave. This is proof.
This is who I’m meant to be….

Look out because here I come….

I’m not scared to be seen.

I make no apologies.

This is me.”