Desperate for hormonal treatments, transgender patients were turning to friends and illicit dealers for unregulated cocktails of drugs. Many were left with health complications and infections that landed them in the waiting room of a busy South Los Angeles clinic.
"For the most part, they were basically getting care on the streets," said Jim Mangia, president and chief executive of St. John's Well Child and Family Center, which runs the West 58th Street health center as part of a network of low-cost Los Angeles-area clinics.
After years of dealing with medical problems created by what he saw as a major gap in the healthcare system, Mangia created a dedicated transgender medical program at the nonprofit South L.A. facility that now serves more than 500 patients. Such specialized care "just wasn't there before" for these patients, he said.
Indeed, Alexa Vasquez, who traveled four hours by bus for an appointment at St. John's on a recent weekday, said that when she began transitioning two years ago, she struggled to find an affordable clinic offering the care she needs. Friends offered her what they said were hormones, but she was scared to take them.
"I felt like I had no option," said Vasquez, 26. "That was the hardest thing: finding someone you can trust with something this personal."
In recent years, and even more so in recent months, acceptance of the transgender community has grown, especially after the high-profile transition of Caitlyn Jenner earlier this year. Also, the Affordable Care Act, which took full effect last year, barred insurance companies from denying coverage to trans people, who were sometimes turned away by firms that considered being transgender a preexisting condition.
Still, accessing medical care remains difficult for many such patients, with some unable to afford care or get certain treatments covered.
Transgender patients such as Vasquez say healthcare is integral to realizing their identities. The transition process can upend relationships or even careers, and hormonal treatments, she said, provide a confidence boost by getting "you one step toward the person that you are."
California has the most supportive legislative and policy environment for trans people in the nation, said Bamby Salcedo, president of the L.A.-based TransLatina Coalition. "But unfortunately, even in Los Angeles, in such a big metropolitan city, things are still not where they are supposed to be," she said.
A recent L.A. County Department of Public Health report estimated that the county is home to 14,500 transgender residents. Salcedo said those patients have only a few places to receive specialized care, including St. John's, the Los Angeles LGBT Center and Children's Hospital Los Angeles. Most patients must wait weeks to see a doctor. "That's definitely not enough," she said.
Part of the problem, transgender health advocates say, is that there aren't enough surgeons who know how to perform gender reassignment surgeries. Medical schools should train more doctors in the specialty, they argue.
Salcedo hopes to secure backing from the L.A. County Board of Supervisors for a new transgender wellness center that would offer medical, mental health and other services.
Trans people tend to be poorer and less likely than most patients to have insurance, which can make it difficult to access medical care, according to a report from the National Transgender Discrimination Survey.
Obamacare is improving the situation, but some patients say they've experienced problems getting approval for some treatments or procedures.
One issue is patients who identify with the opposite gender — as a male, for example — in their health records but then require a pap smear because they still have a cervix, said Dr. Ward Carpenter, who practices at the Los Angeles LGBT Center. That often triggers an automatic denial from insurance companies.
"We end up having to do a lot of fighting with them," Carpenter said.
Insurers say they've followed federal and state regulations and are continually working to ensure patients aren't improperly denied coverage.
Last month, the U.S. Department of Health and Human Services announced proposed rules that would bar insurance companies from denying people services based on their gender identity.
St. John's began offering trans care early last year, including hormone replacement therapy, assistance with name and gender change, HIV testing and case management assistance.
Andrea Castro, a West Hollywood resident who comes to the clinic for hormone therapy as well as treatment for high blood pressure, said she keeps returning because of the staff, many of whom are transgender themselves. Castro, a 39-year-old trans woman, said she hated when nurses at other doctors' offices called her by her male name.
"People would stare at me," she said. At St. John's, she's known as Andrea.
"I will probably never completely be a female, but I feel better with that name," Castro said.
Mangia, St. John's CEO, said the transgender health program has had to expand rapidly to keep up with the demand for services. It had to relocate to a larger facility last month.
"It just grows every day," Mangia said. "We're breaking new ground every step of the way."