There are a growing number of transgender individuals in the United States — largely due to increased awareness and available healthcare. Healthcare for transgender people varies, by region, socio-economic status and insurance coverage; but, transgender health is another area of medicine that can clearly benefit from a team approach to help an individual affirm their gender identity. Research at the Ludeman Center is ensuring that transitioning is safe and affirming for individuals, and a team of physicians at UCHealth is working tirelessly to increase access to care for the transgender and gender diverse community. Many, like UCHealth patient Megan Garcia, waited to transition until later in life, when she felt safe and supported in doing so. “I was a grumpy 50-year-old man when I decided to start my transition journey to becoming a woman because it took that long for me to feel safe doing so,” said Megan.

Megan and her family left Cuba in the 1960. At the time she was known as Robert, the son of Cuban immigrants, and knew that something was different. “I would see a dress and think it was pretty and feel drawn to it,” said Megan. “It was very early that I knew I was different, even though it took a while to realize that I was transgender.”

The family moved around Mexico before finally settling in Miami 18 years later. “I grew up in a conservative and religious neighborhood. Being different wasn’t okay,” said Megan. “I had to go to school being Cuban, a foreigner and transgender. Something was off and the other kids knew. Megan grew up in a community where there were clearly defined gender roles, and knowing she was different made it difficult. “I was really scared. You have these feelings that you might be transgender, but you don’t have anyone to talk to or relate to. You get taught that you’re crazy, or even worse an evil person.”

Megan decided to continue building a life that felt “normal.” She got married and had two children with her wife. After several years of marriage, Megan decided to tell her wife that she was transgender. Ultimately, being transgender caused a divorce and years of mental health issues for Megan. “It was a very bad divorce. I lost almost everything. It was three years of fighting,” said Megan. After losing her job and place in the community, living in Miami was untenable, so she left and moved to Colorado. “I left Miami with my SUV and a small U-Haul that had my bed and a few furnishings and drove to Colorado,” said Megan. “That was when I learned humility because one day I had everything, and the next, I had lost it all. I was moving to Colorado to restart my life.”

From her home in Colorado, Megan decided it was time to transition. At the time, she was working in the controller’s office at CU Boulder when she came across information about the UCHealth Integrated Transgender Program. “I decided I couldn’t put this off anymore. It was central to my identity,” said Megan. “I think about how easy my life would have been if I didn’t come out or transition, but I would have had to hide so much about myself.” That is how Megan found Sean Iwamoto, MD, a researcher at the Ludeman Center and clinician specializing in gender-affirming hormone therapy for adults. “Dr. Iwamoto is an angel, and he takes care of us like nobody else. So many good doctors and nurses are misinformed. Having this resource with Dr. Iwamoto is really important for the transgender community,” said Megan.

Dr. Iwamoto, assistant professor in the CU Division of Endocrinology, Metabolism and Diabetes, is a co-founder of the UCHealth Integrated Transgender Program — the clinic where Megan receives care. This clinic includes a team of professionals who understand how to care for transgender and gender diverse adults through patient engagement. This comprehensive health program provides care from the initial evaluation through hormonal therapy, surgical procedures, mental health care, and routine health maintenance including gynecological care. The UCHealth Integrated Transgender Program continues to grow every year, having served over 300 patients in the last year, and has over two dozen clinicians and staff working with transgender and gender diverse patients at all stages of their journey. It is important to offer holistic care and it is one of the few clinics to offer so many services for transgender adults in one place. “This is an area of medicine that has long been overlooked, leaving transgender patients to find a patchwork of care,” said Dr. Iwamoto.

In addition to this clinic, Dr. Iwamoto has built a significant research program looking at the effects of gender-affirming hormones—estrogen and testosterone—on vascular and metabolic health across the lifespan of adult transgender women and men. “Sex and gender differences in cardiovascular disease risk have been identified such that transgender women have higher risk compared to cisgender men and women. Data remain mixed on the risk among transgender men. It is important that we understand the effects of gender-affirming hormones on the vascular system and metabolism so we can ensure that our patients receive lifesaving hormones and are as healthy as possible long term,” said Dr. Iwamoto. His research projects are focused on enhancing the health of all transgender and gender diverse individuals and informing future care.

In addition to this work, there is a growing cadre of pediatric researchers expanding care for transgender youth. Ludeman Center scientist and assistant professor of pediatric endocrinology Natalie Nokoff, MD, is leading efforts on the pediatric side. Her work looks at the effects of pubertal blocks and subsequent gender-affirming hormone therapy on insulin sensitivity and vascular health in transgender adolescents. Many transgender youths in early puberty are prescribed a puberty blocker that shots down their body’s production of puberty hormones. Later, they are prescribed hormones to give them characteristics that align with their gender identity. “We are trying to make sure that these hormone blockers and later the gender affirming medications are safe long-term and there aren’t any issues that can result,” Dr. Nokoff said. “These therapies dramatically help the psychosocial aspects of a patient’s life, so we want to make sure that we are treating them in a way that doesn’t cause long term complications.

Research consistently shows that adolescents and adults who identify as transgender are at a significantly higher risk of anxiety, depression, eating disorders and suicide. Megan recalled moving to Colorado without having any friends or family after coming out to her spouse. “I had nothing but a little apartment and didn’t see a future. At that moment you have to decide if you even continue. I’m glad I made the choice I did.”

February 24, 2020, Megan started gender-affirming hormone therapy to officially begin her transition — two decades after divorcing her wife and moving to Colorado. Two decades after coming out the first time and losing everything. Megan noted it is a long process to transition. “It is a step-by-step process because you are coming out to the world. There are so many milestones — your first job interview as a transgender woman, when I changed my LinkedIn profile, telling my boss and coworkers.” While Megan celebrated two years of being on gender-affirming hormone therapy, her transition is still ongoing, and she couldn’t be happier. “This is who I am, and I can finally be myself.”