After Crown Point steelworker Amari Victoria came out as a woman, she looked for doctors who could help her complete that transition.
She couldn't find any in Northwest Indiana.
Through her research, she discovered that the nearest clinics specializing in transgender medicine were Howard Brown Health in Chicago and Mosaic Health & Healing Arts in Goshen, Indiana.
Wanting to stay in the state, she made an appointment at Mosaic, which, founded three years ago, is said to be Indiana's first family medical practice focused on LGBTQ care.
While she has been pleased with the treatment she has received at the Goshen clinic, Victoria wishes there was somewhere closer that offered these types of services, or at least more awareness among local health care providers.
"Of course I would like to see them more educated about the community, especially since transgender people and nonbinary people may have concerns other people might not have, something as simple as an intake form for the patient's preferred name, more options for gender other than male or female," Victoria said, noting that the check-in process has become more sensitive at the local hospital she frequents. "The computer systems need to be updated, the medical staff need to be trained."
Victoria, who now runs the advocacy group LGBTQ Northwest Indiana, calls the Region "suburban, conservative, lacking in knowledge and acceptance of the LGBT community," behind even more rural places such as Goshen or Spencer, Indiana, which has one of the state's largest and longest-running LGBT pride festivals. Victoria organized an educational session on transgender awareness for local health care providers but said it wasn't well-attended.
Experts in the field say there a variety of reasons for this apprehension.
"Being trans is a self-diagnosis, so a lot of the current health care system and the way we're trained as physicians as a group, we don't tend to like people telling us who they are. We're trained to make diagnoses," said Dr. Catherine Bast, a family physician and medical director of Mosaic Health & Healing Arts. "In an era of evidence-based medicine, this is the cutting edge. We don't have a lot of data on what happens when you put hormones in your body over the long term. I think there's some fear around that."
Northwest Indiana also has several Catholic hospitals, which often don't offer transgender health services for religious reasons, and doesn't have any university medical centers, which tend to offer the most specialized care.
"It's the Midwest and it's Indiana and it's a very politically Republican state that is maybe not so supportive of LGBTQ rights. I think religion has something to do with it. (The state) tends to be very conservative," said Dr. Janine Fogel, medical director of the Transgender Health & Wellness Program at Eskenazi Health in Indianapolis. "I think it's really breaking new ground, and people willing to put themselves out there — I think it can, to some physicians, be a little daunting. It's a lot of work to learn and to figure out how to do hormone-replacement therapy."
Gender-reassignment surgeries and related care have been on the rise in recent years, in part because of an Obama-era rule outlawing insurers from discriminating against patients based on gender identity. (The Trump administration, however, has proposed rolling back those protections.)
The services include hormone-replacement therapies, which increase the intake of testosterone or estrogen; specialized mental health counseling that insurers and providers sometimes require before surgery; and the gender-affirming procedures themselves, including the removal or implantation of breasts or turning the penis into a vagina, or vice versa.
"It is very much affirming for the rest of their lives," said Dr. Alison Shore, a plastic and reconstructive surgeon affiliated with Advocate Illinois Masonic Medical Center in Chicago, who does about 200 transgender breast reconstructions a year. "By the time I see my patient, this is something that's been important for them, and they have been waiting and desiring and feeling strongly about it, for a long time."
One of the patients Shore operated on was Dylan Pilastro, a 34-year-old transgender male who lives in Griffith.
"It went great. There were no complications," said Pilastro, a deputy coroner. "I didn't take a pain pill, not once after surgery. I went home the same day. I was fine. I was out walking my dog that week."
When Pilastro first came out as male, four years ago, he saw an LGBTQ-friendly therapist in Valparaiso. She referred him to Howard Brown Health, a provider of LGBTQ-affirming care in Chicago. Pilastro started hormone replacement therapy there.
He does a shot in the stomach, once a week. He took about a six-month break recently because the scar tissue was irritating him.
"When you first start, there are mood swings, just because your hormones are changing," he said. "Your body changes. Your weight is distributed in different ways, so you will notice your face may get thinner ... your voice will deepen. Facial hair — that's more of a genetic thing. There's guys that take it for six months and can grow a full beard. I can't.
"Once you take it for about a year, the mood swings stop, everything kind of settles down and evens out."
Pilastro has, at the moment, decided not to do the so-called bottom surgery because he believes the female-to-male version of it hasn't been perfected. In the meantime, he wishes there was more transgender health care in the Region. A widely cited 2016 study from the Williams Institute estimated that 0.6% of the American population is transgender, the equivalent of about 4,600 people in Lake, Porter and LaPorte counties.
"I feel like for the younger kids that are going through this now, it's hard for them," Pilastro said. "They don't have anywhere to go. They don't have the means of going to the city. It would be helpful to have someone here, in this area. For the most part, this area is LGBT-friendly, so it's not a bad area to do it."
Michelle Fore, a 63-year-old transgender woman from Kouts, had her testicles removed with a procedure called an orchiectomy. She had it performed at a local hospital by an Elkhart urologist who has an office in Valparaiso, she said. She is holding off on further "bottom" surgeries until she has the financial means.
Still, Fore is discouraged that she has had to travel two hours for the rest of her care (including hormone-replacement therapy in Goshen). However, she said she was recently approved for insurance through the U.S. Department of Veterans Affairs and plans to do voice training at a Chicago VA facility.
"Very much disappointed that there is nothing closer," she said. "For the most part, transgenders are not accepted and most medical facilities are not willing to take the time to learn what our needs are and what treatments we require."
Dr. Ravi Iyengar, an endocrinologist at Rush University Medical Center, has been helping start a gender identity program at the Chicago hospital. He believes this is necessary because of the discrimination transgender patients often face; a 2015 survey found that a third of them had at least one negative experience in the past year, including being verbally harassed or denied treatment because of how they identified.
"I think this population is faced with a lot of unique stigmas and has a lot of unique needs that are very difficult to find in the current health care setting, which is primarily geared toward cisgender patients," he said.
He noted that all the screening recommendations from the U.S. Preventive Services Task Force are for cisgender men and women, so specialists are needed to advise transgender patients on tests for conditions like osteoporosis and cardiovascular disease, as well as cervical cancer for patients who transitioned from female.
He said Rush has implemented medical school curriculum and training for staff focusing on transgender care.
"Things have gotten better in the sense of more social awareness and a general social acceptance in certain areas," he said. "Contrary to what the current political climate may be, I think that many medical centers are recognizing this is necessary care that needs to be practiced and are very willing to start incorporating some of this education and some of these services. I'm hopeful we will continue to grow and go forward from here."
Dr. Mark McMurtrey, a Valparaiso family physician who practices part time at the Valparaiso University Student Health Center, said doctors don't have to know how to do surgery or hormone-replacement therapy to provide informed care for transgender patients.
"Medicine is not practiced differently because a patient is transgender. High blood pressure and asthma are high blood pressure and asthma, no matter who has it," he said. "But we do need to assess for individual risks for illness. As an example, transgender children have elevated risk for depression and suicide. We need to be mindful of this, and screen and treat appropriately."
(Fogel noted the psychiatric issues are generally the result of discrimination and bullying. "When people grow up in a loving environment, a loving family, mental health outcomes are the same as the rest of society," she said.)
"It is important for providers and clinical staff to be nonjudgmental, professional and confidential," said Dr. Michelle DiCostanzo, a Porter Physician Group family medicine specialist at Hobart Primary Care.
"Mistakes are bound to be made, and apologies should be quickly forthcoming and respectful when that happens. I believe that an attitude of openness and humility, along with a parallelly inclusive atmosphere, can go a long way in making everyone feel welcome. This can make maintaining health and wellness feel more like an alliance than a patient/clinical staff relationship."
Finn McGowan, a transgender male from Valparaiso, said the transgender community often suffers from something called "broken arm syndrome." An individual goes to the emergency room with an arm fracture, and the staff starts questioning the person on where they got reassignment surgery, how it works, etc.
"People want to know what your genitals look like, what you're doing in the transition — all kinds of things that aren't relevant to the type of care you should be getting," the 36-year-old said. "Transgender bones are the same as anyone else's bones."