Dr. Eloho Ufomata: Assistant Dean for Equity and Justice
Interviewed by Naomi Shin
Dr. Ufomata (she/her) is the Assistant Dean for Equity and Justice at UPSOM as well as a general internist. As an internist, she has a special interest in LGBTQ+ health, especially Gender Affirming Care for transgender and gender diverse individuals, Women’s Health, and care for the underserved.
* * *
Q: Can you share your experience and background in providing healthcare services specifically tailored for LGBTQIA folks?
A: I've been doing this officially in a more structured kind of way since around 2017 [...]. I'm a general internist. I did my residency here at UPMC and during my residency I was in the women's health track. With being in the women's health track, I got very familiar with hormones- at least estrogen and progesterone type of hormones and being able to deal with that. Then I did a general internal medicine fellowship again in women's health. That track kind of lends itself to a lot of hormones through the lifespan- reproductive and sexual health. But truly at the time when I was training, there wasn't very much within our training about gender diversity or the medical care to support gender diversity.
So in realizing that, when I started fellowship and I had to pick a master's project, I picked a curriculum in primary care for LGBTQ+ patients as my thesis project. I created a curriculum for internal medicine residents because I thought that it was missing from my training about LGBTQ+ health and transgender health. That was really where this became like an area of focus for me. Again, like I said, it wasn't part of my training, so I had to learn it somewhere.
There are conferences you can attend (the WPATH conference, the Fenway conference), reading online and really self-teaching about LGBTQ+ health and transgender health, more specifically. And along the way also learning from patients.
I remember a specific patient who I was caring for. We checked her hormones and we got her hormone levels back. She's an older woman and I was like, you know, your estrogen levels are within range for a postmenopausal woman. She was like, “No, no. You don't understand. I'm not a postmenopausal cis woman when my levels are this low. I feel like I'm detransitioning.” [...] So I don't have formal training in this. I have training that I have sought for myself. Lots of reading, lots of conferences, things like that. But I did not do a fellowship in gender affirming care. They don't actually exist in internal medicine. There are gender fellowships in some of the surgical specialties, like urology, plastic surgery, but as of right now, they don't exist in internal medicine.
Q: You mentioned a few resources. Can you recommend any other resources to students or other physicians who want to learn more about how to provide inclusive healthcare?
A: I would also recommend the UCSF transgender primary care guidelines. And then there's also the Endocrine Society Guidelines. I think I would say [the Endocrine Society Guidelines] are less about cultural aspects of being trans, less about cultural competency, more about the science of gender affirming care as far as we knew it. They're old, they're from 2017, I believe, and so could be updated because there's newer data, but [...] the WPATH Standards of Care Version 8 are new in the last year. And I think in terms of creation, [the WPATH standards] have more of the trans and gender diverse voice as part of the authorship of those guidelines. Then there's the UCSF primary care guidelines, which are more of a living thing that are hosted on the internet and patients use this as well. There's also the National LGBTQIA Health Education Center. It's another place [with] modules and educational programs that I would recommend for healthcare providers and students to utilize.
Then of course, there are patient facing websites. I think in terms of patient facing websites, there can be a degree of variance in terms of it being more anecdotal as opposed to quote unquote “scientific”. But I do think that there is a lot of value in those stories, because that is how we get to see the science in action, right?
Q: A lot of great resources for people to consider. In your journey of finding this path for yourself, can you talk about how that journey was for you? Did you have a lot of support from other folks who were also pursuing this path? How did you find these resources and get involved?
A: I think that I definitely had support, because there's a core of folks here at Pittsburgh who are very engaged and have been doing a lot of this work for a long time. I want to shout out Dr. Kristen Eckstrand from the Wolff Center, who does a lot of work with UPMC insurance. I want to shout out Dr. Joy Gero, I want to shout out UPMC Health plan, who has made a lot of strides in the time that I've been doing this care in terms of what they cover and what they don't cover. UPMC insurance is one of the few insurances that now will cover facial feminization surgery. We don't have anybody locally in Pittsburgh who does bottom surgery, so metoidioplasty, phalloplasty, but they are covered by the insurance products, so people can go to nearby places to get that care.
Then, there's a whole host of organizations- SisTers PGH, Hugh Lane Foundation, PERSAD, TransYOUniting, to name a few. There's a whole host of organizations in Pittsburgh that are supportive of gender affirming care and gender diverse individuals in the area that we've partnered with and have been able to really help make the care that we're giving, good. Even Allegheny Health Network, they have Charlie Borowitz who's a patient navigator who helps patients find what they need in terms of care.
There's gender collaboratives. There's listservs that I'm on that have all manner of different healthcare providers- psychologists, speech therapists, physical therapists who provide care. So essentially we crowdsource- it's like a grassroots movement. I think there are lots of very like-minded people who have made this possible. And I know I mentioned some names and not other names, but it's hard to mention everybody. But I will say that it hasn't been hard to convince people that this is important, and that we need to be doing it, which I think has been really kind of rewarding.
Q: To kind of go to the basics of sorts, can you broadly describe what gender affirming care encompasses?
A: Yeah, so gender affirming care, I think broadly I would say is any healthcare that affirms that gender is not binary. It's both specific types of medical care provided, but also a culture, right? Gender affirming care is the person being greeted with the right name when they check in. So it's really everything. It’s respecting our patients for who they are and understanding that our patients are the ones who have the clearest understanding of their own gender identity. [...] And then you kind of then can break it down if you want the specific medical aspects of gender affirming care. There's hormone therapy, there's gender affirming surgeries, there's voice therapy, speech therapy. There's things that would traditionally fall under aesthetic buckets that are medically necessary care for transgender folks- things like permanent hair removal that would also fall under gender affirming care. Physical therapy, pelvic floor therapy, things like that. [...] I fall into the medical aspect. I'm not a surgeon, so I do hormone therapy. I also provide primary care that is gender affirming. What does that mean? So appropriate cancer screenings, appropriate vaccinations, just overall providing that culture that is welcoming and accepting that allows people to feel safe so they can engage with the healthcare system to live full healthy lives.
And as far as surgeries, there's top surgery, which could be either adding breast implants, mastectomy, or removing breast tissue. There's also hysterectomy, oophorectomy, phalloplasty, metoidioplasty, orchiectomy. [...] So basically removal of reproductive organs and either the removal or creation of secondary sex characteristics.
Q: Thank you for the explanation. I think that the point you made about gender affirming care starting with welcoming them with the right name is so important.
Do you have any other recommendations for how medical students like us or other physicians can create a more inclusive and welcoming environment for gender diverse individuals?
A: I think one thing is the way that we present ourselves- normalizing that someone's pronouns may not be quote unquote “obvious”. So when I introduce myself to patients, I say, hi, my name is Dr. Ufomata, my pronouns are she/her. So that's just like, even from the moment you meet somebody, giving them an opening to tell you what their pronouns are, what their name is. When I trained, I was taught to walk in the room and, and call the person by their honorific and their last name- so walk in the room and say, Mr. Johnson. I don't do that anymore because I don't know if Mr. Johnson is on the other side of the door. So rather asking people what's the best way to address you I think is really helpful because then you can really learn what their chosen name is as opposed to assuming.
So I think really just starting with a place of curiosity and understanding that we have a lot of work to do. Your person's legal name may not be the best name to call them. So I think just basically having that degree of respect for people and starting with a place of curiosity, allowing people to tell you who they are as opposed to assuming who they are, I think is the biggest thing. And that's for gender, but it also goes for pretty much everything else in medicine too, right? We can't assume the patient's experience.
Q: My next question is can you talk about how you ensure confidentiality and privacy for LGBTQ+ patients, especially considering the sensitive nature of what their needs might be?
A: Yeah, that one's tricky, because in order to get a lot of things covered, you kind of need the documentation to be there. I don't take care of children. All my patients are adults, but there are patients that fall into that middle category where they're truly still adolescents and maybe under their parents' insurance [...], and they may not have the support of their families. So one of the things that I ask in my first meeting with patients is, who is their support system? What is their support structure? Who has access to their medical records? Are those people supportive of them? I also try to discuss with patients what I am documenting. For example, one of the things that is often needed to get coverage of things is the diagnosis of gender dysphoria.
Now, not every trans person has gender dysphoria, and even folks who have gender dysphoria don't have it at all times. So really describing to patients the reason for the needed document and trying to make the language that I use as patient-centered as possible. I tend to use the patient's own words. If there's anything that they would prefer for me to not document that I think needs to be documented, I'm upfront about it. I say, “I actually think that this needs to be documented in your chart. Can we come up with a way of documenting it that you feel would be most true to your experience and/or least harmful to you as a person?” So I think just being upfront from the beginning about what needs to be documented, what doesn't need to be documented, and the why it needs to be documented or not, and then trying to utilize the least harmful form of documentation.
I think if you understand what the patient's concerns might be, then it's helpful to [...] plan it with them and have that conversation of how do we document this? But there are certain things that don't need to be documented. For example, I have patients who engage in sex work who may not want that in their chart. Truly, there's no need for me to document that in their chart because it's not gonna impact the type of care that they're gonna get. So it depends, I guess is what I'm trying to say. Depends on if the thing that we need to keep confidential needs to be documented or not. And if it does need to be documented, then I try to make it a shared decision with the patient. So I tell them upfront, I need to document this, this is why, and then let's figure out how we can do it in the best way.
Q: The last question that I have is, can you talk about challenges that you've encountered in providing healthcare to gender diverse and LGBTQ+ folks and how you have addressed them?
A: I think one big challenge is that many folks- not all but many folks- who are transgender or gender diverse have faced discrimination and because of that may not have financial stability, employment stability. So there is a huge component of the social and structural determinants that impact their care. [...] Also for folks who live in rural areas, I think that there's a huge difference in the care that gender diverse folks who are in rural areas and those who are in big cities can access. I do a lot of telemedicine, which was facilitated by the pandemic, but now some of those protections are going away. For example, testosterone is a controlled substance, so now [...] patients who are from rural areas who've been seeing me virtually for the past three years now need to figure out how to get to Pittsburgh. Transportation might be an issue. I've had patients take video visits with me from the parking lot at McDonald's because they don't have internet access at home, or patients lose insurance in between care. I think those social and structural determinants really, really matter.
Another big thing that's been difficult or time consuming to navigate is insurance- prior authorizations, getting coverage for things. Lots and lots of letters are unnecessary. [...] Lots and lots of paperwork to get [prior authorization]. You change the dose of the estrogen patch and you have to get new prior authorization. So things like that are time consuming and frustrating and cause delays in care for patients because they can't get their medicine because we have to go through this process of prior authorization.
Q: As we wrap up, is there anything I haven't asked that you would like to add?
A: I want to add that this care is really fun. It comes to just the gratitude and the immediate feedback you get from patients when you just talk to them about who they are and you can watch the anxiety coming down because every encounter with a new physician is challenging and it's risky. In Pennsylvania, one in four trans folks in surveys have faced discrimination from their healthcare providers. So, it's just really rewarding to be a part of a positive experience for them, and to help them with medical affirmation. For them, it's been years coming and they start hormones and they feel whole and they feel like themselves even way before the hormones have the chance to kick in. It's just really, really rewarding to do this care.