Sarah Hauwiller was 30 when she tried on women's clothes and makeup for the first time.
Assigned male at birth, Hauwiller thought if she did what her family and society wanted her to do — go to church, do well in school and marry a "good, young lady" — everything would fall into place and be alright.
"But, everything got much worse," says Hauwiller, now 33. "I could not even look at myself in the mirror, let alone be intimate with my wife."
On the day she put on a dress, Hauwiller felt like her real self — the person that she knew she was on the inside. The realization was instantaneous as she saw her reflection in the mirror. Soon afterward, Hauwiller came out to her wife and her parents as a transgender woman.
"I was not prepared for that powerful, emotional joy I felt when I saw myself in those clothes in the mirror," she says. "I knew this is who I was."
Hauwiller's primary care physician referred her to the UCLA Gender Health Program. That’s where she first met Amy Weimer, MD, the program's co-director, and learned about gender-affirming care.
Hauwiller had not heard the phrase "gender-affirming care" at the time, but she saw it in action the moment she walked into the facility.
"UCLA was really one of the first places where I remember being treated like my true self," she says. "Once I let everyone know about my name and gender, that was it. No one even mentioned anything about my past self. They have always treated me as the woman that I am rather than the façade of a guy I had been until then."
This mattered to Hauwiller because her sense of gender dysphoria — the sense of unease an individual experiences because of a mismatch between their sex assigned at birth and their gender identity — had always been very strong.
"Being treated as a woman really gave me the confidence to come out and be my true self," she says.
Gender-affirming care is a broad term that encompasses a range of social, psychological, behavioral and medical interventions that are designed to support and affirm a person's gender identity when it conflicts with the gender they were assigned at birth.
Such compassionate care helps transgender people align various aspects of their lives — biological, emotional and interpersonal — with their gender identity. The Human Rights Campaign defines gender identity as: "One's innermost concept of self as male, female, a blend of both or neither – how individuals perceive themselves and what they call themselves. One's gender identity can be the same or different from their sex assigned at birth."
Gender-affirming care is medical care delivered in a way that supports and recognizes an individual's correct gender, one with which they identify, says Dr. Weimer, who treats Hauwiller and others at the UCLA Gender Health Program.
"This includes simple things like referring to them by their correct names and pronouns," she says, adding that Hauwiller's experience is common among the transgender people she cares for. "As people receive gender-affirming care and go through this process, it finally liberates them…because they are not laden with the discomfort of living an inauthentic life."
Dealing with emotional pain
As was the case with Hauwiller, religion, community, family and social structures can tend to prove restrictive for individuals needing gender affirmation.
Hauwiller grew up in the Mormon faith and in a rural Ohio community that was largely Christian. Even though Hauwiller realized in her teens that she wanted to grow her hair out, wear dresses and date boys, she was constantly told to suppress those thoughts and feelings.
"Everywhere I looked, I got this message that the person I was inside wasn't right," she says. "I went with it because I wanted to fit in. I did not want to be bullied or ridiculed."
She is grateful that her parents were accepting when she came out to them about three years ago. Even so, Hauwiller says she felt severe emotional trauma and resentment thinking about the years of missing out on common experiences for girls and women.
"Those are years I can't get back," she says.
That is why gender-affirming care can be lifesaving for an individual who is transitioning, Hauwiller explains.
"As a transgender girl, it can be really difficult when you feel like you are trapped in an identity you had to build in order to fit in," she says. "When you get used to being that person, it can feel almost impossible to escape that identity. But, once you start recognizing your gender dysphoria, it can be painful to remain in that identity."
Distancing yourself from this made-up identity and embracing one's true identity takes significant effort, Hauwiller says.
"Anything that reminds you of that old identity can pull you back into that pain," she says. "That is why it is important to be provided that validation and to assert your new identity. It helps you distance yourself from that old identity and helps build confidence. It gives you hope that you don't have to suffer forever, that you will be supported and accepted."
A collaborative approach
Hauwiller says she found that exact affirmation at every step in the UCLA Gender Health Program under Dr. Weimer's care. At first, she was grateful to take things slow and go over her options. She chose not to have hormone therapy right away, exploring non-medical approaches such as breast inserts. Hauwiller found six months later that such steps did not make her feel the way she wanted to feel.
"I sat down with Dr. Weimer to talk about the risks and benefits of medical interventions," she says. "I decided it was right for me, and Dr. Weimer provided me with the hormone therapy right there in that session. It was a great comfort to know that I have access to care right when I need it."
Hauwiller has been on hormone therapy for the last year and a half and is now discussing options for breast enhancement surgery, she says.
"To me, gender-affirming care is a personal approach where the doctor listens to the patient and has an honest conversation with them. What I've learned from my experience is that I need medical and emotional care as I go through the next stage of my life."
She sees more physical changes in her future such as getting the chest size she envisions, permanent facial hair removal and continuing with therapy to process the trauma and emotions associated with her transition.
"As I go through life, I want to make sure that I not only present myself as beautiful, but also with confidence so no one has any qualms about treating me as Sarah as soon as they meet me."
Challenges to gender-affirming care
Receiving gender-affirming care is still a challenge for many because of the difficulties that exist around navigating insurance and getting covered for services, says Dr. Weimer.
Procedures such as facial, chest and genital reconstruction surgeries involve techniques that are specific to gender alignment – and there needs to be more awareness to acknowledge that these are required medical procedures, she says.
"It's very clear that these surgeries do improve health outcomes and mental health outcomes," Dr. Weimer says. "Many transgender patients also struggle to get connected with mental health professionals who are knowledgeable about the issues they face."
One answer to providing quality care to the transgender patients is to increase diversity in medical schools and residency programs where such representation is lacking, she says.
Current medical school faculty and medical providers have completed training that is not geared to serve this population, Dr. Weimer says. It was this realization regarding the barriers to receiving care, as well as stories shared by numerous patients that has motivated her to become a gender health specialist.
"We need to have confidence and commitment," she says. "We need to read more, attend conferences, expand our knowledge, listen to patients and learn from their experiences."
It is also important to recognize that the future of gender-affirming care is under threat because of the politicization of transgender issues and "the attempt to erase transgender identities across our country," Dr. Weimer says.
"We need to stay vigilant against that threat. The care that people are able to access will vary depending on where they live."
Gender health should be based on a "shared model," where medical providers and patients employ a collaborative approach to make informed decisions about their healthcare, just as in other areas of healthcare, Dr. Weimer says.
"These may be difficult issues to deal with," she says. "But what I do is also very rewarding. In the end, this is joyous work."
