The clinic strives to make everyone feel comfortable accessing primary care – no stigma, no judgment
Brandon wore his favorite blue nail polish the first time he visited Prism Health, and as he walked into the brightly colored building on Portland’s Southeast Belmont Street, a staff member complimented him on the color.
For some, this exchange may seem unremarkable. But for Brandon, the throwaway line welcomed him in – he let out a sigh of relief. Brandon felt accepted, seen and not judged, a rare occurrence for him at a doctor’s office.
“My kind, they’re not respected where I’m from,” said Brandon, whose long blond locks of hair hang below his shoulders.
He was not fully out as gay in his hometown and did not see the importance of going to a doctor. Brandon, who is using a pseudonym for this story, never felt safe or at ease in doctors’ offices, and the thought of bringing up safe sex or testing for sexually transmitted infections made him shudder.
“No one wants to talk or think about gay sex – even the thought of it,” he said. “I just wouldn’t bring it up.”
Brandon made every excuse not to go to the doctor’s before moving to Portland from Hillsboro. And then he found Prism.
Prism Health is Oregon’s first allopathic health clinic focused on primary care for the LGBTQ+ communities. Prism offers referrals, prescriptions and diagnoses. Patients come to Prism for affirming primary care and LGBTQ+-specific care all in one place.
“At Prism, I can say ‘gay sex,’ and it’s OK. It’s like asking if you want cream in your coffee,” Brandon said.
Now, Brandon has a prescription for PrEP, a pill taken once a day – regardless of sexual activity – that drastically lowers the risk of HIV infection, and continuous contact with a primary care provider, something he has not had since a routine sports physical at 15, where a doctor quickly evaluated him before sending him off to the field.
Opened in May, Prism operates under the umbrella and leadership of Cascade AIDS Project, a Portland nonprofit that offers services to test, treat and assist those living with HIV. Part of Prism’s services include Pivot, a walk-in center that provides free screenings for HIV and sexually transmitted infections for the LGBTQ+ community.
Not all traditional health care practices acknowledge the specialized health care needs of people in the LGBTQ+ community. A transmasculine person, who wished to remain anonymous, said they receive health care in Portland, and their ideal situation is going to a doctor who has basic levels of understanding of trans people and trans issues. They want the care they need without having to educate. Finding appropriate care can take weeks, if not months, and usually falls to those seeking it out, not those who are supposed to provide it.
“It’s not just specialty doctors, like surgeons or OBGYNs that are needed for LGBTQ+-specific health,” they said. “The struggle we have with primary care is those doctors barely have a basic understanding of the community, so many assumptions are made and care that could be provided is missed.”
For instance, a patient who is a transgender man and has top surgery might still need mammograms since breast tissue can be left behind in the chest wall. Or a transgender woman might need prostate exams. Some patients feel safe at Prism because providers ask questions that are pertinent to the queer community, like “what parts of your body do you use for sex?” and it is commonplace for providers to first ask and then use correct pronouns and names.
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Inscribed on her silver bangle bracelet are four words that could be Deven Ferte’s motto: “Until There’s a Cure.” Ferte, the operations manager at Prism, has been wearing this bracelet since the mid-’90s, when her mother bought it for her at The Body Shop during the AIDS epidemic.
For Ferte, opening and managing Prism is important work. Ferte identifies as queer and understands the need for comprehensive, culturally appropriate and trauma-informed health care.
“We hear all the time about the awful health care for the LGBTQ+ community, the lack of understanding, the stigma and the judgment,” Ferte said.
One patient found himself at Prism because when he asked a previous care provider for a PrEP perscription, his doctor gave him a referral to see a counselor instead.
“Would a heterosexual person be given a mental health referral if they asked for birth control pills?” Ferte asked. “No, that would never happen. Yet when people in our community want to be proactive about their sexual health, they are labeled as mentally unwell.”
Another patient drives more than two hours to come to Prism because of the judgment they receive as “the gay person” in their home town.
Ferte said the lack of understanding, stigma and judgment directed at the LGBTQ+ community comes not just from health care providers, but also from insurance companies that take their claims.
“If someone was assigned female at birth yet identifies as male and still has their cervix, they may need annual pap smears,” Ferte said. “If we were to list their sex at birth as male, that claim would not be paid because the insurance would see it and say, ‘Why is a male getting a pap smear?’ And this creates a very uncomfortable situation for the patient.”
Although Prism specializes in care for the LGBTQ+ community, it doesn’t exclude others.
“We do see straight people!” Ferte said with a grin. “I think people see that we are focusing so much on the LGBTQ+ community and people who are heterosexual call and say, ‘Hi, I’m looking for a new primary care provider. I notice that you guys specialize in gay people or the gay community, but I’m straight, will you see me, too?’”
Prism’s intake forms are the most encompassing and comprehensive medical forms some patients have ever seen.
For instance, there are nine different options for a person’s gender identity: male, female, trans male, trans female, two-spirit, gender non-conforming, non-binary, decline, another, and a patient can check all that may apply when it comes to their race and ethnicity.
Prism also documents every patient’s sexual orientation, gender identity, pronoun and preferred name. A disclaimer is included in new patient paperwork that explains why Prism asks for a patient’s assigned sex at birth, gender identity, legal name and the name they go by.
“Many of our patients have a legal name that is used for their insurance, but they have another name they go by. We work hard to collect this information in a way that is respectful and affirming to our patients,” she said.
“Prism is Oregon’s first comprehension standalone primary practice. Everyone from the receptionist to the biller on the opposite end are people trained for the needs of the community, and understand the importance of things like gender identity and pronouns, said Tyler TerMeer, the executive director at CAP. “We’ve designed our intake forms around patients’ visions. The visual and physical (experience) is by and for the community.”
“Don’t mind me sobbing over medical forms because they’re so inclusive,” wrote Ari Chadwick-Saund, a queer optician, on Facebook.
As she waited for her new-patient appointment at Prism, she took a picture of the intake form and shared it on social media. Chadwick-Saund told Street Roots that she is usually allowed to mark only one race on typical intake forms even though she’s multiracial.
Chadwick-Saund was at Portland’s Pride festival when she came across Prism’s booth. She could have been knocked over with a feather, she said. She did not expect to see something like Prism in Oregon’s health care landscape.
“There’s a lot of lack of understanding about the problems that face this community of individuals,” she said. “It’s intersections – class, race, gender identity, politics, religion – the queer community is very, very broad. It can be hard with a community that’s marginalized that you know nothing about to custom-tailor medical care towards them. That’s why Prism is so important.”
Because of a grant from the Oregon Community Foundation, Prism will offer culturally specific mental health services during the first half of 2018.
“We’ve heard a lot of folks talking about the need for LGBTQ+-centered mental health services,” TerMeer said. “This will be a great opportunity to fulfill some of these requests for (patients) who may want to talk about what’s it like to be LGBTQ+.”
FURTHER READING: Portland's low-income clinics pioneer safe health care for trans patients
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Prism’s waiting area feels nothing like a traditional doctor’s office. A sleek, modern, colorful rug lies atop cement flooring, and chairs and couches with pops of color invite people to sit, relax and take a breath – an extension of the overall warmness the staff projects. The sanctuary feel and ambiance of Prism is intentional, and the product of Elena Moon and her team at Osage Orange, a human-centered design studio based in Portland.
One part of designing Prism included research conducted by Osage Orange. Their team of four, all queer-identified themselves, spoke to community members to better understand their health care needs and experiences. Osage Orange was particularly interested in hearing from transgender and queer people of color in the Portland area, as these communities have historically less access to appropriate and affirmative health care. Osage Orange worked from October to February on the project and informed the design through interviews with 11 people, where they learned about challenges experienced within the existing medical system and what an ideal primary health care clinic would look and feel like. Toward the end of the design process, Osage Orange shared ideas for the center’s name, logo design, health care experience, staffing and interior for feedback.
“We found a lot of people in the queer community feel socially isolated,” Moon said. “People want safe spaces with like-minded people and opportunities to connect. We wanted to create a warm, non-clinical environment where somebody would want to spend time, a place where you can hang out.”
Chadwick-Saund receives her primary care at Prism and attains more specialized care at Oregon Health & Science University. She acknowledges that this is a privilege; having access to multiple care providers, as her employer pays for her health insurance.
Chadwick-Saund is most impressed with how she feels included and in control of her care at Prism, along with the amount of compassion and kindness used in exam rooms. She said that a part of this inclusiveness comes from having people who identify as queer work in the health care field; “it brings more inclusiveness to the health care realm.”
“There was no judgment and no stressful situations. Everyone was very calm, and there was a very good flow in the office; the baton passes were seamless, and the way the medical providers communicate with each other was seamless as well,” Chadwick-Saund said.
“My provider responded really well to understanding the possible health side effects of abuse,” she added. “I have medical conditions that are kind of rare, so I lobbed tough questions at them, too. My provider didn’t bat an eye; he did not act surprised; he was professional.”
Chadwick-Saund said her provider responded well to understanding the health side effects of abuse. And for her, this is important: “I don’t have time to be a survivor right now.”
Chadwick-Saund knows what it’s like to come up against high barriers of medical care, to feel like it is “you against the world,” which can be a common experience for LGBTQ+ people accessing or trying to access medical care.
“It’s hard to pull yourself out of that depression,” she said. “There’s a reason, statistically, queer people suffer from depression more, especially because of the oppression that we face.”
It was 2015 when an investigation opened focusing on a hospital in rural Montana where Chadwick-Saund sought care for pain-related medical symptoms. “She just brushed me off,” Chadwick-Saund said.
“People that wear those white coats – you want to believe them all the time, and questioning their methods are really hard,” she said.
Chadwick-Saund believes her case was mishandled, and the hospital ended up paying part of her medical bill.
“Health care in this country has a long way to go, and Prism is paving a path,” she said.
Ferte and Prism staff are trained in trauma-informed care, something at the forefront of being a care provider, especially for the LGBTQ+ community. Staff attend training around cultural sensitivity in the black community and also white privilege.
Ferte said that health care in the United States operates in an antiquated way and that the medical community needs to progress and evolve with society.
“It sounds like an easy thing to understand, and it doesn’t happen – clearly, because Prism is here. Health care is ever-changing, insurance is ever-changing, everything about this business is ever-changing,” she said.
Ferte does not like to assume anything about anybody’s experience but stresses that everybody is treated with an extra sense of sensitivity, because for a lot of patients at Prism, accessing health care on Belmont Street is their last resort.
“We are always mindful and almost assuming that just about anybody who walks through our door has experienced some sort of trauma (in the health care system) at some point in their life,” Ferte said.
Since Prism opened in May, Ferte and other providers have seen folks from all walks of life. Patients range from 15 to 78 years old, and all carry with them a magnitude of experiences within the health care system.
“People won’t be turned away,” said Ferte, who explained how Prism has implemented a sliding fee scale in order to have as many systems in place where people can access care. To use the sliding fee scale, patients have to be up to 200 percent of the federal poverty level. If a patient is over that benchmark and doesn’t qualify for the sliding fee scale, Prism offers a 10 percent discount of what the office would normally bill insurance.
Based on information from October 2017, roughly 35 percent of Prism’s patients are on some sort of public health insurance, such as Medicaid, and for some, this might be the first time they have ever had health insurance.
Lack of insurance is a significant barrier for attaining health care for the LGBTQ+ community. Miguel Carreon, a nurse practitioner at Prism, said that he has patients lose their insurance due to their job status or changing life situations and that they won’t be able to return for care until they have insurance again. This type of inconsistency can have a significant impact on a person’s health.
And more patients are traveling from outside of Portland, even from neighboring states such as Idaho, to access care at Prism and to get prescriptions for PrEP. About 30 percent of Prism’s patients are on the medication, and more are being prescribed and filled each day. A provider at Prism said that the LGBTQ+ community seems to be more aware of PrEP than other colleagues in the medical field.
“People will now do damn near anything to get it, if it’s important. People come from Idaho to get their PrEP, to get competent care with their PrEP. People come from Damascus, Eugene, Stevenson,” Ferte said.
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“It was my dream to work here,” Carreon said. “I myself am a gay male, and I’m working with a population I care about.”
Carreon, like some of his patients, takes PrEP. He said the community he provides care to is more informed than his colleagues in the medical field about the preventive medication.
That’s not a big surprise, he said.
“Throughout the time I was on PrEP, I had three different care providers. None of them knew what the medication is,” he said. “I had to take information to them, to tell them what labs I needed. I even ended up doing my own STD testing.”
Before Carreon meets with any patient, he considers how he wants to be treated at a doctor’s office. His own experiences with doctors left him feeling rushed through the visit.
“I don’t want my patients to feel that way,” he said. “Instead, I’d rather they feel comfortable opening up and discussing issues that concern them.”
And for Brandon, that’s exactly how he feels coming back to Prism for a follow-up appointment – comfortable and not rushed.
“I’m so grateful for this place, I can tell when I come here that they want you to feel safe. I have never once felt less-than here,” he said. “People come from all walks of life. They are going to accept you here; they are going to take care of you. You get that here without any ifs, ands or buts.”
