Homelessness Compounds Health Challenges for Transgender Portlanders

A lack of data has led to funding cuts for some programs that otherwise might support these individuals, while others — such as OHSU — seek to boost their offerings

In her 31 years, Willow Paloma has had many identities: train-hopping hobo, Buddhist, activist, herbalist, self-described “crusty punk” and “queer separatist.”

But one part of her identity never changed, even while raised as a male.

She’s female.

Physiologically intersex, with “pointy bits on the outside, and wiggly bits on the inside,” as she puts it, Paloma still clearly recalls the moment when she was seven and hanging out with a group of boys and her world suddenly went sideways.

“I don’t even remember what I said, but it pertained somehow to me being a girl, and they all just looked at me like I’d lost my mind. Then they started teasing and laughing, and I got really upset and confused, and one of them said to me that ‘You can’t be a girl and have a boy body.’”

“So I was just convinced that I was crazy, and the crazy kind of went inward, and a lot of things got stuffed down, and I created a male persona to be able to survive. Eventually, I met my first traveling companion, who is a transgender man, and over the course of many drunken nights, he broke things down for me.”

Willow Paloma
Willow Paloma outside Stumptown Coffee’s Division Street location. Photo by Thacher Schmid.

Paloma’s among what may be Portland’s fastest-growing group of homeless people: transgender and non-binary persons. Its numbers have tripled in two years amongst adults, and it’s at its high-water mark amongst youth. Part of the growth, experts say, is inmigration due to Oregon’s expanded coverage of transgender health services and passing in June of additional protections. The city also has an accepting culture, and a group of local nonprofits recognized for informed services.

“Portland really is considered somewhat of a Mecca for trans youth,” said Jenn Burleton, Executive Director of TransActive Gender Center. “The word is out. And it’s probably a little bit overrated.”

But even in Portland, Burleton and others say, the “blessing” of increased visibility has been met with “persecution” of transgender homeless people of all ages, who face discrimination, and risk of assault.

This year’s “point in time” homeless count identified 59 transgender and non-binary homeless persons in Multnomah County. That’s triple the 20 identified in the 2015 count. Data from organizations serving homeless youth is at its high point in tracking transgender identity for 13 years: 46, or 6 percent of the total. (A county spokesman said the point in time count is historically adults, so the two numbers likely don’t overlap.)

Those numbers match other statistics that have found Portland has the second-highest percentage of LGBTQ people in the U.S. at 5.4 percent, behind only San Francisco’s 6.2 percent.

There are 1.4 million transgender individuals in the United States, the UCLA’s Williams Institute says — and an estimated one in five has experienced homelessness. “Homelessness is a critical issue for transgender people,” the National Center for Transgender Equality’s website notes.

It’s not known how many youth are transgender, but as many as 40 percent of the nation’s 1.6 million homeless youth are LGBTQ.

Dennis Lundberg, Executive Director of Janus Youth, the point of entry for the shelter system that serves 700 homeless Portland youth 14 to 24 each year, says Portland has an even higher portion of LGBTQ youth than that.

“The number in the homeless youth continuum is close to 50 percent being LGBTQ identified,” Lundberg said. Agencies like Janus typically serve individuals age 18 to 24; those younger than 18 are considered “children,” and more commonly the province of runaway shelters

Paloma started traveling in 2009, at 24, she says, and her freight-hopping and hitchhiking has always led back to Portland, in part because of local health clinics, services agencies and a queer-friendly attorney who is helping her apply for Social Security.

HRT and surgery while homeless?

Starting in 2015, the Oregon Health Plan began comprehensively covering treatment of gender dysphoria, and now pays for gender reassignment surgery, hormone therapy, puberty suppression and psychotherapy. In June, in a bill signed by the nation’s first bisexual governor, Kate Brown, the state allowed the addition of an “X” to state legal documents, and protected those who change their gender on birth certificates from public notification.

But many barriers remain to transgender homeless individuals’ accessing proper social and medical services, starting with lack of money.

“The idea of actually affording any kind of cosmetic enhancement or surgery or modification, when affording food is such an inherently difficult thing, it just doesn’t seem feasible to me,” said Paloma, who says she sometimes dumpster dives for food.

The manager of Oregon Health Science University’s Transgender Health Program says homelessness can be a factor for many of its clients — and clients often don’t reveal details of their housing situation.

“My impression is it’s likely far greater than is ever reported to us,” Penkin said of homelessness amongst transgender individuals at the OHSU program. “I think there are many individuals who are probably afraid to reveal [they’re homeless], because it could be perceived as a reason not to proceed with care.”

Penkin says hormone replacement therapy can be done without substantial risk while homeless, but any surgical procedure should be done while in stable housing to facilitate proper hygiene, rest and healing.

Conquest is a case in point: she’s two years into HRT, but still pondering surgery.

“I can continue taking my pills regardless of where I’m sleeping,” she says. But surgery is another matter: “a big decision.”

“I want to get my bits turned into a vagina. … I still have more consultations to go through. I’m really hoping that my ovaries can be removed from my testicles, because they’re kind of fused together, and if they can potentially make my vagina and sexual organs function in a more traditionally female way, that’d be awesome. But we’ll see what they can actually accomplish.”

Paloma doesn’t have a formal, professional diagnosis of gender dysphoria, which is required by many Oregon providers of health services. Her provider, Outside In, uses an “informed consent model,” a client-centered approach which allows individuals to consent to their own services.

But that’s not the case for many providers, experts say. Jack Marvin, an advocate at New Avenues for Youth, says health care systems have often been hard places for transgender clients to access.

“I think that there’s a lot of harm done in medical settings for trans folks, so there’s a huge barrier to even accessing any kind of health care, because of historical trauma that these folks have faced within any kind of health care setting,” Marvin said.

“And then there’s a lot of discrimination that happens with houseless folks in the realm of health care.”

‘It can happen both ways’

Nonetheless, the OHSU clinic — one of several in the metro area known for progressive care models — has had a “steep increase in the volume of referals and new patient visits,” Penkin said.

About a fifth of OHSU’s transgender clients are from individuals relocating from other parts of the U.S., and many others come from other parts of Oregon, Penkin estimated. But she said some transgender individuals come without a solid housing plan or realizing the city’s in an ongoing housing and homeless state of emergency, almost certain to be extended by Portland’s city council this month.

Conversely, others may lose their housing or their housing options narrow, Penkin said, because of their transitioning.

“It can happen both ways,” Penkin said.

It’s not clear how many providers require formal diagnoses from a qualified mental health professional to treat gender dysphoria. Nor is it clear just how large the population of transgender homeless in the Portland metro area really is.

What’s clear: anti-trans discrimination and violence is real, and officials are working to reduce contined gaps in data on the transgender homeless population—gaps which can reduce funding that might help them.

Sophia Conquest at Pioneer Courthouse Square. Photo by Thacher Schmid.

Sophia Conquest says she “stopped counting” the number of times she’s lost out on housing opportunities because she’s transgender. “I actually had a couple of [recent] housing situations that might have panned out, and then they found out that I was trans, and they were like, ‘Oh, never mind.’”

Another trans houseless woman who requested anonymity said she was diagnosed with gender dysphoria while in the hospital after a suicide attempt. At the time, she was socially identified as a man, and married to a woman.

Within hours, that diagnosis was followed by homelessness.

“[My wife] picked me up from the hospital and when we got home she already had my stuff packed and she told me to leave.”

Paloma is exquisitely cautious about where she pitches her tent, or which ledge she perches under, she says.

“I have avoided camping anywhere near other people,” she said. “For as much as I feel unsafe in the city, even when I’m housed, as a transgender person in a homeless camp, all the more. Not because the homeless people are worse people by any means — simply because I’m so much more exposed.”

Jill Weir, Director of Programs at New Avenues for Youth, says a lack of data collection and frequent changes in how data at multiple levels of government are collected on transgender homelessness has cut funding for transgender homeless.

For example, as recently as 2015, Federal Housing and Urban Development guidance for point-in-time homeless counts in the U.S. used different categories: “transgender (male to female)” and “transgender (female to male).” The 2017 count changed it to “Transgender” and “Don’t identify as male, female, or transgender,” or non-binary.

“It’s underfunded when you look at LGBTQ youth housing needs, because we don’t have the data to point to it, meaning city, county, state,” said Weir.

What’s more, many publicly-funded nonprofits and large medical institutions appear loathe to make data public on homelessness and transgender identity. Among them are Oregon Health Sciences University and Kaiser Permanente.

“Housing status is not something the Transgender Health Program program officially tracks,” notes OHSU spokesperson Tamara Hargens-Bradley. “It’s not a data field within our (electronic health records) that we filter. We are interested in collecting this information, but aren’t able to create a report at this time.”

“I don’t think that we’ll have much data to share,” a Kaiser Permanente spokesperson wrote, noting that Kaiser’s Gender Pathways clinic is still fairly new and the data question is “complicated.”

“While they might be able to identify the number of gender dysphoria (diagnosis) codes which existed by year and track recognizable increases,” they wrote, “that will miss patients who do not or have not wanted that (diagnosis), nor would it encompass those who removed that (diagnosis) after ‘completing’ their transition as they understood it, and it also would miss non-binary/gender non-conforming transgender individuals who have not been identified correctly due to the binary nature of medical record systems.”

Kaiser Permanente, OHSU, New Avenues for Youth and Janus all declined to or said they were unable to facilitate a client interview with a transgender homeless client.

This lack of collaboration with media can perpetuate invisibility for this population, TransActive’s Burleton says.

“It’s a Catch-22, it’s an endless cycle,” she said. “Nobody wants to talk, so the end result is the injustice serves the injustice.”

On the other hand, the risks to these clients are very real. All three transgender housless individuals interviewed for this story spoke of past suicide attempts, and Paloma and Conquest have both been physically attacked for being transgender.

“I’ve been assaulted many times,” Sophia Conquest noted in an August interview in Pioneer Courthouse Square. “Yesterday I had a kid throwing rocks at me.” Earlier that week, Conquest added, a woman physically attacked her at a nearby bus stop; she prefers shelter or couch surfing to taking her chances in a homeless camp “because I don’t feel like being raped or murdered.”

“There’s been a lot of rapings, people getting drugged,” said a homeless friend of Conquest’s, Brandi Beckett. “I have [trans homeless] friends who have been roofied.”

Portland police spokesman Sgt. Chris Burley noted that so far in 2017, there are no reports of sexual assaults or assaults against transgender individuals in Portland — but he said such crimes would only be known if they were “bias” crimes, for which transgender status is identified. (There were only 10 bias crimes last year in Portland, a tiny fraction of the 57,823 crimes tracked by Portland police in 2016.)

At a hearing Wednesday during which the Portland City Council considered extending its housing and homelessness state of emergency for another 18 months, Portland Housing Bureau Director Kurt Creager said the bureau is working to revamp its data systems by the end of that period.

Among other things, Creager said, “appropriate metrics” would improve data on “sexual minorities” and “needs by gender.”

This story was first published in The Lund Report.