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DAP Health Magazine Posts

A Safe Space in a Sea of Hate

by suelowe

A Safe Space in a Sea of Hate

How DAP Health is elevating lifesaving gender-affirming care in Southern California.

Words by Jacob Anderson-Minshall

 

As seen in DAP Health Magazine Issue 4

 

Navigating the Storm: The Landscape of Gender-Affirming Care

A wave of legislation targeting trans and nonbinary people — especially youth — is radically reshaping Americans’ rights in states across the nation. There are new restrictions on access to LGBTQ+ books, public restrooms, and participation in sports. But the greatest threat to trans lives is undoubtedly the recent criminalization of gender-affirming care.

The Battle Against Discrimination: Upholding Gender-Affirming Care

The ACLU is currently tracking 492 anti-LGBTQ+ bills — more than in any previous period in U.S. history — nearly half specifically targeted at transgender, gender-nonconforming, and nonbinary people. In fact, against the advice of the American Medical Association and the American Academy of Pediatrics, at least 90 of those bills will prevent trans youth from accessing age-appropriate, medically necessary, and life-saving health care. (When that happens, suicide rates also rise.)

Just this year, 19 states (Texas being the largest) have restricted some (often all) gender-affirming care for anyone under 18. Despite the propaganda, genital surgeries aren’t and haven’t been offered to trans kids, but these laws can eliminate access to hormone therapy and puberty blockers. Criminalizing gender-affirming care intensifies the already significant barriers trans people face when seeking medical services.

Anthony Velasco, a senior nurse practitioner specialist who led the development of DAP Health’s gender wellness program, explains, “In my research on stigma and primary care access among transgender and gender-diverse people, many reported experiencing violence and victimization when accessing care.”

A Beacon of Hope: DAP Health's Gender Wellness Program

DAP Health aims to turn that tide and improve access to gender-affirming medical care across Southern California.

“Creating safe spaces for all people, regardless of their gender identities” is a natural extension for DAP Health, Velasco says. “We exercise social justice by continuously engaging our communities, interrogating social injustices, and addressing health inequities.”

The same could be said for Velasco, who uses he/they pronouns. He identifies as a “queer person of color, an immigrant, and a first-generation student” who provides care for “systemically and historically minoritized communities.”

Standing Firm: The Fight for Inclusive Healthcare

Now that DAP Health has absorbed the Borrego Health system, it is poised to further elevate lifesaving gender-affirming care with Cathedral City’s LGBTQ+ clinic Stonewall Medical Center. Dr. Jason Halperin will be leading that charge — working out of both Stonewall and DAP Health’s clinic in Escondido — as the incoming director of specialty programs for gender-affirming care as well as those living with, or at risk of, contracting HIV.

Dr. Halperin hails from New Orleans, a blue city in a deeply red state. It’s “an island of inclusion in a sea of oppression,” he says. But even in places that embrace diversity, like much of Southern California, Dr. Halperin maintains, “We must be aware of the national backlash against so many of the communities we serve, especially those of trans experience. [In Louisiana] I witnessed the impact of clinics that provided reproductive health services and gender-affirming care shuttered due to the politics of hate.”

Manager of Gender Health and Wellness Programs Mita Beach has witnessed the chilling effects the anti-trans backlash has had locally. “In all of Southern California, there are two clinics in L.A., one clinic in San Diego, and our clinic in Palm Springs that will see trans youth,” they say, adding that there were two or three more in 2021, but providers are being “scared away” by the criminalization of trans care.

As trans people, families with trans kids, and trans adults flee other states, DAP Health is committed to boosting Stonewall Center’s beacon and serving as a safe haven where care is accessible to everyone.

The nonprofit already has “a proven track record of shifting the norm to a more equitable one,” Velasco says. “As we expand our clinics within and around the Coachella Valley, we continue to be committed to opening our doors even wider so we can provide more services to our trans and gender-diverse patients.”

Breaking Barriers: Overcoming Obstacles to Care

Empowering trans, nonbinary, and other gender-expansive people to walk through DAP Health’s doors is Beach’s job. There are numerous barriers to care that trans and nonbinary folks face, including social determinants of health like lower incomes and lack of transportation.

Just connecting isolated trans and nonbinary folks with each other is difficult in rural areas with a widely dispersed population, says Beach. Another issue is “misinformation in general,” they say. Many don’t know what care is available, or that it is accessible, even for those who need financial assistance.

To overcome those hurdles, Beach has done outreach at every LGBTQ+ event they could find. “I would go and put up posters and signs at coffee shops out in the middle of nowhere, and I would get one or two phone calls,” they say. “But a lot of it is word of mouth.” Beach thinks DAP Health’s track record of “engaging with the community outside of the clinic’s doors” will help spread the word about safe, accessible, and competent gender-affirming care.

The Road Ahead: Expanding Services and Support

Even before the two federally qualified health centers had joined forces, DAP Health’s gender wellness initiative had begun to make inroads.

“We were able to increase the number of actively engaged transgender and gender-diverse patients by more than 400%,” Velasco adds. “Creating an interdisciplinary team and grounding our program using a trauma-informed and patient-centered approach was critical.”

Working with different departments within DAP Health was also crucial in meeting the psychosocial needs of patients, like “housing, social services, access to food, care navigation,” Velasco says. And, with the expansion of DAP Health, “we will be able to offer these services to more trans people.”

Beach is there to connect trans people to appropriate care even before they arrive. They help patients overcome their fears and share relevant details with providers. Making potential clients feel welcome also takes representation. “From the front desk to the provider, somewhere in that chain, we have to have some trans and gender-diverse folks.”

Beach, who is nonbinary and queer, is personally dedicated to that effort, currently studying to become a nurse practitioner “because I don’t see enough people that look like me.”

Of course, providing competent gender-affirming medical care isn’t as easy as hiring a few trans or nonbinary folks. Providers need to understand trans care, and how it differs.
“Trans health care isn’t typical health care,” Beach explains. “Typically, when people go to the clinic, it’s because they’re sick or because they have to go once a year for a checkup.” But trans people often need to see a provider more frequently, especially if they are receiving gender-affirming hormone therapy, which needs to be monitored.

Circumstances can also complicate access to care, especially the dysphoria that can exist in a physical body that doesn’t reflect one’s true gender. For example, Velasco points to one study on cervical cancer screenings. When retesting was necessary, trans men waited nearly 420 days, compared to the 80 days cisgender women wait.

The experience of receiving gynecological care can be a fraught one for many trans men and nonbinary people assigned female at birth, Velasco explains. “Some trans people may find getting a Pap smear dysphoric, and, thus, avoid or delay getting testing and retesting.” Velasco adds, “Finding gender-affirming health care providers…can also be very challenging.”

Culturally competent providers are especially important for youth, but their care is becoming the most criminalized in the U.S. Fortunately, it is still embraced in California. Following international protocols and recommendations from dozens of medical associations, the Stonewall Medical Center and Escondido will continue providing nonsurgical interventions for youth. Teens can be prescribed puberty blockers and/or gender-affirming hormone therapy.

At DAP Health, services provided to trans and nonbinary patients already run the gamut, Velasco says, including primary care, behavioral health, dentistry, sexual wellness, chiropractic, and social services.“We hope to expand our gender-affirming services to include speech therapy (for voice feminization and masculinization), electrolysis/laser hair removal services, and legal clinics (for legal transition needs),” Velasco adds. “We hope to eventually expand our services to include surgical and post-surgical services to our [adult] trans and nonbinary patients.”

Stigma increases against those who find themselves at the intersections of various identities, including gender identity, expression, and sexual orientation. Both Velasco (a credentialed HIV specialist) and Dr. Halperin (the former infectious disease director at New Orleans’ CrescentCare) understand another intersection.

“People of trans experience and nonbinary communities have increased rates of HIV acquisition, especially those of color,” Dr. Halperin says. “We know that racism and stigma play the greatest role in driving these increased rates. Furthermore, when structures of power such as the police — or increasingly, legislatures — target and stigmatize communities, we will inevitably see worsening health outcomes due to exclusion.”

Shining the Light: A Call to Action

That’s why, Dr. Halperin adds, DAP Health “must commit even more to this work. We must shine our light bright and far. Our clinics need to ensure easy and supportive accessibility to gender-affirming care. We must also continue to work in solidarity with those across our country.”

A Prescription for Positive Change

by suelowe
Manny Muro

A Prescription for Positive Change

By adding wellness programs to conventional medicine, DAP Health elevates patient care.

Words by Ellen Bluestein • Photo by Zach Ivey

As seen in Issue 4 of DAP Health magazine.

Integrative Healthcare at DAP Health

At DAP Health, health care means more than just a routine physical or a sick visit. It means treatment that addresses the whole person and extends beyond conventional medicine to include complementary wellness programs and services.

Tailored Wellness Approach

“It’s all-encompassing, it’s collaborative, and it goes beyond the physical well-being,” says DAP Health Chief Academic and Medical Service Officer Carol Wood, who previously served for six years as the organization’s chief of clinical operations. “It really includes emotional, social, and financial aspects of the patient’s life situation, and each patient is different.”

The Role of Mental Health Integration

This integrative approach focuses on body, mind, and soul, and is tailored to an individual’s needs. “We try to address the patient where they are,” continues Wood. “What issues are affecting them that may be making it more difficult for them to be well. It might not be the medical side of things — that might not be the biggest issue.”

Complementary Services Offered

DAP Health Director of Behavioral Health Sharareh Gandy, Psy.D. agrees. “I’ve seen a lot of health care shifting toward this integrative model. It’s considering the different parts of ourselves, the different things kind of going on in our lives that impact our overall well-being, including our physical well-being, our emotional well-being, our spiritual well-being. And so, it’s been wonderful to see health care acknowledge that and bring in multiple different services to work as one in helping people integrate not only their health care but integrate the different parts of themselves.”

Addressing Social Isolation and Loneliness

For mental health practitioners like Dr. Gandy, the shift has had tremendous impact. “I’ve been really excited for mental health to be integrated into the medical model,” she says. “Historically it’s been [that mental health care] has been that thing that’s over there, that’s super private. But now, it’s like, ‘Well, it’s here!’ It’s in our day-to-day lives, it’s part of who we are, it’s a part of our health care, and it’s really reduced a lot of stigma for people. Over the years — with that integrative model and with telehealth — that it’s just increased access to care…and people are a lot more involved and engaged in seeking out services.”

Personal Development Opportunities

By implementing complementary services, DAP Health acknowledges the importance of alternative therapies as part of routine medical care. “In the wellness department, we offer services like acupuncture, massage, yoga — all those things that aren’t really considered conventional health care,” says DAP Health’s Wellness Center Manager Cory Lujan. “Wellness itself is complementary. We’re to be used in conjunction with, or are married to, the medical side.”

Enriching Programs Beyond Medical Care

From reducing pain and combating loneliness to addressing addiction and recovery, DAP Health’s wellness department offers a robust slate of programs and services — all of which are free to clients and designed to supplement medical care. These include:

Mind and body wellness modalities, including acupuncture, chair massage, chiropractic care, Reiki, Transcendental Meditation, and yoga, which can help with pain management.

Artistic expression, including clay sculpting, knitting, and quilting groups that bring together those with similar interests, alleviating social isolation and creating friendships. It also serves as a means of self-expression and encourages creativity, bolstering mental health.

Social support groups on topics such as HIV and aging, recovery, stress management, healthy relationships, intimacy, liver health, smoking cessation, and diabetes prevention, all of which impart important information and best practices, help clients navigate their health journeys, and decrease social alienation by encouraging conversation.

Personal development, including stylist and barber services, employment services, and computer proficiency classes that help clients acquire the skills necessary to be gainfully employed and move toward financial stability.

A monthly mobile market from FIND Food Bank, which provides free, healthy food — including fresh fruits and vegetables — ensuring access to the nutrition clients need. Located on the DAP Health Sunrise campus in Palm Springs, the mobile market is open to the public.

Various other programs and services, including a trending topics speaker series, lunch-and-learn presentations, and a book club that spark conversation and enrich lives by engaging clients’ minds and reducing social isolation.

Philosophy of Holistic Health

“It’s our philosophy, and we know it to be true, that housing is health care, food and nutrition are health care, spiritual wellness is health care,” concludes Wood. “It’s not all about just going to the doctor and getting a prescription. There are a lot of mental and spiritual things we can provide for our patients that are going to also impact their health outcomes in a positive way. That’s why we do these things. And if more interventions pop up on the radar that we believe might also help our patients, we at DAP Health are probably going to be the first ones to try them."

The Plight of the Migrant Farmworker

by suelowe
Portrait of Farmworker

The Plight of the Migrant Farmworker

 

The health care needs of an essential yet marginalized community require special attention that is long overdue.

As seen in Issue 4 of DAP Health magazine 

Words by Trey Burnette

Invisible Yet Indispensable: The Role of Migrant Farmworkers

Migrant field workers are one of society’s most indispensable people. They’re the frontline of not only the United States’ $162.7 billion agricultural industry but, arguably — considering their hands are the first to touch the harvested food consumed by virtually all Americans — of the nutrition and health care industries. 

The Health Crisis: Neglected Needs of a Marginalized Population

They’re also one of the most marginalized and neglected populations. A whopping 23% of farmworkers in the U.S. live in poverty. The average individual’s annual income falls between $12,500 and $14,000 ($17,500 to $19,999 for families). And neither does the National Labor Relations Act of 1935 (which permits private sector employees to organize into trade unions, engage in collective bargaining, and go on strike) nor the Fair Labor Standards Act of 1938 (which preserves the right to a minimum wage and “time-and-a-half” overtime pay for toiling more than 40 hours a week, plus prohibits the employment of minors in “oppressive child labor”) cover most workers. Beyond the low pay and lack of many workplace protections, health care is one of the most significant stressors for farmworkers. Some 25% of them depend on community health centers. 

Barriers to Wellness: Challenges Faced by Farmworkers

Of the 2.5 million farmworkers who live and work in the U.S., 500,000 to 800,000 reside in California. Their age falls between 14 and 61, and most have been working for 18 years. Some 34% of them identify as women. Another 400,000 are minors.

In 2021, the U.S. Department of Health and Human Services reported that, of the 1,015,162 agricultural workers and their family members who received health services, the most common diagnoses were being overweight/obesity (25.5%), hypertension (11.4%), diabetes (9%), anxiety disorders, including post-traumatic stress disorder (5%), other mental health issues (7%), and asthma (2.5%.) But that isn’t the full scope of the health issues facing this community, because only 56% of U. S. field workers have health insurance. In California, that number drops to 37%. No matter where they are, many never seek help.

Expanding Healthcare Access: Medi-Cal's Impact on Undocumented Residents

Israel Ochoa manages DAP Health’s Centro Medico Oasis in the agricultural town of Thermal, just southwest of Mecca. He is the son of migrant farmworkers, and most of his days are spent serving farmworkers and their families. His assessment of his clinic’s patients aligns with the national statistics. He says access to affordable, nutritious food is a leading cause of their health issues. Fieldwork is arduous manual labor; the workers are up before sunrise and have to power through an excruciating workday. They rely on inexpensive sugary beverages like Gatorade, colas, and juices to stay hydrated and maintain energy, and eat a lot of processed food that “keeps” and can be eaten throughout their long workdays.

Furthermore, their children’s diets are not immune to their parents’ work schedules. Typically, 2.5 families live in one mobile trailer, and the kids are usually left with breakfast food they can make without having to turn on a stove — cereal, Pop-Tarts, or microwavable dishes. All eligible California children can get a no-cost breakfast and lunch at school, but obtaining those meals in the summer is difficult, if not impossible, because moms and dads can’t afford, or aren’t allowed, to take time off work.

Community Outreach: Bridging Gaps in Healthcare Education

Fear of being fired is also why workers don’t take personal or medical time off. They’re generally contracted, getting paid in two ways: by the hour ($15.50, plus 40 cents per box of product harvested and packed) or just by the box (about $4.25 per). Workers should get three sick days per season, but aren’t paid if they don’t work. Most avoid reporting job injuries for similar reasons. 

There are many other barriers to prosperity for farmworkers in the U.S. The lack of legal residence status is an obstacle. Nationally, 64% of workers are estimated to be undocumented — that figure is 75% in California — and most government programs, except for emergencies and sliding-scale payments, require documentation. Fortunately, on January 1, 2024, Medi-Cal expands full-scope health care for all income-eligible residents of California, regardless of immigration status. Obtaining preventive and routine care at a clinic will help people avoid emergency room visits and more severe illnesses. 

Empowering Through Education: Overcoming Educational Hurdles

Veronica Garcia is a care coordinator specialist regional coordinator and certified enrollment counselor at DAP Health. Alongside five siblings, she was raised in Coachella by her single farmworker mother, who also toiled at a citrus-packing plant. She does frontline community work and says her employer has an excellent outreach program. With the expanded Medi-Cal program, more people will be counseled and given health care. Outreach is critical because health workers can personally converse with farmworkers and clarify program misunderstandings. Many people think government programs, like Medi-Cal or the Medically Indigent Services Program, are debt services, so people hesitate to utilize them. 

Addressing Essential Needs: Affordable Housing and Nutrition Education

In addition to program education, Dr. Frank Figueroa — a councilmember for the city of Coachella who serves on DAP Health’s board of directors, as he did on Borrego Health’s board of trustees — says other fears about using programs can be laid to rest. He, whose grandparents and parents were farmworkers, states there’s the belief that those applying for permanent residence, work visas, or citizenship will be “flagged,” only to face negative consequences like losing rights they currently have, or could gain in the future. Undocumented workers are scared of deportation if they seek help. Applying DAP Health’s educational outreach to explain legal rights, enrollment, and using health care benefits will spur great progress in the health of this population. 

Education is also a challenge toward that progress. It’s estimated that 78% of farmworkers lack a high school diploma, with ninth grade being the average level of education. Just over 1% of these employees have a college degree, so there is a need to improve technology literacy.

Riverside County Supervisor Manny Perez, a son of migrant farmworkers, says that one of the many things that make DAP Health a superior federally qualified health center (FQHC) is its ability to provide affordable housing, a significant need for farmworkers as rents increase. He also strongly advocates for community clinics because they can address specific community needs like nutrition education through ancillary services. 

While Perez believes community health centers like Centro Medico Oasis are expertly poised to provide care for the rural poor, Ochoa insists finding health care providers to serve in remote locations such as Thermal is a challenge. All true. But it’s a challenge DAP Health is determined to meet as it endeavors to bring better wellness to this vital yet often-forgotten populace.