It began with a question.
In 2013, the staff at M Health Fairview Clinic – Smiley’s gathered for a meeting. On the agenda was a single, far-reaching item: How could the clinic, located off Hiawatha Avenue in Minneapolis, better serve its community? For Family Medicine Physician Carrie Link, MD, who attended the meeting, the answer was clear: improve healthcare access for transgender and gender nonconforming people.
Link’s response was a watershed moment for Smiley’s. Soon after, the clinic began a years-long effort to become a safe place offering gender-affirming primary and specialty care. In 2013, Smiley’s knowingly served less than five transgender or gender nonconforming patients. By early 2015, that number had grown to approximately 350 people. Last year, the clinic saw more than 500 transgender or gender nonconforming patients, including some who travel from nearby states like Nebraska and South Dakota for help. Now, the clinic stands as one example of how M Health Fairview is working to improve local and national health equity.
Link, Clinic Supervisor Andrea Olson, and other clinic leaders say Smiley’s emergence as a compassionate hub for gender-affirming primary care was the result of many simple and profound changes – some led by clinic staff, others driven by patients providing formal and informal feedback during extensive community needs surveys.
Some changes were designed to make the clinic a more welcoming space. Bathrooms at the clinic are single stall and gender neutral. Medical forms have a space for preferred names and pronouns. A prominent sign in the lobby reads “We are dedicated to caring and advocating for all races, ethnicities, religions, genders, disabilities, and sexual orientations.”
Other changes were structural. Smiley’s staff created a Gender Support program that offers hormone therapy and other services. The clinic’s on-site pharmacy was overhauled to meet the needs of people at every stage of their transition. In 2016, the clinic became a designated Behavioral Health Home, with a team of mental health experts and a social worker offering “whole person” care that addresses social determinants that may affect or complicate overall health.
The clinic also developed deep partnerships with the M Health Fairview Center for Sexual Health and, when it launched in 2018, the M Health Fairview Comprehensive Gender Care program so that patients have referral access to comprehensive surgical and mental health or therapy needs.
Crucially, all doctors, nurses, and administrative workers at the clinic receive extensive and continual training so that they can provide sensitive, respectful care for transgender, gender nonconforming people – a process that starts the moment someone contacts the clinic. Along with that training, the clinic has fostered a culture of “gentle accountability,” Link said. For example, a staff person who accidentally misgendered a patient will be corrected by other staff on the spot to ensure that patients feel supported, Link said.
Medical residents from the University of Minnesota Medical School have played a critical role in the clinic’s ongoing transformation. Not only do the Family Medicine residents stationed at the clinic routinely see transgender and gender nonconforming patients, they also train other residents and medical students who are temporarily rotating through the clinic on the fundamentals of transgender-competent care.
“We are both serving our patients and also training the next generation of physicians how to take care of all people, no matter their orientation or gender identity,” said Anna Larson, DO, who spent three years working as a resident at the clinic. In 2015, Larson moved from Georgia to Minnesota so that she could serve at the clinic. At the time, Smiley’s was one of a small number of family medicine residency programs that had integrated gender-affirming care within their curricula.
Another former resident, Amanda Meegan, DO, spearheaded the development of Smiley’s Gender Support Clinic program as a way to offer further training for family medicine residents in gender care, including the initiation of gender-affirming hormone therapy. This clinic was designed around an initial consultation, followed by additional appointments with the various residents for ongoing care.
Ultimately, Link, Meegan and other current and former clinic staff say the goal of their work is not just to train physicians and provide better care, but to address local and national health equity issues that affect LGBTQIA+ people, and – simply – to be a better neighbor. After all, the clinic’s identity is tied to the neighborhoods and people it serves. So much so that the Smiley’s mission statement reads: “We care, we teach, we partner.”
“I believe it is important to adapt and embrace new care models to better serve our patients,” said Maddie Randall, RN, a care coordinator at the clinic. “We have a responsibility to provide unbiased care and always advocate for our patients.”
“The only way I know how to make a difference is to use my privilege to change the system,” said Link, who emphasized the benefits of evidence-based care for transgender and gender nonconforming people. “[With the Smiley’s transformation] I just feel like we set out to do what was right.”