Three hours before Michael David Battle starts his day, he begins thinking about binding his breasts, and the questions he might face. What shirt will best conceal his chest? What if someone addresses him by the wrong pronoun?

"It's much different than I really hate my body,'" says Battle. "It's that constant fear and dysphoria that goes with you every single day of your life."

Battle, who identifies as a black man of transgender experience, binds his chest daily and has taken hormones for two years. On Aug. 29, he will have chest reconstruction surgery. He'll pay for the procedure all $6,738 of it with money from fundraising and his own savings.

That's because for Battle and many others, most insurance policies don't cover transition-related health care and in some cases even standard health care for transgender patients. And even if they did, a patient has to find a friendly doctor, something advocates and transgender residents say can be hard to do.

"It's a highly stigmatized issue," says Sandra Soloski, program director at Persad, a Garfield-based counseling center for LGBTQ and HIV-positive people. The center provides referrals for trans clients and has a trans team that coordinates resources, which can be hard to find. "Some doctors are not clinically competent because they've just never looked in that direction," Soloski says. "Some may have attitudes themselves about it."

Indeed, despite living in a city known for its "eds-and-meds" culture with health-care giants UPMC and West Penn Allegheny Health System, the transgender community often gets left out.

While the Allegheny County Health Department provides services to whomever comes through its doors, it doesn't offer specialized services for transgender patients. And while some UPMC/WPAHS physicians do work with trans patients, the lion's share of medical support is being picked up by a small group of physicians and advocates, many of whom work in community-health clinics. Among them, the best-known is Metro Family Practice in Wilkinsburg.

Trans care "[is] not part of people's consciousness," says Metro's Dr. Martin Seltman. "[Doctors] aren't conscious about it and patients have to be pretty comfortable to reveal it."

Finding a trans-friendly doctor in Pittsburgh often relies on word-of-mouth referral, with friendliness defined both by clinical competency knowledge about medial issues like hormone therapy as well as cultural competency. Do intake forms include transgender or gender-non-conforming status? Are the pamphlets and waiting-room materials sensitive to trans concerns? Protocols for providing informed, empathetic care for trans patients have been issued by a number of organizations, including the World Professional Association for Transgender Health. But that doesn't mean every doctor uses them or even knows about them.

"The way some doctors communicate about trans patients is demeaning the wording people use, there's not a respect or understanding or an acceptance," says Dr. Stacy Lane, a physician who provides primary care to transgender patients, among others, at West End Health Center. Lane recalls that in one patient's file, for example, a physician described a patient has "a 35-year-old male who wants to be called a woman."

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