This story is part of a partnership between MedPage Today and VICE News.
The drag show's host, Jenna Jive, took the microphone with her backstage so that her voice would continue to fill the neon-lit room of patrons at Play Dance Bar in Louisville, Kentucky.
"Goddamn, she looks so fuckin' gorgeous," Jive said of the next performer, as the crowd erupted in cheers and applause.
Bianca Nicole stepped onto the stage looking like a cross between a mermaid and a belly dancer and began lip syncing to Charli XCX's "Boom Clap." Straight and LGBT guests watched her in awe, their faces glowing in the blue stage lights as they lined up to give her a dollar in exchange for a kiss.
But this is Kentucky, where a transgender high school student's wish to use the girl's bathroom prompted state legislators to introduce the so-called "bathroom bill" to keep transgender teens out; where holdout clerks still refuse to marry same-sex couples despite the Supreme Court's marriage equality ruling; and where state legislators have already filed anti-LGBT bills six months ahead of the legislative session.
And this is the state that will serve as the backdrop to the first-ever medical school-wide LGBT curriculum in the country.
"When they first start medical school, they take an oath to treat [patients] with respect no matter what," said Dr. Faye Jones, the assistant vice president for health affairs in charge of diversity initiatives at the University of Louisville, where the program will be piloted. "We just need to make sure we know how to do it."
A big small town
Louisville residents say their city is more like a big small town. Its neighborhoods — Butchertown, NULU, the Highlands, Old Louisville, Downtown — are never more than a 15 minute drive from one another. And the Victorian homes peppered throughout the city are often dwarfed by ancient trees twice their height.
In the middle of it all, the University of Louisville School of Medicine's modern concrete and glass campus has been home to innovation for more than 100 years. Its accomplishments include the first implantation of an artificial heart and the first successful hand transplant.
And now the school is home to the nation's first LGBT pilot program, eQuality, which kicked off this month to teach students how to treat lesbian, gay, bisexual, and transgender patients, as well as those who are gender nonconforming and those born with differences of sex development (DSD). Unlike certificate programs for treating these patients, which last a day or so, the school's class of 2019 will get an education built using new guidelines from Association of American Medical Colleges that will be woven into their already packed curriculums for the next four years.
In a conference room on a rainy day in August, the eQuality steering committee hashed out last-minute class schedule details as students in a mix of street clothes and powder blue scrubs strode through the halls. The first-year med students were to begin the program by taking surveys to determine how much they knew, what they believed and whether they identified as LGBT. Then, starting the following Tuesday, they would dive in with a class on substance abuse history that would include LGBT content.
"This is not just about being nice," said Stacie Steinbock, who sits at the head of the table and directs the LGBT center's satellite office on the university's health sciences campus. "Being LGBT is associated with [poor] medical outcomes."
According to the U.S. Department of Health and Human Services, men who had sex with men comprised 77 percent of all HIV cases diagnosed in 2010. Women who aren't heterosexual are less likely to have health insurance and more likely to smoke and binge drink, according to an HHS analysis of data from the Centers for Disease Control and Prevention and the National Institutes of Health.
"The people aren't bad," Steinbock said. "It's because the system is bad."
A broken system
In 2009, a Louisville-based doctor insisted to a gay patient that his sore throat was likely HIV, according to a complaint the patient submitted to the Kentucky Board of Medical Licensure. He told her he had tested negative for HIV three weeks earlier, but she didn't believe him.
"I looked her in her eyes as I begged her to describe the other symptoms that informed her diagnosis that something as profound, as life changing, as HIV was my probable fate," the man, whom VICE News was not able to reach and therefore chose not to identify, wrote in the four-page letter obtained by VICE News. "She stared blankly back at me without answering."
After leaving the man to wait for half an hour, the doctor gave him a refund and sent him away.
The next morning, his throat was so swollen that his boyfriend of eight years took him to a clinic inside a grocery store. They sent him to an emergency room, where he was diagnosed with acute pharyngitis, a sore and swollen throat likely caused by a bacterial infection. He didn't have HIV, and he recovered with some antibiotics and steroids.
The doctor told the medical board that this was a lack of insurance issue, and nothing more. The board ruled that the misconduct did not warrant disciplinary action, but it did warrant a formal letter of concern.
But not all LGBT patient encounters with physicians are so extreme. In many cases, doctors just don't know how to talk to them.
For instance, when second year University of Louisville medical student Adam Neff, 24, asked his physician for STD testing three years ago -- before he'd come out as gay to his extended group of friends and family -- he said his doctor acted disinterested and disregarded him.
"I think he knew," Neff said. "I didn't go to another physician for a year."
Another medical school student, Virginia Ferguson, 24, said it was years before a doctor finally asked her about her sexual orientation, but the doctor did it in front of Ferguson's mother. Ferguson was out at the time, but if she wasn't, the doctor would have forced her to have that conversation with her family before she was ready, she said.
Still, before that appointment, Ferguson said doctors asked whether she used condoms without considering that perhaps she wasn't having sex with men. When she answered that she was sexually active but didn't use them, she said doctors would give her "looks."
"I was always kind of confused," she said.
The University of Louisville program aims to churn out doctors who know better.
"So stinking hard"
For transgender patients, finding a doctor who will not only treat them, but has experience with trans patients presents its own unique challenge -- especially in places like Kentucky.
When Bobbie Giannova transitioned a few years ago, she found a few doctors who boasted on their websites that they had experience treating LGBT patients, but after she pressed them, they told her she was their first transgender patient.
Wearing an A-line teal and black pleated dress paired with tan heels, Giannova, 64, has lived in Louisville for 38 years, but has only spent the last four of them as a woman.
"It's so stinking hard to find the right place to start and not waste years working with people that are clueless," she said, holding her French-manicured hands in her lap.
At an amusement park one weekend this month, she noticed that her ankles suddenly swelled up. She went to an urgent care clinic the following Monday, where doctors told her to take her blood pressure medication and eat less salt. She replied that she wasn't on blood pressure medication, and eventually they realized it was the hormones.
"Pregnant lady syndrome," Giannova said. "I can't have a baby, but I can have fat ankles."
They told her she was also at risk for blood clots in her legs because of the hormones, which surprised her. How could she be at risk for deep vein thrombosis, which can lead to a fatal stroke, for three years and not know it? Why had none of her doctors told her that?
"That's how little is known," she said.
Giannova made herself available to Steinbock and the University of Louisville's eQuality committee as they were developing their curriculum.
Potentially fatal complications aside, Giannova stressed that something as simple as a pronoun mix-up or using a legal name can be embarrassing enough to keep a transgender patient from returning. Other little things that make medical care uncomfortable include forcing transgender women to share hospital rooms with men and vice versa.
"There is no cure"
At 12 years old, Giannova said she began dabbling in hormones by stealing them from her father's drug store. At 25, in 1976, she told her wife that she was transgender, but at the time, they didn't know what it meant and hoped Giannova would outgrow it somehow.
Four times over the three decades they were married, Giannova decided she couldn't take it anymore; she needed to live as a woman. But each time, her wife threatened to leave and went running to the church to tell its members.
"'Brother, you need help,'" Giannova recalled fellow churchgoers telling her. "The only kind of mental health you can get is conversion therapy."
Wanting to hold onto her marriage and her four children, she spent 25 to 30 years in conversion therapy, which is aimed at changing someone's sexual orientation from homosexual to heterosexual. The American Psychological Association opposes it, and several states have passed laws to prevent health care providers from offering it to patients.
Giannova said she also tried to be "superman" getting degree after degree, but it didn't change anything. (She has three master's degrees and a doctorate.) Then, she said she was "passively suicidal," engaging in risky behavior like white water rafting and thinking that if she died, that wasn't so bad.
"There is no cure. It doesn't shut up. It never goes away," Giannova said. "So it's very easy for despair to set in, and it becomes easier and easier to convince yourself that everyone would be better off without you -- including yourself."
Forty-one percent of transgender people try to commit suicide, according to the National Transgender Discrimination Survey. By comparison, 4.6 percent of the general population attempts suicide, according to the survey.
Finally, Giannova made the decision to transition at 58 years old. She lost friends, her wife divorced her and she was ridiculed, but she says she needed to do it.
It was Giannova's mental health provider who connected her with Steinbock from the University of Louisville's eQuality committee. Giannova and Steinbock started by emailing back and forth, and then Giannova was invited to attend a daylong conference about eQuality, which included members of the medical community and the LGBT community.
"The big day arrived, and I got there over an hour early so I could sit on the front row and just revel in the moment that I had lived long enough to see a day like this happen," Giannova said.
She said she's since accompanied Steinbock to her presentations to different groups of doctors completing their residency programs.
Although the Supreme Court ruled in favor of marriage equality this summer, making same-sex marriage the law of the land nationwide, Kentucky was no where near passing any such law on its own, said Chris Hartman, who directs the Fairness Campaign in Louisville.
The nonprofit LGBT advocacy group was founded in 1991 to pass an anti-discrimination ordinance after two high profile firings of gay and lesbian employees in Louisville. It finally passed in 1999, but a government restructuring meant they had to pass it again in 2004, when there was still a vocal opposition, Hartman said.
"We're southern-ish," Hartman said. "There's a long, storied history of republicans and democrats being opposed to LGBT rights. It's finally softening, but it's 2015."
Now, seven other Kentucky cities have anti-discrimination laws, but 75 percent of Kentucky's LGBT citizens are still vulnerable.
"You can get married today and be denied an apartment tomorrow," Hartman said.
A holy war
One of Giannova's employers is a Baptist institution, but she works remotely and they don't know about her transition, even though it's been several years. She just hopes they don't find out and use it as grounds to fire her because the anti-discrimination ordinance doesn't apply to religious institutions.
"There are a lot of people who believe themselves to be Christians," Giannova said. "They're engaged in a holy war as far as the LGBT community goes."
The Southern Baptist Church ruled recently that it opposes bullying of transgender individuals, but it doesn't support the claim that perceived sex can differ from biological sex. As a result, it doesn't support transgender body alterations or any validation of claims to transgender identity.
Evangelical Christians are no picnic either, said University of Louisville graduate Andrea Tucker, 29, whose evangelical parents refuse to see her unless she's wearing her shoulder-length auburn hair in a ponytail, no make-up and a loose sweatshirt to hide her breasts.
Her parents tried to change her mind about transitioning when she was still an undergraduate student by cutting off the money they gave her to pay for her cell phone and car bills. She dropped out to get a job, but Brian Buford, who founded the university's LGBT center in 2007, kept in touch and made sure she returned the following year.
Separating self from patient
People at the University of Louisville believed it was the first school to have the capacity to pilot the eQuality program, thanks in part to its thriving LGBT center. And it didn't hurt that a straight 3rd year student primed administrators without realizing it after taking an LGBT elective course and wanting to know more, Steinbock said.
Although they said there's been no push-back about the LGBT program so far, the University of Louisville School of Medicine's eQuality steering committee discussed a few hiccups that could come up along the way.
"We suspect a small but passionate group of medical students we see to give feedback on surveys about this not feeling right to them," said Dr. Amy Holthouser, the university's associate dean for medical education, explaining the faith is central to Kentuckians.
The committee wondered aloud whether students would answer "I don't know" to LGBT survey questions because they were mad, and talked about how a student in last year's seminar said he wasn't comfortable treating a transgender patient, prompting the other students to ridicule him into silence.
But silencing the less tolerant students won't do, either, Steinbock said. If a student stops participating, then that student doesn't get as much out of the class.
She said students will need to learn to separate themselves from what the patient needs.
"How do we have our own values and do evidenced-based medicine?" Steinbock asked, explaining that this is something she hopes every student learns to do. "We're really doing our best to deal with implicit bias."
She said piloting the eQuality program is like flying an airplane and building it at the same time.
"It's scary," she said. "But it's also part of the joy of the process. The biggest struggle and greatest joy."