Despite its reputation as a sanctuary for queer people, San Francisco’s LGBTQ+ community is grappling with unequal access to services for the transgender community — particularly for trans men, who use city health services far less often than trans women.
The lack of services is no secret: The Department of Public Health’s most recent Sexual Orientation and Gender Identity report concluded that LGBTQ+ individuals often went underserved, despite programs geared towards the queer community across the city.
City data reveals an apparent disparity in service utilization between transgender men and women. Although their numbers are roughly equal, trans men in San Francisco are less likely to seek city medical services, compared to trans women. The report shows that trans men access primary and specialized healthcare services, as well as city hospitals, like San Francisco General and Laguna Honda, less frequently.
This report, covering 2019 to 2020, predates Covid-19, but advocates assert that the inequalities persist to this day.
“I’ve been to several doctors that are supposed to be gender-affirming and providing trans services, but when I get into the clinic, I’m being deadnamed and disrespected,” said Xavier Davenport, a transgender man and founder of Pyramid Kings, an organization primarily serving Black transgender masculine individuals.
“Some trans men have babies, periods and need access to Plan B; nobody thinks about these things,” said Davenport, who added that some doctors will tell trans men to take a pill and do a PrEP system that isn’t designed for their bodies, referencing the HIV prophylactic.
So widespread is the ignorance, the report concludes, that LGBTQ “people may deliberately avoid care settings” and “Transgender people have an added burden.”
While the transgender community in the city is relatively small — estimated at less than 2,000 people, with slightly more trans women than men — the 2022 point-in-time homeless count revealed that trans people were about 18 times more likely than the general population to experience homelessness.
“Services are not one-size-fits-all,” said Honey Mahogany, a trans woman who co-founded the city’s Transgender District and placed second last year in the District 6 supervisor’s race.
According to Mahogany and others, the lack of transgender services can be traced to the historical emphasis on catering primarily to white, gay men within LGBTQ+ services.
“All four queer representatives of San Francisco are white, gay men. There are no lesbians, no trans folks, and no people of color. That speaks clearly for LGBT services in the community,” Mahogany said.
The medical system needs to be better, Davenport added. At present, “You don’t feel like you belong, and you don’t want to be there and get the help you need.”
Julia Arroyo, co-executive director of the Young Women’s Freedom Center, recalled the housing struggles of Banko Brown, a homeless, Black transgender man who was shot and killed on April 27, 2023, by a Walgreens security guard. “One of the things Banko said early on was that, ‘I don’t feel safe in a lot of places. People try to put me into cis female, or male housing. I don’t feel safe in any of them.”
Davenport said that Brown’s situation was not unique, adding that many homeless transmasculine folks choose not to access shelters because “they know they won’t receive the necessary support.” Instead, many — Brown included — seek unstable housing arrangements with others.
Even the LGBTQ+ services that cater to one group can be heavily skewed toward making one gender more comfortable.
Eli Berry St. John, the communications director at the Transgender Gender-Variant & Intersex Justice Project, said that existing housing programs for Black feminine-presenting transgender or intersex folks have evolved to include trans men.
Still, Berry St. John said, masculine-presenting trans individuals entering the space come in “with an understanding that the space was initially catered toward women.”
But even with some specialized services, advocates say there are too few shelters that exclusively cater to transgender individuals.
For some city services, eligibility criteria can exacerbate hardship for trans individuals.
Kazani Kalani Finao, co-founder of the Banko coalition, cites Transitional Age Youth Housing services as one such example.
Transitional housing specifically aids young adults moving from public systems, like foster care. While these services can sometimes be extended beyond 18- to 24-year-olds up to age 27, problems arise when individuals age out of the program.
“These people are left with having to start back at zero,” Kalani Finao described. For trans individuals, such restrictions in program eligibility can especially exacerbate the cycles of housing instability and homelessness, despite the interventions provided by the programs.
Such implicit qualifications many times also complicate access for trans individuals who prefer to keep their transgender identity private — as access is often conditional on visibility.
Difficulty accessing services for Black, masculine-presenting trans folk
City services can be particularly challenging to access for Black, masculine-presenting trans or intersex individuals who are often underrepresented, and struggle with limited support.
Kalani Finao said: “I don’t believe transmasculine folks, particularly those who are Black and Brown, are prioritized or seen as well.”
Leaders agreed that societal conceptions of masculinity factor into the lack of services and spaces for Black, masculine-presenting trans folks.
“Many people have an ‘Oh, you’re a man, be tough’ attitude,” said Davenport.
Associations of masculinity with toughness and a lack of expressed emotional vulnerability and struggle, said Berry St. John, can lead to “this assumption that there’s not as much need for services for Black trans men, but that’s not true. There’s a big need for reproductive services, mental health services, addressing high rates of mental and physical illness.”
More awareness, and funding, needed
Arroyo said that the city would benefit from redesigning systems and existing programs to provide appropriate, specific, and inclusive support for masculine trans individuals. This involves creating more tailored services, more transitional and long-term housing, as well as “more access to housing, based on their own self-determination.”
Additionally, Arroyo said, the city could invest in more long-term, universal-based income programs for transgender individuals to provide more economic and housing stability and autonomy.
Mahogany, for her part, agreed, saying a lack of funding causes “programs to be stretched too thin, providers to be unable to see as many clients as they should, long waitlists, and a reduction in the quality of care provided.”
Both Mahogany and Berry St. John emphasized that non-trans individuals need not wait for the city to better its services: They pointed to organizations like Showing Up for Racial Justice, which partners with trans organizations and involves white people in racial justice fights, as one example of a group of individuals using racial and economic privilege to advocate for others.
“It’s important to take the time to invest in these organizations that are doing the work and listen to what they have to say,” said Mahogany.
Adds Berry St. John: “It starts small, it starts at home, starts with talking to your family. Organize your home, your mom, your cousins, your uncle. Get your people together. That’s how people can show up.”