Navigating the U.S. health care system is difficult enough. Add in the distinct medical challenges that come with being a part of the LGBTQ community, and even a straightforward doctor’s visit can become a Sisyphean experience. That was a fact Kari Kuka, director of Denver Health’s LGBT Center of Excellence, recognized when the Colorado Department of Public Health and Environment (CDPHE) tasked the medical system with trying to expand primary preventive care for patients with disabilities and those in the LGBTQ community. “I didn’t feel comfortable going out into the community and saying, ‘Come to Denver Health,’ until we figured out which providers were LGBTQ-affirming—what special needs the patients had,” Kuka says. “I quickly realized, ‘Wow, this is a huge job.’”

Kuka ended up spearheading an initiative to get Denver Health named an LGBT Center of Excellence—the only hospital in Colorado to do so. In order to receive this designation, a medical center has to be recognized for its efforts by a national organization; in this case, that was the Human Rights Campaign, which gave Denver Health 100 out of 100 possible points on its Healthcare Equality Index. Although the index partly looks at employee benefits and policies, most of the kudos came from the work Kuka and her staff have done to incorporate questions about gender identity and sexual orientation into doctors’ routines, expand surgeries for transgender patients, and offer training to all employees on how to treat LGBTQ folks.

It’s not the only award Denver Health has received for this work. In August, LGBTQ advocacy organization One Colorado gave the hospital one of its Ally Awards, and, this past weekend, the GLBT Center of Colorado honored Kuka for all she’s done to transform healthcare access for the local transgender community in particular.

We chatted with Kuka to hear exactly how she—and the village of hardworking folks around her—transformed Denver Health into one of the most inclusive medical systems in the state.

5280: Why did you feel so strongly about truly transforming Denver Health’s care for LGBTQ individuals?

Kuka: I’m part of the LGBTQ community [Kuka identifies as a lesbian], so even for myself, I want good primary care. I want to be able to bring my wife to an appointment with me. But I also heard within the community that Denver Health was not always their first choice of care. I saw these young people in school-based education centers who were getting lost. They got good care while at school, but they didn’t know what provider to go to at Denver Health as an adult. Our tagline is, ‘For life’s journey,’ and I believe that if you’re going to live in Denver, we should be able to care for you during your entire lifespan.

What kind of new services are you now offering?

We were already doing things like hysterectomies for our cis patients [people who identify with the gender that matches the sex they were born with], but we expanded those and made sure our surgeons were trained on how to work with trans men for that procedure. We found surgeons who wanted to be our “LGBTQ champions”; they’re able to do both breast augmentation and chest reconstruction, the ovariectomies, the hysterectomies, and the vaginoplasties. We started gender reassignment surgeries in May.

I know a big part of the initiative involved training. What did that entail?

We did mandatory training for all our employees on cultural competency terminology. Then we launched what we’re calling the SOGI—sexual orientation and gender identity—form in our electronic medical record. We started asking all our patients the SOGI questions when they come in through primary care. We did that almost a year ago. In January, we launched that for inpatient folks as well.

That information is helpful for providers and nurses to know who may be coming in; if I’m in a car accident and they ask me, I can say my wife is coming… The same thing with our trans patients: If you know that my sex assigned at birth is different than my current gender identity, I may have different organs that need to be tested. I may have undergone all gender confirmation surgeries and have breasts and a vagina but still have a prostate that needs to be checked. That training needed to go out to all of our clinics. We had hundreds of presentations on how to ask the questions, what to do if a patient gets angry with the questions, and then what to do with the information.

Some of these employees got even more advanced training, right?

Yes, we surveyed all our family medicine doctors, internal medicine doctors, behavioral health providers, and pediatricians and asked a lot of questions like, ‘Do you feel competent treating the LGB community? Do you feel confident treating the T or Q? Would you like to be a champion? What additional training do you need if so?’ The champions were self-selected. We have over 40 in our system, and they’re spread out, so a patient can go to their nearest community health clinic and be paired with a champion. Instead of calling the main call center to get an appointment, you call the LGBT Center of Excellence. Our patient advocates will match you to a provider and explain how to start the process if you want gender confirmation surgeries. We have staff who will gather all the insurance information, make sure you get to the surgeries, etc.

What does their extra training look like?

They learn how to prescribe and manage cross-sex hormones; do aftercare for gender confirmation surgeries; care for patients post-vaginoplasty or post-top surgery; what screenings still need to be done; how to document that, what to look for in the electronic medical record. When a patient fills out the SOGI form, if they identify as anything other than cisgender, their preferred pronouns will pop up in the medical chart so we can make sure we’re gendering them correctly—preferred name and all that.

Have all of these advancements brought more LGBTQ patients to Denver Health?

Since January 2017, we’ve had about 700 new patients that had never come to Denver Health before. Eighty percent of those identify as trans or non-binary. That really signifies the need in the community. I don’t know how many patients were in our system before because we didn’t ask the SOGI questions. And of those 700 new patients, about 50 percent of them have commercial insurance. There’s a myth that Denver Health only takes Medicaid patients.

Do you have plans to expand your services for the LGBTQ community even further?

We’ve got a surgeon who’s going to start facial feminization, and an ear, nose, and throat doctor who’s going to start doing tracheal shaves [surgeries that reduce the size of the Adam’s apple]. We’ve got a speech therapist who’s very excited to start offering voice therapy. But it’s a process; these are services that are usually not covered by insurance, so they’re out-of-pocket expenses. We do a lot of work behind the scenes to make sure we’re collecting the money on the front end; asking what price we want to set for each of these services; how do we determine that; going through the process of making sure every department is communicating, so we don’t drop a bill to their insurance for a self-pay procedure. Because wouldn’t you be mad if you just paid $20,000 and then got a bill from your insurance?

You’ve done a lot for transgender folks specifically; anything you’d like to add that targets the LGB part of the community?

I have dreams. They’re a couple years out probably because it takes a long time to implement services. I would love for us to be able to offer insemination services and sperm and egg storage for anyone who needs it. We can also increase access for men who have sex with men and get more providers trained on HIV and PrEP [Pre-exposure prophylaxis; a category of medicines that reduces the risk of contracting HIV] care. And letting same-sex couples know they can deliver here. We do a lot of deliveries every year, but we haven’t advertised to the community that we’re actually a center of excellence—and we’re going to take good care of you.