Alexander Gallagher's new eye doctor didn't know the 15-year-old was transgender until he saw that the youth was taking testosterone.
As Alexander tells it, the doctor didn't seem to quite know what to say.
"He told me he was so proud of me," Alexander said, and laughed. "I don't want you to be proud of me. I need you to fix my eyes."
For transgender people such as Alexander, who was born a girl but is living as a boy, navigating the health care system can be complicated.
Many grapple with how to tell a doctor that they are not living the gender they were born with, and worry about the reaction they might get. Some avoid getting checkups out of concern they will be judged or treated badly.
While there is a growing understanding of transgenderism, it has not been accepted by all physicians. But small steps have been made to provide legal protections to transgender people, and to make sure that health care providers are culturally sensitive to them, and that they aren't denied medical treatment.
CareFirst BlueCross BlueShield, the state's largest insurer, recently expanded coverage for gender reassignment surgery in Maryland. It also eliminated language from its policies that denied coverage for any "treatment leading to or in connection with transsexualism, or sex changes or modifications, including, but not limited to surgery."
Hospitals such as the University of Maryland Medical Center and Johns Hopkins Medicine are training doctors, nurses and other staff on how to treat transgender patients. And Chase Brexton Health Care recently launched Gender Journeys of Youth, or Gender JOY, aimed at young transgender people. The organization said it will be the first in the region to provide comprehensive care — medical, mental and social services — to the younger transgender community.
"I think there have been amazing strides made and we still have a long way to go," said Jamison Green, president of The World Professional Association For Transgender Health.
"There has been an increasing number of health care providers who are coming to understand the issues and coming to feel some compassion toward trans patients and realize this is not something they have to be afraid of and that they actually can treat these individuals like normal human beings and that they are deserving of care."
Transgender people go to the doctor for colds, flus, infections and other routine ailments, but they also have medical needs that are different from others.
Parents may decide to allow transgender children to take powerful "hormone blockers" to prevent them from going into puberty, which would make their biological gender more apparent. Transgender adults take hormones that could affect treatment for other ailments.
Some wrestle with whether to undergo complex surgery for sexual reassignment.
Not all transgender people undergo such surgery, which can bring other challenges. A transgender man still needs to get pap smears and mammograms and could get uterine cancer. A transgender woman still needs to get regular prostate exams.
Underlying anxiety affects many transgender people at some point in their lives as they worry about what people will think if or when they find out their past or biological gender.
Nearly 75 percent of transgender patients worry that medical personnel will treat them differently based on their gender status, according to a survey by Washington-based Advocates for Youth.
Research has shown transgender people are more likely to suffer from depression and other mental disorders, or to have complications from untreated illnesses because they don't go to the doctor.
The health care providers at Chase Brexton hope that by intervening early they can help transgender people overcome such challenges.
Deborah Dunn, a physician assistant and transhealth coordinator at Chase Brexton who has worked with transgender children for years, said parents would come to her because they couldn't find a doctor they felt understood their children.
"I personally have witnessed what a difference it can make for patients who come in," Dunn said. "They become more outgoing and confident."
Greater visibility of transgender issues has prompted doctors and hospitals to look at ways to better treat patients. A new generation of medical students is also bringing the discussion to medical schools.
Still, treating transgender people is new for many doctors, and many don't always know what particular issues they should be sensitive about.
Johns Hopkins Medicine has created two task forces to look at transgender issues and is training some staff how to better serve transgender patients. There are plans to create educational materials for doctors, nurses and other employees.
"We don't want any of our patients to feel like an anomaly when they come into our facility," said James Page Jr., the system's chief diversity officer.
Dr. Rachel Bluebond-Langner, an assistant professor in the division of plastic surgery at University of Maryland School of Medicine, has given talks to nurses and other providers at University of Maryland Medical Center about treating transgender patients.
"We want these patients to feel comfortable anywhere they go within the system," she said.
Hospitals around the country are trying different approaches. Many transgender people don't change their birth name right away, and their insurance card may have a name that doesn't fit the gender they look like. This can draw attention when a patient is called from the waiting room to see a health care provider.
Some doctors offices now ask for the name patients preferred to be called. Others have included a space in patient forms where people can identify themselves as transgender. That way they don't have to figure out how to tell their doctor.
"Sometimes that is all that is needed to decrease anxiety, being called a name that feels comfortable for them," said Dr. Elyse D. Pine, Chase Brexton's lead physician for transgender youth.
"When somebody presents a gender they are not comfortable with for several years, having to hear that former name over and over again can be disconcerting and difficult."
Green said more change needs to come. He still hears stories about medical staff who act as if they don't want to treat transgender patients.
One patient described going into the emergency room and feeling like a freak when cleaning staff showed up before the doctor to get a look at him. He said it was clear people were talking about him.
Alexander was 13 and in seventh grade when he told his mom and sister he was a boy.
Born as Corrina, he said he spent years of feeling like a "weird girl" who didn't belong in his own body.
After hitting puberty, he overcompensated by wearing push-up bras and overly girly clothes in hopes of making himself "blossom into womanhood."
He told his father while on a walk around their Catonsville neighborhood: "Dad, I'm a dude."
The family didn't know much about transgenderism. His mother, Karry, and father, Jamey, both asked Corrina if she was a lesbian.
They worried their child was too young to make the decision to live as a different gender. But they realized he was serious, and found a psychologist who specialized in treating transgender patients.
"We wanted to get somebody who would understand what he was going through," Karry Gallagher said.
They applauded Chase Brexton's program.
"It's good for parents too, because it is a whole learning curve," said Jamey Gallagher. "You want to make sure you're helping your child the best way you can."
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Alexander said he has never been mistreated by doctors, but he often feels the awkwardness in the room when they find out.
It happened with his pediatrician, and recently with a dentist.
Some doctors will ask about the hormones he takes, but nothing else on the medication list, such as antidepressants. He wishes doctors would just be up front with their discomfort and ask questions rather than act overly supportive. But he said he also sees it as a sign that doctors want to learn.
And he doesn't mind being the teacher.
"If I can help people better understand transgender, then I'm OK with that," he said.