Htwe, 38, is from Myanmar and worked as an OB-GYN there until a military coup overthrew the government in February 2021. Alongside other medical workers, she against the military, and, fled the country with her husband and young daughter.

Htwe and her family spent six months in Thailand before they resettled in Missoula as refugees early last year. That move around the globe took less time than the eight months she waited to get a dental appointment after arriving in Montana.

“In my country, dental care is not like it is here,” said Htwe, who is now a community health worker at Partnership Health Center in Missoula. “Here we need to wait for dental care. In Myanmar, it’s not like that. We can go at any time when we need a consultation or something.”

Refugee advocates in Montana hear stories like Htwe’s often. And these stories are similar to what low-income people can contend with across the U.S. Long wait times for dental appointments, high costs, and finding dentists willing to take new Medicaid patients make access to dental care difficult.

Refugees in the U.S. getting dental care because of cultural differences, and language and transportation issues, but their specific circumstances vary widely depending on where they resettle, and if the state offers dental coverage for refugees.

The flow of refugees admitted to the U.S. is growing since the Biden administration set the annual cap for the fiscal year that began in October to 125,000, . More than 24,000 refugees arrived between October and April, . The state and country are on pace to welcome more refugees .

“It’s a health equity issue when patients have an array of barriers to getting care,” said Jane Grover, a dentist and the director of the Council on Access, Prevention, and Interprofessional Relations for the American Dental Association.

She added that dental pain complicates a person’s ability to eat, work, and do daily tasks. When oral health is suboptimal, the risk for gum and periodontal disease increases. That can then lead to like heart disease and diabetes.

“Often, refugees come to us with some or very little previous dental care,” said Bonnie Medlin, health and education programs coordinator for the International Rescue Committee in Missoula.

Refugees spend an average of about 10 years in refugee camps before resettlement, and those camps may or may not have dental services, said Medlin.

When refugees arrive in Montana, they are enrolled in the state’s Medicaid program and are eligible for most like exams, teeth cleanings, and X-rays. State Medicaid programs decide the level of adult dental benefits to offer, and Montana is among 18 states, plus Washington, D.C., that . But having health coverage doesn’t guarantee a person can see a dentist quickly or at all.

Montana health department spokesperson Jon Ebelt said private practice dentists are not required to have a certain percentage of their patients covered by Medicaid. They can choose whether to accept Medicaid or any other insurance.

A run by the Department of Health and Human Services provides short-term medical coverage to refugees for Medicaid, but are covered.

In Missoula, three private dental clinics frequently work with refugees who are on Medicaid. One is strictly a pediatric dental office, however, and the other two perform only surgical procedures.

States set Medicaid reimbursement rates for dental care and Montana’s rates . Despite this, the numbers don’t always add up. “Dentists in private practice want to help and accept Medicaid patients when they can, but the margin just makes it impossible for them,” said Lara Salazar, CEO of , a community health clinic based in Missoula.

“We see patients regardless of their socioeconomic status, offer a sliding scale fee, and accept all insurance for the 65,000 visits we get across our clinics per year,” said Salazar.

PHC’s dental clinics provide comprehensive and emergency dental care for adults and children and see around 975 patients a month. Most mornings 10 to 20 people line up for urgent, same-day appointments at the center’s downtown clinic. Some of the patients needing urgent dental care are part of Missoula’s refugee population.

“People are dealing with abscesses, root canals and suddenly they’re in a dental chair and things are happening. It’s especially scary when they haven’t been to a dentist before,” said Helen Maas, a senior community health specialist who works on PHC’s refugee-focused health team with Htwe. “Trying to explain how the health care system works gets very complicated,” she said.

require providers serving Medicaid patients to offer interpretation services when needed, but Medicaid reimbursement doesn’t cover all the costs, said Maas. “I know this is an issue for providers in town and a reason they are not able to accommodate everyone.”

Patients and providers at PHC connect with via phone and video chat. Maas said the translation service is great, but sometimes it can take up to an hour to find an appropriate interpreter for less common languages, like Dari and Pashto.

According to Maas, limited transportation is an additional obstacle for refugee families and can make getting to scheduled appointments particularly hard once they start working.

Another challenge is appointment wait times. New patient appointments for refugee children happen soon after arrival. But adults on Medicaid often wait up to nine months for an initial dental exam at PHC or another clinic in Missoula unless they are in acute pain that prohibits eating or causes major health concerns. “Timing depends on if providers outside of Partnership are accepting new Medicaid patients, and many are not,” said Maas.

To help accommodate the need, some dentists in the community donate services to refugee patients. Maas hopes to see more of this in the future.

In the meantime, outcomes look promising for refugees like Htwe who needed dental care after resettlement. “When I went to my appointment, the dentist set up a long-term plan for my teeth,” she said. “I’ve had two cleaning appointments and I now have a habit of flossing.”

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Tens of millions of Americans use menstrual products, and while manufacturers contend they are safe, most disclose little about the chemicals they contain. Now, amid calls for more disclosure and research into the health effects of these products, some states require more transparency.

The manufacture and sale of period and related products is a big business, with revenue expected to top in the United States this year. On average, a person uses up to in their lifetime, and they might also use rubber or silicone cups, or absorbent period underwear.

The FDA regulates and classifies menstrual products as medical devices, meaning they are not subject to the same labeling laws as other consumer items. But companies can voluntarily disclose what’s in their products.

Now, some states are stepping into the breach. In 2021, New York became the first state to enact a requiring companies to list all intentionally added ingredients on packaging. California’s governor signed a that took effect this year, but it gives manufacturers trade secret protections, so not all ingredients are necessarily disclosed. At least have to address safety and disclosure of ingredients in these products.

Advocacy groups studying the effects of the New York law say the new labels in menstrual products that may contain carcinogens, reproductive toxicants, endocrine disruptors, and allergens.

Shruthi Mahalingaiah, an assistant professor of environmental, reproductive, and women’s health at Harvard T.H. Chan School of Public Health, evaluates endocrine disruptors in personal care products and studies menstrual health. She said the health risk depends on the dose, duration, and sensitivity of a person to the ingredients and their mixtures.

Harmful chemicals could come from manufacturing processes, through materials and shipping, from equipment cleaners, from contact with contaminants, or from companies adding them intentionally, said Alexandra Scranton, director of science and research for Women’s Voices for the Earth, a Montana-based nonprofit focused on eliminating toxic chemicals that affect women’s health.

Vaginal and vulvar tissues are capable of , . Scranton said scarcity of clinical studies and funding for vaginal health research limits understanding about the long-term effects of the ingredients and additives in period products.

“We think manufacturers should do better and be more careful with the ingredients they choose to use,” Scranton said. “The presence of toxic and hormone-disrupting chemicals in menstrual products is unsettling. We know that chemicals can cause disease, and exposures do add up over time.”

Scranton’s organization advocates for the chemical name of the ingredient, the component in which the ingredient is used, and the function of the ingredient.

K. Malaika Walton, operations director for the Center for Baby and Adult Hygiene Products, a trade industry group, said in an email, “BAHP supports accurate and transparent information for users of period products and many of our list ingredients on their packages and websites.”

In a written statement, Procter & Gamble, a major manufacturer of menstrual products, said that ingredients it uses go through rigorous safety evaluations and are continuously tested, and that all fragrance components are added at levels the industry considers safe.

Even though manufacturing of for the U.S. market has mostly , in other menstrual products. Laws protecting trade secrets keep details about fragrances in pads and tampons confidential so competitors can’t copy the formulas. lists phthalates, a group of chemicals commonly called plasticizers that are suspected , as an ingredient found in fragrances.

Manufacturers follow by registering with the FDA and submitting a detailed risk assessment of their products’ components and design, and a safety profile, before being cleared to sell in the U.S.

Pads and menstrual cups are considered exempt from regulatory guidance and do not require premarket review, according to FDA spokesperson Carly Kempler. While tampons do require review, the FDA “does not clear or approve individual materials that are used in the fabrication of medical devices.”

“There’s an understanding that the FDA is regulating these products, and they are; it’s just not very adequate,” said Laura Strausfeld, an attorney and a co-founder of Period Law, an organization working to advance state and federal period-equity policies that would stop taxation of products and make them freely available in places like schools and prisons. “The consumer is supposed to trust that when these products are put on shelves they’ve been vetted by the government. But it’s basically a rubber stamp.”

In a , a congressional committee directed the FDA to update its guidance for menstrual products to recommend that labels disclose intentionally added ingredients, such as fragrances, and test for contaminants. The FDA is reviewing the directives outlined by the House Appropriations Committee and will update the 2005 guidance as soon as possible, Kempler said. “We will share additional details when we are able to.”

At least one period product company makes disclosure of its ingredients a selling point. Alex Friedman, co-founder of Lola, said a lack of knowledge is a problem, and more action and awareness are needed to keep people safe.

“The hardest part to swallow is why this is even up for debate. We should all know what’s in these products,” Friedman said.

New York’s law requires companies to disclose all intentionally added ingredients no matter how much is used, with no trade secret protections for fragrances. Though it applies only to products sold in that state, similar detailed labeling is appearing elsewhere, advocates said.

“We’re also seeing similar or identical disclosure on packaging in other states outside of New York, which is a testament to the power of the law,” said Jamie McConnell, deputy director of Women’s Voices for the Earth.

Manufacturers have 18 months from the passage of the New York law to comply, and some products on shelves in New York still list few ingredients other than “absorbent material,” “surfactant,” “ink,” and “adhesive.”

“We’re like, ‘OK, what is that exactly?’” McConnell said.

Her organization is calling for a federal law at least as strong as New York’s. Previous federal legislation failed to advance, including the most recent, the , introduced in 2022.

BAHP, the trade group, supported the federal legislation and the California law. McConnell said she opposed both bills because they didn’t require companies to list all fragrance ingredients.

“I think what it boiled down to at the federal level was the support of corporate interests over public health,” she said.

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“Little did I know that would be me a few years later,” said Bahige.

Bahige’s harrowing refugee journey began when he was kidnapped and forced to become a child soldier when war broke out in his country, which became the Democratic Republic of Congo in 1997. He escaped at age 15 to a Mozambique refugee camp, where he lived for five years until he arrived in Baltimore in 2004 through a .

Bahige, now 42, said the way he grew up was to “just buckle up and tough it out,” and he carried that philosophy into adjusting to life in the U.S. He worked multiple jobs and took community college classes until he went to the University of Wyoming on a scholarship. He is now an elementary school principal in Gillette, Wyoming, and said his coping strategy, then and now, is to keep himself busy.

“In retrospect, I don’t think I ever even dealt with my own trauma,” he said.

Refugees are arriving in the U.S. in greater numbers this year after resettlement counts reached . These new arrivals, like those refugees before them, are to have post-traumatic stress disorder, depression, and anxiety. Many of them, like Bahige, fled their homelands because of violence or persecution. They then must deal with the mental toll of integrating into new environments that are as different as, well, Wyoming is from Central Africa.

This has Bahige concerned about the welfare of the new generation of refugees.

“The type of system that a person lived in might be completely different than the new life and system of the world they live in now,” Bahige said.

While their need for mental health services is greater than that of the general population, refugees are much less likely to receive such care. Part of the shortfall stems from societal differences. But a big factor is the overall in the U.S., and the myriad obstacles and barriers to receiving mental health care that refugees encounter.

Whether they end up in a rural area like the Northern Rocky Mountains or in an urban setting such as Atlanta, refugees can face months-long waits for care, plus a lack of clinicians who understand the culture of the people they are serving.

Since 1975, have been admitted to the United States. The annual admissions dropped during the Trump administration from about 85,000 in 2016 to 11,814 in 2020, according to the State Department.

President Joe Biden raised the cap on refugee admissions to 125,000 for the 2022 federal fiscal year, which ends Sept. 30. With fewer than 18,000 arrivals by the beginning of August, that ceiling is unlikely to be reached, but the number of people admitted is increasing monthly.

Refugees receive mental health screening, along with a general medical assessment, within 90 days of their arrival. But the effectiveness of that testing largely depends on a screener’s ability to navigate complex cultural and linguistic issues, said Dr. Ranit Mishori, a professor of family medicine at Georgetown University and the senior medical adviser for Physicians for Human Rights.

Although rates of trauma are higher in the refugee population, not all displaced people need mental health services, Mishori said.

For refugees dealing with the effects of stress and adversity, resettlement agencies like the International Rescue Committee provide support.

“Some folks will come in and immediately request services, and some won’t need it for a few years until they feel fully safe, and their body has adjusted, and the trauma response has started to dissipate a little bit,” said Mackinley Gwinner, the mental health navigator for the IRC in Missoula, Montana.

Unlike Bahige’s adopted state of Wyoming, which has no refugee resettlement services, IRC Missoula has placed refugees from the Democratic Republic of the Congo, Syria, Myanmar, Iraq, Afghanistan, Eritrea, and Ukraine in Montana in recent years. A major challenge in accessing mental health services in rural areas is that very few providers speak the languages of those countries.

In the Atlanta suburb of Clarkston, which has a large population of refugees from Myanmar, the Democratic Republic of the Congo, and Syria, translation services are more available. Five mental health clinicians will work alongside IRC caseworkers under a new program by the IRC in Atlanta and Georgia State University’s Prevention Research Center. The clinicians will assess refugees’ mental health needs as the caseworkers help with their housing, employment, education, and other issues.

Seeking mental health care from a professional, though, can be an unfamiliar idea for many refugees, said Farduus Ahmed, a Somali-born former refugee mental health clinician at the University of Colorado School of Medicine.

For refugees needing mental health care, stigma can be a barrier to treatment. Some refugees fear that if U.S. authorities find out they’re struggling with mental health, they could face deportation, and some single mothers worry they will lose their children for the same reason, Ahmed said.

“Some people think seeking services means they’re ‘crazy,’” she said. “It’s very important to understand the perspective of different cultures and how they perceive mental health services.”

Long wait times, lack of cultural and language resources, and societal differences have led some health professionals to suggest alternative ways to address the mental health needs of refugees.

Widening the scope beyond individual therapy to include peer interventions can rebuild dignity and hope, said Dr. Suzan Song, a professor of psychiatry at George Washington University.

Spending time with someone who shares the same language or figuring out how to use the bus to go to the grocery store are “incredibly healing and allow someone to feel a sense of belonging,” Song said.

In Clarkston, the Prevention Research Center will soon launch an alternative allowing refugees to play a more direct role in caring for the mental health needs of community members. The center plans to train six to eight refugee women as “,” who will counsel and train other women and mothers using a technique called narrative exposure therapy to address complex and multiple traumas.

The treatment, in which patients create a chronological narrative of their lives with the help of a therapist, focuses on traumatic experiences over a person’s lifetime.

The therapy can be culturally adapted and implemented in underserved communities, said Jonathan Orr, coordinator of the clinical mental health counseling program at Georgia State University’s Counseling and Psychological Services.

The American Psychological Association, though, narrative exposure therapy for adult patients with PTSD, advising that more research is needed.

But the method worked for Mohamad Alo, a 25-year-old Kurdish refugee living in Snellville, Georgia, after arriving in the U.S. from Syria in 2016.

Alo was attending Georgia State while working full time to support himself when the covid-19 pandemic started. While downtime during the pandemic gave him time to reflect, he didn’t have the tools to process his past, which included fleeing Syria and the threat of violence.

When his busy schedule picked back up, he felt unable to deal with his newfound anxiety and loss of focus. The narrative exposure therapy, he said, helped him deal with that stress.

Regardless of treatment options, mental health is not necessarily the top priority when a refugee arrives in the United States. “When someone has lived a life of survival, vulnerability is the last thing you’re going to portray,” Bahige said.

But Bahige also sees resettlement as an opportunity for refugees to address their mental health needs.

He said it’s important to help refugees “understand that if they take care of their mental health, they can be successful and thrive in all facets of the life they’re trying to create. Changing that mindset can be empowering, and it’s something I am still learning.”

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Howard underwent hormone therapy, had gender-affirming surgery, and began changing her name and gender on official documents. “It has been a godsend for me,” Howard said. “I feel so right and at ease with myself for the first time in so many ways.”

She has been able to change her Social Security card, driver’s license, and pension accounts. But she has not been able to alter one crucial piece of personal identification. “Everything’s been changed except my birth certificate,” Howard said. “That’s the only thing hanging up. Everybody else has acknowledged my gender, but they will not do it.”

A string of legislative and administrative actions has made Montana where amending their birth certificates is nearly impossible for transgender people.

Montana health officials defend the restrictions as a way to preserve the accuracy of vital records. LGBTQ+ advocates say it deprives transgender people of their dignity and denies them equal protection under the law.

In June 2021, the American Medical Association saying it will advocate for the removal of sex designations on publicly available birth certificates, saying that would protect people’s privacy and prevent discrimination. The AMA said that, under this policy, an individual’s sex designation at birth would still be collected and submitted for medical, public health, and statistical uses.

The AMA already had policies recognizing “the ” and the idea that every person has the and sex designation on government documents.

Dr. Nicole Clark, the Montana delegate to the AMA, said the Montana Medical Association had accepted the AMA’s birth certificate policy.

In the vast majority of states, the process for transgender people to update their documents is relatively easy, without the kind of administrative hurdles created by Montana. The three exceptions, besides Montana, include Tennessee, which has a law that bans trans people from amending their birth certificates. (The state has been challenging that policy since 2019.) In Oklahoma, Gov. Kevin Stitt signed in November barring transgender people from changing their birth certificates. And in West Virginia, circuit courts had previously approved sex designation changes on birth certificates, but a 2020 said they can’t order the state health department to make them.

Cathryn Oakley, state legislative director and senior counsel for the Human Rights Campaign, an LGBTQ+ advocacy group, said taking away someone’s opportunity to change a birth certificate denies the person the “ability to be a full, complete member of society.”

“It disregards all modern medical knowledge about what it means to be transgender and goes against the American Psychological Association, the American Medical Association, the National Association [of] Social Workers, who say that affirming someone’s gender identity is in their best interest from a health standpoint,” Oakley said.

In April 2021, Montana Gov. Greg Gianforte signed into law , which said the state Department of Public Health and Human Services could change a birth certificate only after receiving a court order saying the person’s sex had been surgically changed.

The law supplanted a 2017 rule that required transgender people to simply affirm their gender to change their birth certificates. The rule did not require gender-confirmation surgery or other surgical procedures, which can be unnecessary or cost-prohibitive.

Two Montanans represented by the American Civil Liberties Union and challenged the 2021 law on constitutional grounds, arguing that it was vague and violated privacy and equal protection rights.

In April 2022, Yellowstone County District Court Judge Michael Moses temporarily barred the health department from enforcing the law while the case was being litigated. Transgender advocates expected that order would restore the 2017 rule and that trans people would again be allowed to amend their birth certificates by filling out a form. But the health department .

A month later, the health department issued an emergency rule more restrictive than SB 280. The rule said Montanans can amend a birth certificate only in cases that involve a clerical error or when people use a DNA test to prove their sex was misidentified at birth. “Sex is different from gender and is an immutable genetic fact, which is not changeable, even by surgery,” the rule reads.

The state health department is seeking to keep in place as long as Moses’ injunction of the 2021 law is in effect.

Health department spokesperson Jon Ebelt said the judge’s injunction created a regulatory gap for processing birth certificates that needed to be filled. “There was no rule in place to which the Department could revert. And the Department has an obligation to ensure the accuracy of vital records,” Ebelt said in an email.

The ACLU of Montana asking Moses to clarify the requirements of the injunction and order the health department to follow the more permissive 2017 rule.

“Leaving transgender Montanans without any avenue for accessing an accurate, usable birth certificate is very dangerous,” said ACLU attorney Malita Picasso. “It’s hard to emphasize how extreme that move would be.”

On May 18, several months after Howard started the process to change her birth certificate, she obtained a judge’s order confirming that her sex had been surgically changed. Following the requirements laid out in the 2021 law, she sent the documents to the health department two days later via certified mail. She expected the final approval May 23, but that turned out to be the day the emergency rule took effect.

After not hearing anything for a few days, Howard called the health department’s Office of Vital Records. It said that her form had been received but that according to the new rule the sex on her birth certificate couldn’t be changed, despite her court order. Howard was told the state was not processing any gender changes on birth certificates.

“I don’t know how to explain how disheartening it was at that moment,” Howard said. “It just felt awful.”

Dr. Carl Streed Jr., an assistant professor at the Boston University School of Medicine and the research lead in the Center for Transgender Medicine and Surgery at Boston Medical Center, said the gender marker on a birth certificate “doesn’t reflect the reality of what it means to be a human or the reality of biology or sex and gender” because there are several chromosomal variations besides XX and XY.

Streed, who is also a primary care physician, said stress around identity can negatively affect a person’s health, leading to “significant mental health and mental distress over the long term.”

Updating a birth certificate doesn’t retroactively change public health statistics that have already been reported, he added.

According to UCLA’s Williams Institute, which does research on sexual orientation and gender identity law and public policy, an estimated 3,900 transgender people age 13 and older live in Montana. One of those people is Howard.

Before she transitioned, there were times when Howard didn’t want to live. But now she loves feeling free to be herself, looking forward to every day.

“I can’t think of any other way to define myself as a person. I am just a transgender woman living her life at age 63,” Howard said. “What’s the big deal if I want to change my gender marker? Why does it bother you if I change my gender marker? I’m not changing yours. I just don’t understand the hostility.”

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