Gender affirming care

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0:00:03.4 Speaker 1: Gender-affirming care, to me, is providing patients a form of care that not only affirms their identity, but can also help further their transition, and however, they see fit. Transition doesn't always have to be medical, sometimes it can be social or emotional, but whatever steps that have to be in place to further that care counts as gender-affirming care, in my eyes. I think the first time I felt like I was receiving gender-affirming care was when my doctor asked about my personal identity and asked what I preferred to be addressed as. Although this wasn't anything specific to my gender identity, it felt as though I was being seen in a healthcare setting for the first time.

0:00:49.5 Vic Gibson: You may have seen the term "gender-affirming care" in the news or on social media. Often this term is used to refer to surgical procedures to help an individual's body match their gender identity, but gender-affirming care is actually much more than that, it involves a combination of medical, psychological, social, and legal factors.

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0:01:09.8 VG: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level, from the microscopic to the macro-economic, the social, to the environmental, from cities to neighborhoods, states to countries, and around the world.

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0:01:40.2 VG: In this episode, we'll talk with healthcare and public health experts, as well as members of the trans community to explore what gender-affirming care actually is, and how can it impact health outcomes for transgender and non-binary individuals. Many of us cannot begin to understand the need for gender-affirming care without first understanding the experience of being a transgender person in a healthcare setting. The Michigan Organization on Adolescent Sexual Health or MOASH is a community health organization focused on mobilizing youth voices to advance sexual health, identities, and rights.

0:02:13.4 VG: Vic Gibson is a facilitator for the Michigan Youth Trans Voice Advisory Council at MOASH as a queer trans man himself and an advocate working with trans youth, Vic offers some perspective on seeking health care as a trans individual.

0:02:27.5 S1: Some common themes I noticed with my youth when they enter healthcare settings is they often judge based on their first interaction within that space, whether they're going to be able to be themselves or not. Some healthcare settings give youth the opportunity to share how they identify or what they wish to address in that medical interaction. Other facilities won't, and we'll just go based off of assumptions and paperwork, and sometimes will ask inopportune or inappropriate questions when they're meant to be addressing something else. Some youth have said that they were uncomfortable because their visits would only focus on their identity and not in the good way healthcare professionals would treat the medical interaction as an opportunity to ask every question about trans people that they've ever wanted to... And that was an irk to the patient because they might have been there for something completely unrelated to their gender identity. A lot of youth have said that they feel affirmed when they go to doctor's offices and they aren't put into a very binary system, although healthcare itself can be something that's very biologically-based or treated, it doesn't mean that the interactions have to be. You can still go off of somebody's biology and still treat them accordingly without disrespecting their identity in that moment.

0:03:43.2 S1: I think gender-affirming care impacts everybody because everybody has a gender, everybody has gender-affirming moments, and they don't have to be trans to experience gender-affirming care. One example I can think of is that in the basis of Endocrinology, which has to do with hormones, there are plenty of cisgender folks, which... Cisgender is somebody who is assigned a sex at birth and identifies with that sex at birth. When a cis person receives endocrinology care whether that be through receiving hormones to even out their hormone levels, or they might have a condition where their levels are extra high or extra low, or sometimes even if they just need blood work, they have to go through endocrinology and for trans folks, they might experience the same things just for different reasons, but that process of accessing that care can be gender-affirming for some folks because some cis women might have higher levels of testosterone and that might make them feel very negative about themselves, and being able to correct those levels will make them feel more confident in their state of being a woman, that process would be affirming their gender as a woman.

0:04:51.7 VG: Most young people must rely on the adults in their lives to advocate for their best interests in healthcare settings. For any minors, but especially for trans and non-binary youth, support from a parent or guardian can make or break access to gender-affirming care and be the determining factor for how our local health and public health organizations respond to the needs of those young people.

0:05:11.6 S1: Parents largely impact gender-affirming care when it comes to youth. Since most parents are in charge of their youth's access to healthcare, it's often up to them to be the first decision makers on whether the youth can even access that gender-affirming care. Parents are given the unique opportunity to be able to advocate for their children or the youth that they're caring for when it comes to these circumstances. Parents also provide affirming spaces for youth and can give their child a safe space to grow and experiment. There's many different ways that youth can experiment to feel comfortable and to feel affirmed in their gender identity. Parents can use the opportunity that they're given to be able to educate themselves, to learn what gender-affirming care looks like and what its benefits might be for the youth that they're caring for.

0:05:57.7 S1: In my personal experience, I know that my mom has been my biggest supporter in my transition. Although at first, she had a hard time accepting my identity and she had a hard time adjusting to my identity. She put in the work to educate herself on what being trans meant, what transitioning looked like, and how she could best support me. She has become my number one supporter, and she has used the knowledge that she has gained to best support me in my transition. She's made sure that I am very thoughtful about the steps I take in my transition, especially when it comes to physical transition or medical transition, and she has always spoken up for me when I was afraid to speak up for myself. If it weren't for parental support, I don't know where I would be in my transition or in my adulthood. I don't know if I would have felt as comfortable seeking out gender-affirming care if I didn't have that support from my mom or my family for that matter, I feel like parental support gives you the reassurance that they're okay to be who they are.

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0:07:01.6 S1: One interaction that was very memorable for me was when me and my parents were on call with a psychiatrist discussing starting hormone replacement therapy. At the time I had been doing years of research because I had been constantly contemplating on how I could achieve the goals I was setting for myself. My parents, up until this call had been very hesitant about physical transition and had been very concerned on the impacts it might have on me. During the call, my parents asked a list of questions showing that they took the time to research the hormone that I would be starting, and the impacts that it would have on me showing that they truly cared about me and my physical well-being, and they included me in the discussion the whole time. Sometimes they would ask questions that they thought might make me feel uncomfortable to make sure that I would be safe and that I was taking the right steps.

0:07:53.3 S1: I felt very comfortable when my parents asked these questions because it showed their love for me and it showed that they weren't closed off to the idea of me being myself. I think that folks understanding that gender-affirming care comes in many forms is also super important because not all gender-affirming care is just surgeries or permanent medical adjustments. I know lots of trans youth have benefited just from being in support groups or programs where they can communicate with others in a way that's authentic to their identity. That process of communicating and building community based on their identity can be gender-affirming.

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0:08:38.8 VG: Health disparities, impacting transgender individuals have been widely documented. Medical, legal, and social gender affirmation can play a significant role in mitigating some of those disparities. Wesley King, a doctoral student at the University of Michigan School of Public Health, explains how health outcomes are linked to access to gender-affirming care.

0:08:58.0 Wesley King: Trans populations are impacted by a host of social and health inequities and medical gender affirmation, gender-affirming care and other types of gender affirmation can help mitigate or reduce adverse health outcomes and start to work towards reducing those inequities. The idea of gender affirmation comes out of research looking at HIV among trans women, and in particular black and Latina trans women who experienced the steepest health inequities and HIV prevention and care outcomes, and numerous studies over a long period of time at this point have shown that when trans women are able to access medical gender affirmation, legal gender affirmation and have more gender-affirming social and interpersonal relationships, that those experiences make them better able to prioritize HIV prevention and engage in HIV treatment, thereby reducing some of the HIV inequities that this population faces.

0:10:00.4 WK: We also see this now that gender affirmation has been expanded to other trans populations and other health outcomes with trans youth. Trans youth experience various steep inequities regarding mental healthcare in particular, depression, anxiety, trauma and suicidality, and there are now numerous studies showing that when trans youth [0:10:20.2] ____ adults can access medical, gender affirmation and gender-affirming healthcare that those experiences have lasting positive mental health effects.

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0:10:35.6 WK: Social gender affirmation, such as having teachers and parents use correct names and pronouns with them has been shown to have beneficial mental health outcomes, and I believe also impact academic outcomes. And we know for trans adults that legal gender affirmation confers access to a lot of really important resources for generally thriving in life. So for example, it can help a trans person avoid discrimination in healthcare or job applications, housing applications, and sort of reduce the impacts of those social determinants of health in their life. Legal gender affirmation refers to official or governmental recognition of someone's trans status. So this is achieved through changing names and gender markers on identification, whether that's like a driver's license or passport, but also in places like health insurance, school records, et cetera.

0:11:28.1 WK: While public health has devoted generally less attention to understanding the health impacts of social legal gender affirmation, initial evidence suggests that these are just as important determinants of health for trans people as medical gender affirmation, especially for youth who do not medically qualify for Medical gender affirmation yet or are interested in it. Currently, the research team I'm a part of, is looking at how access to legal gender affirmation can be strengthened for trans women of colour in Detroit and how that might impact their health outcomes. So for example, there are women that I work with who have unpaid parking tickets or really minor traffic infractions or have been charged with offenses related to sex work that cannot change their name or gender marker because of the unpaid fees they have, or because in the state of Michigan, with name change in particular, that is left to a discretion of a judge in the case of someone having a criminal record, so because we know that communities of colour, poor communities are over-policed and more likely to be subject to fines and fees for very minor things than white and affluent communities, legal gender affirmation and increasing accessibility to that is really important to addressing the racial inequities that this community is already set up for.

0:12:56.6 WK: So currently we're looking at developing a medical-legal partnership to allow these women to access legal gender affirmation that's affordable and in the place where they're already accessing their gender-affirming healthcare to make it more convenient for their lives. And the hope is that we will see that having name and gender markers recognized will allow them to access the resources they need such as jobs, getting into housing programs that may also be gender segregated, opening bank accounts, really everything that you need a name or gender marker for to support whatever their goals are.

0:13:37.3 VG: In most cases, legal gender affirmation requires lawmakers to pass gender-affirming legislation. However, legislation related to trans health has largely been diverted to hot-button issues that don't address widespread health inequity for the community.

0:13:52.4 WK: Recently, the Florida Governor signed the bill banning gender-affirming healthcare, transition-related healthcare for trans youth's in that state. And that's sort of emblematic of the current political moment that is really trying to use trans youths' access to health care as a culture war political bargaining chip for a lot of different purposes. So the current political conversations around trans people focus on gender-affirming care for youth, youth sports participation and bathroom use in schools, and those policies have very real implications for those children, but they have pretty limited implications for issues that are more likely to impact trans people of colour like poverty and incarceration and interpersonal violence, and the issues that are really underlying the inequitable rates of trauma, HIV, chronic disease, violent death and overall mortality in these groups.

0:14:51.1 WK: Part of my dissertation is looking at a lot of different policies and how they impact trans women of colour versus white trans women. And my preliminary results are suggesting that there are several types of policies that are only associated with positive health outcomes for white trans women. So for example, white trans women living in states where private insurers are required to cover medical gender affirmation and are prohibited from discriminating against people on the basis of gender identity, those laws are associated with better health for white trans people. But when looking at just the trans people of colour, in the sample, there is no relationship, and that is likely because white trans people are more likely to have the social and economic resources that give them access to private insurance in the first place, like having a full-time job that provides benefits or a spouse with a full-time job that provides benefits, whereas trans people of colour are more likely to be using Medicaid or other public insurance, and therefore less likely to be impacted by laws governing gender affirmation that focus on private insurance.

0:16:00.6 WK: And there are similar trends looking across non-discrimination policies and policies that govern access to legal gender affirmation, where we're not seeing any measurable impacts on trans people of colour. There are also some states that have introduced bills banning gender-affirming healthcare for adults, but the policies that have more of an impact on access to gender-affirming healthcare for adults and for structurally vulnerable trans people are state policies that require Medicaid to cover gender-affirming healthcare, and even in states where Medicaid already does coverage under affirming healthcare, changing structures so that that care is geographically and logistically accessible to the most structurally vulnerable trans people. So just because the state covers care through Medicaid doesn't mean that there are enough providers, that the providers that are there actually are trained and knowledgeable about how to provide gender-affirming healthcare.

0:16:58.5 WK: Training for medical providers is essential to increasing access to gender-affirming healthcare. Caring for trans people is often thought of as a specialist thing for endocrinologists or sometimes pediatricians to do, but there are a range of medical providers that should feel comfortable with, able to and are trained in either delivering gender-affirming healthcare, such as prescribing hormones, monitoring those levels and certainly referring trans people to financially, geographically, logistically accessible resources for surgeries or other gender-affirming healthcare that that particular provider may not be able to provide.

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0:17:43.6 VG: John Randolph is a Professor of Epidemiology at the University of Michigan School of Public Health, and a professor of Obstetrics and Gynecology at Michigan Medicine. He specializes in reproductive endocrinology and transgender medicine and is one of the founding clinicians of the comprehensive gender services program at Michigan Medicine, which helps transgender, gender non-conforming and non-binary adults access gender-affirming medical care. Dr. Randolph has been working with transgender patients seeking affirming care like hormone therapy and gender-affirming for surgery for more than 20 years. He spoke with us about the evolution of understanding around transgender medical care in that time and what we should know about how gender-affirming care can impact health outcomes.

0:18:22.4 John Randolph: Gender-affirming care encompasses multifaceted aspects of helping somebody fulfill their potential. It includes a lot of psychosocial assistance in addition from a medical perspective, both hormonal treatments and potentially surgical treatment, depending on what some of his wishes are. My primary interest is in hormone management and helping people achieve their bodies of identity as much as we can achieve. The comprehensive program started in '94. I was sort of organized then and I was one of the people on the team at that time, so I've been doing it for a long time, and I'm trained as an OBGYN. So at that time, I basically was the GYN surgeon on the team, and then we had a medical endocrinologist, he did the hormones, and at the time the demand was not very high because most people weren't out or didn't recognize things and then, oh, about 10 years later, when he retired, I sort of became the primary hormone provider for adults. And then within the last 15 years, the demand has just exploded and probably not because the prevalence is any higher, but probably 'cause the recognition and the availability of care and there's a lot more information that's out there. But in terms of training, there wasn't anything and then when we got busier and busier and busier, people basically came to us, so I've had lots and lots of students and residents and fellows in our clinics to learn how to do things that way.

0:19:54.9 JR: But we used to have a long way to go. And what we've been pushing for, certainly for the last five years, but even longer than that, is to try to incorporate education in this area into the curricula of medical schools and primary care residency programs, and so we now, just in our department of OBGYN, we have five now, people who provide hormone care, do hysterectomies. We have a team that does the called the vaginectomies for the transgender men who wanna go on to bigger surgery, and then there's a program within plastic surgery to do all those surgeries and in urology, there's a number of family medicine people who do hormone therapy.

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0:20:36.6 JR: With trans care, you almost always start off with just, how do you interact with people? And it's simple, but not always obvious things like, how do you address somebody? What do you call them? And how can you approach... And so it's not even just in this community. It's basically anybody. So just when you walk in the room, ask, how would you like me to address you? 'Cause, it may not always be obvious and that kind of stuff, and so that's a part of it, just the socialization, so the standard thing of what do the different words mean, and then a lot of it is just building a culture of respect. When we started there was somebody who basically pulled the group together because she had connections in a very small trans community at that time, and most of those people didn't get healthcare because there was no comfortable, safe place to go to. That was a part of our program that was unique at the time, was it included primary care providers in the very beginning and said, "We need to provide total health care for this populace in addition to the specialty services." And that's continued, there's a lot of family medicine, both faculty and residents here that see trans folks and are very comfortable in managing their hormones.

0:21:50.7 JR: If you look within the population in terms of risk, and there's a whole bunch of risks, there was a study now, probably 10 years, but looking at people who self-identified as being gender-nonconforming, they had a 25-fold higher incidence of suicide, it was much higher than being gay in terms of at risk. If you look at homelessness, if you look at drug use, if you look at sex workers an unusually high proportion are gender non-conforming, and so there's a lot of social... And a big thing is mental health. Just the risk to this population, and there are good data that if this population is raised in a loving home, treated with respect, they don't have any higher mental health issues than their peers, and so a lot of it that... We believe that most of this is social.

0:22:44.6 JR: If people don't seek care or can't access care, which traditionally has been an enormous issue and continues to be a big issue, many, many places, and if folks can't find comfortable care, they won't seek any care, not only with respect to their gender-specific care, they won't get their glucose checked, they won't get their blood pressure checked, they won't get screening for colon cancer, they won't get breast cancer screening, and so they're at much greater risk for all of those long-term health outcomes to be adverse because care is not comfortable. And so simply providing an environment where people feel that they're treated with respect and can get the care that they deserve is really important, and it's the right thing to do. If you could see the patients and how happy they are after never having felt right. And now they feel better. I saw a bunch yesterday. And I always ask, "Are you happy?" And it's like, "Yes." It's really, really affirming. It would be very, very difficult to think this was a bad thing when you talk to people who have experience in this.

0:24:00.5 VG: Enhancing gender-affirming care within training for health professionals could be a big step toward creating a healthier atmosphere for gender-affirming care, and it's something that public health experts like Dr Randolph continue to advocate for.

0:24:12.5 JR: It's demographics. If you look at the latest surveys in terms of just the prevalence of being gender non-conforming, it's... We're talking at least 1%-1.5% of the population that's probably worldwide, and it may be higher than that, and so if you just do the numbers, there's not enough specialty providers to do that, especially once somebody starts on hormone therapy, it's probably life-long. So if you're a 20-year-old and you're gonna start on testosterone and you don't make any of your own, you're talking maybe 80 years of testosterone and once someone's on a stable dose, it stays pretty stable for a long time. So to have to go to... Come to a specialist annually, 'cause testosterone is a controlled substance it needs to be renewed every year. It's something that a primary care provider absolutely can do because they're gonna provide their healthcare anyway. And so just like somebody would come in and have their diabetes managed or their blood pressure or their thyroid, managing their gender hormone would be the same thing, and so that needs to be a capacity simply from a manpower perspective, it's just one more aspect of somebody's health care, so all PCPs should have this capacity. And the thing about it is it's a very manageable body of knowledge, so it's not so intricate that you have to have years of special training to be able to do it.

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0:25:42.3 VG: Gender-affirming care encompasses everything from bedside manner and conversational etiquette to hormone and speech therapy and transitional surgeries. With such a breadth of coverage, the exact definition and description of gender-affirming care can be difficult to ascertain from news headlines. It's important to remember that at the root of gender-affirming care is a person simply seeking health care.

0:26:03.8 S?: Think of it as any type of healthcare that recognizes and affirms a trans person's identity, trans people need the same healthcare that everyone else does, dental care, checkups treatment for chronic conditions, et cetera, and all of that healthcare can be gender-affirming. All healthcare providers can deliver gender-affirming healthcare in their settings they work in by shifting the structures and practices they use to better address trans people's needs. So that could look like changing the forms and documentation that healthcare providers request trans patients to fill out before coming in for an appointment. That could look like being thoughtful about either asking about how someone's trans status impacts the health problem that they're coming in with, or thoughtfully not asking about that if it's in a very obvious situation where there's no relationship between those two things. But basically any time a trans person feels recognized and affirmed in a healthcare setting that is gender-affirming healthcare.

0:27:09.6 VG: On the next edition of Population Healthy.

0:27:12.0 S?: I remember waking up and just thinking of my grandma, I had this intense sensation of wanting to go get her physically, if I have to carry her over the border to safety, 'cause she's deathly afraid of flying. I love her endlessly, and I spent most of my childhood with her, at least the summers, but we were talking about maybe we can take you somewhere else, bring you to safety. But her attitude is that she survived Russians before and she will again, and I love her for it, but I still have that feeling of wanting to just pick her up and take her somewhere else.

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0:27:56.3 VG: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us and hope you learned something that will help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Be sure to follow us @umichsph on Twitter, Instagram and Facebook, so you can share your perspectives on the issues we discuss learn more from Michigan public health experts and share episodes of the podcast with your friends on social media, you're invited to subscribe to our weekly newsletter to get the latest research news and analysis from the University of Michigan School of Public Health. Visit publichealth.umich.edu/news/newsletter to sign up. You can also check out the show notes on our website population-healthy.com for more resources on the topics discussed in this episode. We hope you can join us for our next edition where we'll dig in further to public health topics that affect all of us at a population level.

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