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Treating trans youth: Separating fact from fiction · 20-Minute Health Talk

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This is 20-Minute Health Talk.
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I'm David Reich-Hale. in recent months, more states have debated and
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even passed legislation that limits how health care is delivered
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to transgender individuals. In the last year alone, more than 20 such
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bills have been passed Nationwide in part 1
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of this special two-part conversation, we take a closer look at the
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impact
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these laws are having on transgender care with a panel of experts at
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the local state and federal level.
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In part two, we discuss PrEP injectables the
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newest treatment for HIV.
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The injectable received FDA approval in December
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Here to discuss these topics are
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Dr. David Rosenthal.
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Medical director for Northwell's Center for Young Adult Adolescent and
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pediatric HIV.
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He is also medical director for the health systems Center for
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Transgender Care.
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Joining us remotely are doctor Demetre Daskalakis, who serves as the
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CDC's Director of the division of HIV/AIDS prevention, as well as
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Dr. Charles Gonzalez, who serves as the medical director for the New York
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State Department of Health's AIDS Institute.
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Thank you all for joining us
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Dr. Rosenthal, when you appeared on the show in 2021, we spoke about
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legislation in various states restricting, medical care for Trans
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youth.
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Sadly, we are having some of those same conversations today.
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Most recently with a controversial law in Alabama, attempting to
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criminalize gender-affirming treatments, like puberty blockers.
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With that said, how can healthcare professionals help patients
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and their families feel safe?
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Dr. Rosenthal: So, I think that this whole concept is very, very complicated.
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I want to take it apart into a few pieces.
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One is that I think that it is critically important that the medical
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relationship between a doctor and their patient remains sacrosanct.
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And I think that what we need to do is we need to make sure that we
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can provide the best kind of medical care to individuals to figure out
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what's going on.
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I take care of a bunch of trans youth and a bunch of trans youth from
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communities of color.
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And I think it's essential what we're able to do is, is there were
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Able to realize that we're treating them along their Journey because
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everyone who has gender diversity, everyone, who has a gender
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identity
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that's different than their sex assigned at birth, is on a path and
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has a journey.
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And what we need to do is we need to make sure we're finding out what
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their journey is and we're helping them to be their authentic self.
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While at the same time, we're doing things that make sense.
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Looking at the the impact both on their physical and mental health
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currently and into the future, because both of those things are really
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important.
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And so we need to talk about the importance of the high
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rate of unfortunately of suicidality that we see in transgender youth,
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we need to talk about the self-harm and the self-cutting that occurs
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within transgender youth.
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We need to talk about the fact that we need to make sure that we're
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helping people provide a direction and steps that help them see
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themselves as being authentic.
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And making sure they can be happy and healthy and the work that
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they're doing.
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And one of the really important points that we talked about with this
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is that you know the first step for a lot of individuals is a social
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transition.
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It's cutting someone's hair.
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It's wearing a binder, it's being called a different name that they
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were assigned at Birth.
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These social and identities are very important in creating supportive
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environments for teachers and families and schools.
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That endorse these things that let the young person develop and
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identify as themselves is, critically important.
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Host: Following up on that actually, Alabama's new law attempts to among other
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things, ban hormone therapy and puberty blockers.
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A federal judge has issued a preliminary injunction blocking most
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of its provisions from going into effect, stating that appears to be
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discriminatory
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Dr. Rosenthal
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what are puberty blockers and why are they a necessary treatment for
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some transgender youth?
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Dr. Rosenthal: Hormone blockers are puberty, blockers is an early intervention that
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we can put into place for a lot of individuals and what this does.
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is it basically halts puberty where it is and stops it from
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moving forward
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It's sort of like an audio tape that you put on pause, or it's an MP3
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that you put on pause.
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And what that does is it
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lets the young person determine more
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what's going on with themselves
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It lets them become their authentic selves.
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It gives them a chance to do things and the advantages is these
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medications have been given since the 1970s for children and during
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puberty early, and they don't have long-term sequelae on fertility and
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other things like that that we've seen in the
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medical literature.
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Even through two generations that we've been able to see.
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So it's important to realize we're talking about doing interventions
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for transgender youth
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we're not talking about doing something that doesn't make any sense.
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We're talking about really treating them for who they are, and helping
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them to figure out how they can develop through their life.
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And that's a really important piece, I think that's misconstrued and
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misunderstood greatly by politicians and by communities. And the other
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piece that's very disturbing to me
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also, in the literature, and we've been seeing is that if you have
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two Mommies and you're in kindergarten, you should be able to talk about
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your mommies
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when you talk about what you do at school that day.
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You should be able to talk about what's going on in your life, and
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your home and your family.
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And those are important things for us to consider and to talk about as
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well.
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So I think there are some certain challenges that we have, but I think
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providing Health Equity and providing appropriate, gender specific
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care to individuals is highly important and really critical in order
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to maintain that and really figure out how we're going to do that.
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And I think that that will help open the door to having healthier and
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safer youth.
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Turn into healthier and safer, young adults, as they continue to go
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through this Cascade.
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Host: Dr. Gonzalez thoughts,
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Dr. Gonzalez: I want to Applause, I really do.
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I think that that's absolutely beautiful, David.
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I would just add that no one in the history of the world has ever been
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forced to take a puberty blocker.
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Okay? This is something that's offered and no one is forced ever.
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Take it.
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I mean, just on the most basic level. And the discussions that one
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has if you don't if you are unable to trust your clinician, then you
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have to get another clinician. But that trust is absolutely essential
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for any therapeutic, emotional or advice.
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That's given to a young person or someone transitioning at 70.
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It is a it has
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To be there.
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And if there is any fear on either the provider or the person in their
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cares, part that there were going to be legal repercussions or
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difficulty, that trust is blown up almost immediately, and very
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little can go forward.
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Host: What message would you have for patients and their families in areas
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of the country where these sort of laws are being?
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Debated. Dr. Daskalakis?
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Dr. Daskalakis: You know, one of the things that people maybe don't know or haven't seen
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is the data that we have from our division of Adolescent and school
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health around
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what happens if you have a supportive environment for LGBTQ children
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or young adults in schools, what happens is that the depression scores
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and all of the other mental health indicators in those schools.
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Get better for everyone, not just for the
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LGBTQ kids.
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So really creating an environment I think that is hard for any
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individual, especially an LGBTQ person ends up being detrimental for
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others as well.
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So, it's just, you know, that the sort of aggression there is one that
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rubs off even beyond the communities that are actually experiencing
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the primary aggression.
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And I think, you know, I can't really comment on specific legislation
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in jurisdictions.
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But in terms of messages to people who live in jurisdictions that are
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restrictive in this way, it's to really keep that that that connection
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with your provider as strong as possible.
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And that you know, in the sort of medical environment, you know
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providers need to do what's right for the individual in front of
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them.
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And so don't hide from the providers.
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And from the people that care for you, even if there's an environment
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that makes you feel less comfortable.
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I's not a perfect answer but it's the first thing that
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popped in my head which is that the attempt to silence should not
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actually result in silence
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Host: Dr. Gonzalez what would your advice be?
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It's incumbent upon a health
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care provider to swing that bat in protection of his and her patients
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and their patients.
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It is absolutely necessary. That comes with your obligations to
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protect and to seek
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the best
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care for your patients.
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It's just it's just there.
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The glib answer is always, you know, what was done in the 60s are
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Greyhound bus tickets, family moving to other jurisdictions, which
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will happen because parents will want to protect their children as
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much as possible.
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What Dr. Daskalakis was talking about was this opening up of the community
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discussion allows
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the betterment of the entire Community.
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It is not just; the point here
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the political point that's made is to marginalize the marginal, the
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already marginalized, and that it has never been helpful.
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It has made, for example, the HIV epidemic for longest period of time
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go underground.
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It still has a little reasons for other sexually transmitted diseases
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and infections to go underground.
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The idea that your marginalizing folks that are already feeling
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marginalized is detrimental to human health and to communities at
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large and to individual well-being
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Dr. Rosenthal: I think this ties into the data
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that we saw earlier with suicidality among trans youth, basically
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being somewhere in the 42 to 58 percent for ideation, we're seeing
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bullying
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that's occurring in 36 percent of individuals, based on something came
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out of vital signs
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using 2019 youth population survey data. We're seeing about 2% of
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the population that identifying as transgender.
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So what we're understanding and what we're talking
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about is real people that are really experiencing these situations
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and how we need to make sure they get the care they need.
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I was at South by Southwest talking about transgender Health, with a
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panel of individuals, really, an interesting conversation and someone
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from Oklahoma was telling me that they're already getting calls from
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individuals about how they can get the care.
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They need
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How they can make sure that they can take care of their transgender
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kids and how we can really make sure we need to do what we need to do.
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I think just over the a couple of days ago in Texas, there was
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thankfully part of the law that came through was partially
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blocked by some work that was done by Lambda legal and the ACLU
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regarding some of the issues that were happening in Texas.
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And and not being able to and finding people and bringing child abuse
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charges against those parents that were initiated by the governor and
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I think, what's important is that where we allow is as we allow for
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protection of children, using the standard modalities that we need to
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protect children through just like, we have always done so rather than
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politicizing this and rather than taking this to a political realm
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because I think that healthcare should be for everyone
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children should be taken care of by everyone and we should make sure
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that we're not turning people into Political footballs for no reason
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whatsoever.
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Host: How do we continue to message this?
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Because in some, in some parts of the country, this
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Barely acceptable or mostly acceptable but in other parts of the
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country, not so much.
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Dr. Rosenthal: I think culture and politics are making a big difference here.
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And I think the problem is what we need to realize is that we need to
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identify the medical issues.
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And we need to let medical providers that want to take care of
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patients, provide the proper Medical Care using standards that are
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universal.
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That are there are substantiated by evidence, and by best practice,
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and guidance, both throughout the United States and through the world.
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And I think that if we are allowing the conversation to occur between
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doctors and patients in letting that become
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the relationship by which the proper care is being delivered
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that is the key message
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how we can make sure that people are being taken care of properly.
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And I think that, you know, Charles said earlier, Dr. Gonzalez said
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earlier, if you can't find a doctor that you can talk to about your
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sexual health, if you can't be honest about your sexual health, if you
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can't be honest, about your gender identity or sexual orientation with
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your provider, then find a doctor that you can.
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Because it's really important that you have that relationship where
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you can be your authentic self to the people around you, including
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your healthcare provider.
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Dr. Gonzalez: And healthcare professionals were based on data and the science behind
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it and those are the decisions that should drive the discussions.
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And we need to stand on that
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as fact, not trying to come into arguments of political persuasion.
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That's not what we're there for.
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I mean, we can swing a good bat when we need to but
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Same time.
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It's when we are speaking.
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And to our patients, we're providing the best guidance based on
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evidence, based on data.
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And based on reality, not someone's figment of what political reality should be
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Host: Dr. Gonzalez...
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Dr. Rosenthal: Now I'm giving you snaps
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Host: And Dr. Gonzalez, is there sort of hope that that will be able to educate
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enough of the public to, where these sort of conversations are no
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longer that political and are
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Or sort of tied to pure health care?
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Dr. Gonzalez: Well, you know
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We've come far.
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We haven't come far enough.
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I think that's fair.
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And these, this is the intersection of what culture and politics get
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us to. But we have expanded that mindset to the point where you can now
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put
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You know, ads; perhaps not late night but reasonably on for
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The things such as PrEP, such as medications that will suppress your
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viral load.
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These are ads
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that essentially mimic the social acceptance of U equals U.
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What affects one member of our society.
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What determines
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one community in our society comes back and hits us all.
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It's just even if it's only in terms of self-interest, if you make
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sexual activity illicit
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if you make pregnancy and abortion illegal, this will come back to
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every member of society this is always happened.
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And if you do it to one group, you will do a to another this is, you
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know,
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We have this melting pot idea. Our Canadian cousins talk about a
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mosaic and mosaics are what make culture and having different groups
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protecting each other and access to care is what makes it very
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beautiful Mosaic.
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And tightens the links between communities, because communities; there,
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you know, you can consider yourself, you know, Hispanic and gay.
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But, where do you, which Community belong to?
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We are all multifaceted too many communities.
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And, you know, you start cutting off certain ends, you end up, you
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know, with no one in the community, there's nobody left, it's just
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very peculiar, but yeah, we've Advanced a great deal, but we have not
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openly discussed this for a while.
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Okay, we have not openly discussed how members
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of brown and black communities are more affected by HIV
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which is part of less access to
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healthcare generally, which is part of equity.
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And those things are not, haven't been until Covid, front and center of
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our conversations.
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As we've said, everyone said a thousand times that Covid has
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ripped that part of the facade or of the, you know,
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political pablum, if you will, off,
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Dr. Rosenthal: No, but I think with that, I think that that actually is a great lead
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in very much to the work that we were doing about six months ago when
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we were really talking about Health Equity and setting, competencies
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for healthcare providers for Health Equity.
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And also kind of trying to set competencies to support
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those Healthcare institutions in order to create that
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Health Equity.
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Because if we don't necessarily find ways to address social
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determinants of Health, if we don't find ways to kind of equalize issues
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and making sure that we're able to address things
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across the board with poverty, food stability, housing stability
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all of these other social determinants of Health LGBT
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status.
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We need to make sure that we're using, we're able to overcome these in
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a real substantial way to affect, not only ending the epidemic for HIV
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helping people get on PrEP that needs to be on it
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decreasing STIs.
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But also really to helping us have a healthier population as a whole.
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So I think that these competencies that we've talked about that we
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started setting out, really helped form the groundwork.
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And then the question is, how are we going to be able to move that to
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the next step?
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How are we going to be able to continue to make sure we have
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healthcare providers
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that really can make that happen.
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Host: Dr. Rosenthal you mentioned a set of Health Equity, competencies are
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issued by the New York State Department of Health. For context
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those four competencies include
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1. Addressing social determinants of Health. 2. Taking an active role in
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community and institution. 3. Employing a person-centered model of care,
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4. Seeking to avoid bias and provide affirming Services.
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Dr. Gonzales, can you talk a little bit more about this?
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Dr. Gonzalez: Thank you for that lead in.
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You know, we did develop these competencies or what we discussed is,
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competencies for healthcare providers.
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That go beyond HIV, and
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STIs.
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And we did it to try to be as practical as possible simply because,
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you know, for the vast majority of providers
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65 to 75 percent of patients interactions are pretty easy
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It's the remaining, you know, 15% or so that provide most of our
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difficulty, whether it's social determinants of health or
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Or, you know, substance use or any of those.
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And those are the things that providers are, you know, essentially
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throw up their hands about not knowing what to do next.
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And we come up with some very practical for points upon, which they
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can build on, you know, in terms of Engagement and to help someone
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through these interactions both on a person-to-person
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basis, but also a second set of competencies so that they may affect
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something within their organization.
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But it really matters is that the clinician has a community
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responsibility and the need to convey engage with their community and
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to be known in their Community as someone who will protect both, their
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private medical issues, but also be issues and the needs of their
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Community.
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It's absolutely necessary for that to be done.
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It cannot be done alone.
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But to say that, we as, as clinicians that, this is not our Province.
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It's just when eighty to ninety percent of all the chronic
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conditions and acute infections that were talking about are
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essentially determined by Often by your ZIP code, you know, in New York City
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We've looked, even if you go to the more prestigious academic
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institutions, your viral load
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suppression is more correlated with your zip code than where you're
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receiving care.
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That's extraordinary.
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That's extraordinary, same Health Care.
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Same thing.
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We need to engage and have the community trust once again, the
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healthcare provider in years past the, the doctors word was
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was golden okay.
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We may not want to return to that level because there's a
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power dynamics that makes it very difficult to engage communities and
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to engage folks for their lived experience.
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But that's one of the things that we've sort of tried to do in our
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competencies to discuss, you know.
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And to realize the difference in power dynamics and to engage what's
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important to that individual and to
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their care and their needs. Not just their physical needs, but their
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psychological needs.
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Whether that is fear of, you know, poverty or fear of developing
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diabetes.
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These things are incredibly important and underline the absolute need
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for a trusted and therapeutic relationship.
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Host: This has been part one of our conversation with Drs. Rosenthal
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Daskalakis and Gonzalez.
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In part 2, we discuss the newest tool in the fight against HIV — PrEP injectables.
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Thank you for joining us
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on 20-Minute Health Talk.
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I'm David Reich-Hale. Have a great day.