Science AMA Series: We are two medical professionals and the transgender patient advocate from Fenway Health in Boston. We are passionate about the importance of gender-affirming care to promote overall health in this population. Ask us anything about hormone therapy, surgery, and primary care!

Abstract

Hi reddit! We are Dr. Julie Thompson, Dr. Alexis Drutchas, Dr. Danielle O'Banion and trans patient advocate, Cei Lambert, and we work at Fenway Health in Boston. Fenway is a large community health center dedicated to the care of the LGBT community and the clinic's surrounding neighborhoods. The four of us have special interest in transgender health and gender-affirming care.

I’m Julie Thompson, a physician assistant in primary care at Fenway Health since 2010. Though my work at Fenway includes all aspects of primary care, I have a special interest in caring for individuals with diverse gender identities and HIV/AIDS medicine and management. In 2016 I was named the Co-Medical Director of the Transgender Health Program at Fenway, and I share this role with Dr Tim Cavanaugh, to help guide Fenway’s multidisciplinary team approach to provide high-quality, informed, and affirming care for our expanding population of individuals with various gender identities and expressions. I am also core faculty on TransECHO, hosted by the National LGBT Education Center, and I participate on Transline, both of which are consultation services for medical providers across the country. I am extremely passionate about my work with transgender and gender non-binary individuals and the importance of an integrated approach to transgender care. The goal is that imbedding trans health into primary care will expand access to gender-affirming care and promote a more holistic approach to this population.

Hello! My name is Cei and I am the Transgender Health Program Patient Advocate at Fenway Health. To picture what I do, imagine combining a medical case manager, a medical researcher, a social worker, a project manager, and a teacher. Now imagine that while I do all of the above, I am watching live-streaming osprey nests via Audubon’s live camera and that I look a bit like a Hobbit. That’s me! My formal education is in fine art, but I cut my teeth doing gender advocacy well over 12 years ago. Since then I have worked in a variety of capacities doing advocacy, outreach, training, and strategic planning for recreation centers, social services, the NCAA, and most recently in the medical field. I’ve alternated being paid to do art and advocacy and doing the other on the side, and find that the work is the same regardless.
When I’m not doing the above, I enjoy audiobooks, making art, practicing Tae Kwon Do, running, cycling, hiking, and eating those candy covered chocolate pieces from Trader Joes.

Hi reddit, I'm Danielle O'Banion! I’ve been a Fenway primary care provider since 2016. I’m relatively new to transgender health care, but it is one of the most rewarding and affirming branches of medicine in which I have worked. My particular training is in Family Medicine, which emphasizes a holistic patient approach and focuses on the biopsychosocial foundation of a person’s health. This been particularly helpful in taking care of the trans/nonbinary community. One thing that makes the Fenway model unique is that we work really hard to provide access to patients who need it, whereas specialty centers have limited access and patients have to wait for a long time to be seen. Furthermore, our incorporation of trans health into the primary care, community health setting allows us to take care of all of a person’s needs, including mental health, instead of siloing this care. I love my job and am excited to help out today.

We'll be back around noon EST to answer your questions, AUA!

I was so very excited to see your AMA! Learning about HRT is part of what has driven me to seek a career as PA once I am out of the US Air Force.

I really feel like the studies on HRT have overall been very inadequate and that the current guidelines that many doctors follow is dangerously misguided. Here are a few potential problems that I have been able to identify, but may need further studies conducted. This is really based off of research mostly from www.ncbi.nlm.nih.gov and in discussion with a friend with a PHD in biology who does research for a living, a doctor who treats a lot of trans patients and a handful of others.

Synthetic and bio-identical hormones are often not differentiated from despite having very different health risks. An example is that bio-identical progesterone seems to decrease breast cancer risk where progestins increase it.

The use of progestins rather than bioidentical progesterone is often used despite having much higher risks and even experienced doctors don't seem to understand this.

The use of finasteride, especially in 5mg doses is fairly dangerous largely due to it's effect on allopregnanolone. It also doesn't really do anything of value if testosterone is already low.

The use of high doses of spironolactone(anything over 50mg but especially anything over 100mg) is also fairy dangerous and it is largely way overused. Estradiol and progesterone act to lower testosterone in the body even without spironolactone. Spironolactone has several side effects such as impact on brain function, it's effects as a potassium sparing diuretic, and visceral fat increases. Often doctors will prescribe Spironolactone until testosterone is much lower than normal female levels and they will keep the estradiol levels of their patients fairly low as well out of fear...this leads to all sorts of problems of course...

The lack of understanding of the risks of estradiol vs estrone and how to manage it is also a major problem. Doctors often do not test for estrone and they often prescribe hormones in a way that keeps estrone high and estradiol relatively low. Estrone is a weak activator and inhibits effective feminization when too high. Estrone also carries very high risks if it is too high. Estradiol, a much more feminizing form of estrogen is very low risk. Doctors will often have their patients swallow estradiol pills (rather than use sublingual, injections, transdermal or other methods) which often leads to higher estrone and lower estradiol and higher liver damage risk. This process is much less feminizing, can really mess up someone's mental health and puts them at long term risks for things like strokes.

Often with injections(and other methods but not as easily) patients can reach 300-400 pg/ml serum levels of estradiol while maintaining low estrone with no anti-androgens...leading to a minimizing of side effects and maximizing of mental health as well as feminization. Many guidelines often point to 200pg/ml "max", but this is based on the fear caused by studies that showed high risks of estrogen usage...except that it was effected by the dangers of synthetic hormones and high estrone levels.

Doctors in an attempt to "play it safe" use these guidelines and in the process end up managing less effective and much more dangerous HRT plans.

Now this is all based on what I have been able to discover. After I had a mental break down and tried to commit suicide about 3 years ago even though the only thing I changed was that I started hormones, I started digging into this and managed to slowly shift to a healthier HRT plan and now I am doing amazingly well.

From what you have seen is there any significant awareness of these issues and is there any move to create new guidelines and to help educate doctors on better HRT practices in the works? Thank you.(sorry if this is a mess, I am not on my desktop where I could proof-read it more effectively)

***fine print: If you are a transwoman reading this in an attempt to manage your own care without a doctor...please don't, but if you would like PM me with questions and I can provide resources and explanations you can take to your doctor so that you and them can discuss options. My life is crazy right now with politics threatening my job in the military, but I will help as much as I can as soon as I can.

Murasaki42

Hello! Cei here. We have created a set of guidelines through Fenway that echo very closely your findings, Murasaki42: http://www.lgbthealtheducation.org/wp-content/uploads/COM-2245-The-Medical-Care-of-Transgender-Persons.pdf

We stick to estradiol for feminizing hormones, and use spironolactone as our primary anti-androgen. Lupron would be ideal, but it's near impossible to get it covered for adult patients using it to suppress androgen production. We instruct for sublingual, injectable, or patch form estradiol and have very good success both in helping our patients to feminize and in minimizing risk.

In general we try not to chase numbers, but rather to assess how well someone is feminizing as per their goals. We will check levels once or twice a year once someone is on a consistent dose, and make sure to check for prolactin levels, liver function, and so on.


I have some questions regarding the value of expanded gender concepts from a medical perspective.

So from a medical standpoint what are the advantages of considering gender beyond that of sex? Is there a sufficiently large correlation between gender identity and biological differences between them and people of same sex (but different gender identity)? How do you account for socially developed gender identity (Culture/society can cause a person to feel different about themselves, thus I would postulate they may have developed their gender identity around such encounters rather than purely biological reasons)?

In case the answer is that gender identity helps diagnose psychological issues such as depression or anxiety: To what extend are these caused more by societies nonacceptance of their unique personality/biology, rather than their biology making them more prone to depression/anxiety? Could larger understanding that individuals don't necessarily conform to stereotypes (such as traditional gender roles[male/female]) help mitigate this? (as opposed to expanding our concept of gender.) What advantage does "gender identity" hold when attempting to help these people come to terms with their differences?

Lastly, aren't all people non-binary to some extend? As in, we all exhibit some traits commonly attributed to the opposite sex, it's simply a question of how much. Wouldn't the underlying issue then be our persistence in trying to apply stereotypes to individuals? I have traits that are very feminine, but see no reason to classify myself as anything other than male [as per my sexual organs, which is all I see gender to be] (not trying to say others do not exhibit a much stronger dissonance, just as an example of the issue being cultural rather than biological). All humans are bound to be a unique result of our biology and experiences, and our biology doesn't care about gender roles. We then attempt to conform to societal expectations (perhaps due to the advantages this brings when dealing with other people), so men attempt to become more masculine and women more feminine. This would lead me to think the issue is our culture of over stereotyping, and the solution is to change that part in culture not expand gender (a stereotype to begin with) to encompass more possibilities.

Additional question: I see gender as an inherently flawed concept since biological sex organs are a poor indicator of biological diversity and its consequent effect on personality. Is it realistic to expand our concept of gender in a way that it would be "less flawed" in describing our biology's effect on character (won't some amount of people always feel inadequate in any of the categories [and thus feel discriminated against] and won't the pressure to find your own "cateogry" eventually overshadow the advantages?)

P.S. Sorry for the wall of text, I tried to edit this to be shorter (Yes I see the irony of this apology compounding that)

newbiecorner

Hi there! Danielle here. I’ll try to break down the questions in order to the best of my ability.

  1. I guess I don’t know what you mean by ‘advantages,’ but I think that as a medical provider, I benefit patients the most when I divorce myself from the idea that sex assigned at birth necessarily dictates gender identity. What limited data we have points to a number of possible factors that impact how biological sex informs gender identity, from environmental circumstances (estrogenized chemicals) to biochemical processes (in vitro fertilization). Gender expression/presentation complicates this still further, because that is tremendously affected by the cultural milieu in which people exist.

    In short, given limited hard data, I’m comfortable living with a degree of uncertainty around what comprises people’s gender identity and expression, as well as why they possess those traits. Instead I focus on letting the patient dictate the goals of their gender affirmation process, whether that includes medical treatment, surgery, or just talking in a room for 30 minutes about their story. My job as a provider is to keep people safe while they affirm their gender, whatever that is and why they identify with it.

  2. I disagree with this: “gender identity helps diagnose psychological issues such as depression or anxiety.” As with any population of individuals, mental health disorders are comorbid to existence. In fact, as a primary care doctor, the number one chief complaint I see in my non-trans population is anxiety and depression. So I see gender identity and mental health as two separate things. Indeed, I have a ton of patients who have no depression or anxiety at all, but who happen to have a gender incongruent with their biological sex. Furthermore, we know that most gender diverse people experience a lot of discrimination and trauma, and that mental health outcomes improve as support from school, family, and friends improves. (http://transpulseproject.ca/wp-content/uploads/2012/10/Impacts-of-Strong-Parental-Support-for-Trans-Youth-vFINAL.pdf) I know that in my own patient panel, my patients exist with fewer mental health complications when they are accepted by their families and friends than when they are ostracized, though this is anecdotal. We as a society could unquestionably create a better environment if we chill out about stereotypes, although I think this issue is a bit larger than "sterotypes." Transgender and gender diverse people actually identify with a gender that does not fit the binary cis format. It doesn’t matter to gender diverse people if everyone else is worrying about ‘stereotypes,’ because they are trans/nonbinary apart from any stereotypes society holds about gender. So I guess I’ll round this out by saying that we all win when we stop discriminating against people who are gender diverse, or any group that is marginalized and faces oppression. Also, when we realize that gender diverse people are people, and are living their lives, going to the grocery store, and watching Netflix just like anyone else. Their gender identity is a small part of who they are.

  3. I guess it depends on how much biological sex actually informs gender identity and gender expression, which is complicated. In my experience working with gender diverse patients, it is not helpful to apply my own conception of gender expression/presentation to their lived experience. Even though one person sees the world through their own lens (say, binary, masculine versus feminine) that is definitely not universal. Everyone’s lived experience is valuable and it does patients a disservice to erase their experience with my own opinion of what their gender affirmation should look like. Patients spend so much time wrestling with their gender identity and expression before they ever set foot into my office, that I don’t really care what cultural norm they are trying to adhere to; I just want to know what goals they are trying to accomplish. If they want to ‘masculinize,’ I have the tools to do that. If they want to ‘feminize,' I can do that too. If they want to exist completely devoid of gender, I can put together a plan that helps them to accomplish that. We’re always working with or against biology to achieve our aims, but I do not see this as any different than treating, say, Diabetes or asthma, except the goals are more fluid.


Is there any research being done for permanent solutions to hormone therapy? For instance, removing the gonads reduces male hormones. Can that also be done in reverse by some kind of tissue transplant so that hormones adapt naturally?

bdd4

Hi - Julie here. Well, short answer is yes, there is lots of research being done on tissue transplant. However, this research is not necessarily being done for gender-affirming care or with the goal of fully supporting hormone replacement endogenously.
There has been testicular transplants and theoretically it would be possible for an ovary transplant, but this comes with extreme risk and expense. Uterine and penile transplants have also been done. Remember, organ donation and transfer requires the donor and recipient to be a perfect blood and tissue match, and there is still the very real and serious risk of rejection.
Even with that all possible, it is unclear if it is possible for the testicles or ovaries to be able to perform and produce hormone in a body that has gone through puberty of the opposite sex. The hypogonadal axis is basically the same, but stimulation of these organs after a transplant may be ver different or not possible. Unfortunately, I think that the medical risk and financial burden alone will be a major barrier in continuing active pursuit of this for many folks.


A college friend committed suicide after transitioning. I don't think transitioning caused his suicide--quite the opposite. He suffered from severe depression from the start, and the process of transitioning gave him a goal to work towards. After he had finished his transition, he was left with the original anxiety.

My question is: I wonder if sometimes gender based anxiety masks other forms of depression and anxiety. How do you tease those apart and make sure the person gets appropriate treatment?

asbruckman

Hi there - Julie here. I’m so sorry to hear about your friend.
You are right that often times mental health issues that trans or non-binary people face may be very closely related to their gender dysphoria or social stressors, BUT that mental illness may just be a separate co-morbidity that may get exacerbated by being transgender in a cis-/binary world.
The goal of seeking gender-affirming care with medical and/or mental health providers should not just be focused on treatment with cross-sex hormone therapy (CSHT), but also with an aim for the individual to address other aspects of transition — pressures and stress of social transition, family supports, and addressing other medical and mental health issues so that they are reasonably well controlled. Typically, if these other aspects of health are not addressed, hormones alone will not make for an easy or successful transition/affirmation process.
One of the things I feel most proud of at Fenway Health is that we have fully incorporated gender-affirming care into primary care so that we can take the time and have the resources on hand to address a patient a little more holistically. We follow the WPATH guidelines for initiating hormone therapy and by having an informed consent model. As one of the criteria for starting on hormone therapy, WPATH does recommend that “all medical and mental health issues be reasonably well controlled.” This does not mean that a patient’s mental health has to be perfect by any means, but rather as close to stable as possible and at THEIR baseline (what is reasonable for them). Also, part of informed consent is discussing not only the potential benefits and risks of hormone therapy, but also making sure the individual has realistic expectations of what hormone therapy can do. So often, individuals express that “if I just start on hormone therapy, [insert negative life experience] will get better.” By not addressing the limitations of hormone therapy (both physical, but also the societal challenges that may arise), a patient can be set up for failure or disappointment that was not expected and therefore may even be more intolerable. Though therapy is not required before initiation of hormone therapy, mental health counseling can be extremely beneficial in the exploration of someone’s gender identity, but also the source of distress, teasing out underlying mental health issues, and providing on-going support during mental and social transition. Certainly utilizing our behavioral health specialists out there can be invaluable for an individual trying to navigate the world through all of this. It is really important to remember that trans individuals are going to have mental health co-morbidities just as often as the general population. Just because someone is schizophrenic, bipolar, or suicidal does not mean they are not also trans and should not be considered for gender-affirming care, hormone therapy, or even surgery. It just means that the appropriate supports should be in place to best treat and affirm this person as a whole.


Hi, I'm am affirming pastor who has the full variety of the LGBT community who attend my small predominantly straight church. As a straight cis-gendered male my knowledge and understanding is progressively weakest in regard to intergendered, transgendered, non-binary, non-conforming, and gender fluid.

We have several gay youth who seem to be playing with gender fluidity as they are developing their identity (I'm using that in a more traditional sense of the process reverend good through as teenagers).

My first question is two part: 1. How can I help give them the safe space to go through this process? 2. How can I best advocate for them with their parents to intercept pre/mis-labeling them?

We also have a few young adult (20-30) trans-women who attend with their parents and siblings.

My second question is are their any books or other resources that you could recommend to me to help me advocate to the families or resources I can point the parents toward?

As you can imagine there was no part of my religious training that prepared me for this, so I need to find resources that can help rapidly bring me up to speed. Thank you in advance.

wallaceant

Hello! Cei here. Thank you for your question and for your willingness to learn and grow for your community! Question 1.a. If you are providing a space (a group, a confirmation class, a retreat, a bible study, a weekly potluck, a movie night, etc) for these young people to be themselves- to use they name they choose, to use the pronouns that fit for them, and to create norms where the other youth in the space must be respectful of these identities- then you are creating a safe space for the youth to go through the process of self-actualization in their identity. Ideally the church congregation would also be asked to affirm these youth in their identity. Depending on your comfort level, you could address the congregation and explain that you would like the church to be a sacred and safe space for all, and that in the interest of achieving this goal, you would ask them to respect names, pronouns, and gender expressions of all congregation members. b. One of the best ways to advocate for young people to their parents is to explain that the young person is happy, responding well, and thriving in environments where they are allowed to be themselves. If you have a young person who comes to your group/bible study/etc. who is using the name they choose, the pronouns that fit their identity, and is affirmed by the group around them and they are thriving, tell the young person's parents so. It may be that at home the parents see a kid who is struggling and sad and they are scared that being gender diverse will make things harder for their already unhappy child. To show that gender affirmation can radically improve a kid's quality of life is often the best motivator for parents to adopt affirming language.

  1. Here are links to a few resources that we've found helpful over the years: Trans Bodies, Trans Selves, The Transgender Teen, The Genderquest Workbook, Confi's Article on Gender, Families In TRANSition.

I hope this helps, and thanks again for advocating for the gender diverse people at your church!


I'm a 4th year medical student and although I haven't had a transgender patient, I'm sure the day will come. So, how do you recommend eliciting gender identity efficiently in a clinical setting, particularly in acute care or inpatient settings where you may have limited/no background on the patient? What aspects of gender history and identity are immediately pertinent?

TheRealNegrodamoose

Hi! Julie here. By the time you are a 4th year medical student, I bet you have seen a trans or gender non-conforming patient … you just probably didn’t know it! The risk of never asking about someone’s gender identity or sexual orientation is that you may be missing key aspects of this person’s health risks, not to mention missing them completely as a person, which will make it difficult to form a true doctor-patient trusting relationship. Asking about someone’s gender identity and sexual orientation is easy… just ask!! With all of my new patients, I always ask this question, even if in for a sore throat. There was a recent article in the NY Times, “We’ll Tell, Just Ask” (https://www.nytimes.com/2017/05/29/health/lgbt-patients-doctors.html?mcubz=0) , which reported that the vast majority of patients do not mind, and actually like, being asked their gender identity, AND this went for both LGBT individuals and those not identifying as LGBT.
Further more, the importance of asking sexual orientation/gender identity (SOGI) data is to bring a voice to this population. HRSA is now requiring that all federally qualified health centers record SOGI data on all patients, with the knowledge that if we are not asking, then this population will remain unseen. We cannot address gaps in care if we do not see a population and their needs. Therefore asking is SO important. And much easier than you can imagine. It might take a little practice and getting used to, but if you do it for all patients, it will become habit in no time. Examples of how to do it:
- Hey, by the way, how do you identify your gender? What pronouns do you use? - HI, I’m Julie. What name do you prefer? What pronouns do you use? - I ask all patients this at their physical every year, because I know that identities can shift and change. How do you identify your gender these days and what pronouns feel best?


Has there ever been an to attempt to treat gender dysphoria with a regimen of hormonal interventions that treat the brain as the source of the problem, i.e. supplementing the hormones that should be present to make the mental gender match the genitalia? Were those results uniformly negative?

The reason I ask is because I am female, would be diagnosed today as suffering from gender dysphoria, but back then it was just called tomboy and told I would grow out of it. The dysphoria became markedly better (not gone completely but better) when I started taking birth control pills, I was much more comfortable doing the girly stuff. So, therefore they were correct and I grew out of it, right? Except then I stopped taking OCP and now that I'm not taking extra doses of female hormones every day it's the same as before, but not bad enough to make me consider officially transitioning.

In short, if the goal is to make the outside and inside match do you ever work on the inside first to make it match the outside?

mrsmetalbeard

Hi there — Julie here.
There have actually been several studies looking at the “source of transgenderism” and essentially the question of “where is this coming from??” Unfortunately, so far, none of this has been conclusive. There does not seem to be one spot or structure in the brain that can predict transgenderism, and therefore target for therapy and care.
There was one study in 2011 showing significant differences between male and female brains in 4 separate regions, and interestingly, the brain structure of these regions in the transgender participants was found to be halfway between that of the cis-males and cis-females in the study. But, really, there is no evidence these these regions have anything in particular to do with gender, nor does this account for all transgender individuals OR anyone who does not identify on the gender binary. The question really is what is the benefit of this knowledge. Here we are talking about structures, not something that is “treatable” or that can be changed with medication. Some argue that having “proof” of gender variance could help to advocate for insurance coverage of treatment, or could be helping in supporting our youth to block puberty and transition at a younger age. However, the risk is to see this application and research as a method to cure someone from being transgender. Treating trans identities and experiences as pathological or wrong really goes against the vast amount of data we DO have.
We know that trans and gender diverse experiences are not a mental health or medical issue, but rather gender arises inherently within individuals, just as ALL people experience their gender. The poor health outcomes really come from the pressures of our society on this population and marginalization that has come with lack of understanding. We also know is that the best, most effective, treatment for gender dysphoria is gender-affirming medical and behavioral health care providing support through social and, for many, medical transition. Trying to change the way a person thinks or understands themselves has proven time and again to not only be ineffective, but also extremely dangerous and damaging.


Has there ever been an to attempt to treat gender dysphoria with a regimen of hormonal interventions that treat the brain as the source of the problem, i.e. supplementing the hormones that should be present to make the mental gender match the genitalia? Were those results uniformly negative?

The reason I ask is because I am female, would be diagnosed today as suffering from gender dysphoria, but back then it was just called tomboy and told I would grow out of it. The dysphoria became markedly better (not gone completely but better) when I started taking birth control pills, I was much more comfortable doing the girly stuff. So, therefore they were correct and I grew out of it, right? Except then I stopped taking OCP and now that I'm not taking extra doses of female hormones every day it's the same as before, but not bad enough to make me consider officially transitioning.

In short, if the goal is to make the outside and inside match do you ever work on the inside first to make it match the outside?

mrsmetalbeard

Hello! This is Cei.

It's challenging to figure out the "source" of gender dysphoria, and even to determine whether or not it is a problem. The American Psychiatric Association defines gender dysphoria as: "conflict between a person's physical or assigned gender and the gender with which he/she/they identify. People with gender dysphoria may be very uncomfortable with the gender they were assigned, sometimes described as being uncomfortable with their body (particularly developments during puberty) or being uncomfortable with the expected roles of their assigned gender."

This definition is pretty expansive, and in my experience people do/do not come to the realization that they need to transition for all kinds of reasons, and need to pursue transition in lots of different orders. For example, I know plenty of people who feel that they want to trial hormones to see if that helps them feel better. In many cases this is really not a terrible idea and can be clarifying. So long as patients understand the irreversible effects of such treatment, then it may be a viable option. In other cases patients want to know all the way to the deepest part of them that this is what is right before they start hormones. At the end of the day I don't generally see a lot of difference between the myriad approaches-- five years down the line people who have decided to transition, in whatever order, are usually at a similar place in terms of having succeeded in aligning their gender presentation and body with their gender identity.

We also take an approach that focuses more on what is causing a patient distress than trying to figure out "are you transgender or not?". So if someone has significant dysphoria about their chest but doesn't feel the need to have other masculine secondary sex characteristics, well, then we'd focus on helping that person align their body with their identity without supposing that they must make a declaration of a pre-defined gender. Gender is infinitely more complex than male and female, and figuring out what in particular is distressing can help answer a lot of questions.


How is research in the field progressing regarding comparative brain topography between transgender patients and their cisgendered counterparts? I remember reading about foundational studies, but I thought that there had to be more to the story.

Deauxnim

Hello! Cei here. There are constant progressions in this and other studies. A recent study and write up with several providers including Boston Medical Center's Joshua Safer, can be found here:http://www.medscape.com/viewarticle/840538_3 The basic observation has been that people who identify as women, whether trans or cis, demonstrate similar brain topography, and adjunctly, those who identify as men demonstrate similar brain topography regardless of being cis or trans. These studies came out of an ancient set of studies that were trying to show that gay men's brain topography would match that of cisgender women (it doesn't). Keep an eye out! Teams worldwide are working to continue research into gender diversity.


I have a question regarding President Trump's recent ban on transgenders serving in the military. Is it true that having transgender people in active duty would require additional logistics to accommodate their needs, in particular a constant supply of hormone treatments even after they have fully transitioned?

a12oxcart

Hello! Cei here. A friend of mine wrote an excellent response to the ban, and I will post it here as the best answer to this question:

"Here are some statistics on transgender people in the military:

Trans people are twice as likely as the general population to have served in the U.S. military- 20% of trans people vs. 10% of cis people

Trans and gender non-conforming people who served in the military experienced homelessness at an alarming rate (21%). This figure is almost three times higher than the general population lifetime rate of homelessness (7.4%).

Source: http://williamsinstitute.law.ucla.edu/…/Harrison-Quintana-H…

Though transgender people are more likely to serve than cisgender people, they are an extremely small percentage of the US military.

It is estimated as of 2014 that there are approximately 15,500 transgender individuals either serving on active duty or in the National Guard or Army Reserve forces within the U.S. Military (Gates G.J., Herman J.L., "Transgender Military Service in the United States," (2014) Williams Institute, UCLA School of Law). The projected active duty end strength in the armed forces for FY 2017 was 1,281,900 people, with an additional 801,200 people in the seven reserve components. This means that approximately 0.74% of the U.S. Military is comprised of transgender individuals.

The healthcare costs of trans people in the military are absolutely negligible given their small percentage of the population. Military spending on the F-35 fighter jet, on the other hand, is climbing over a trillion dollars: http://www.businessinsider.com/f-35-reliability-affordabili…

To try to make transgender people the scapegoats of high healthcare costs is absolutely absurd.

Pause and think for a minute on what "will not accept or allow Transgender individuals to serve in any capacity" means. Do you know how many different kinds of jobs there are in the US Military, including data and desk jobs?"

People who are transgender and using hormones will need to stay on those hormones for the rest of their lives. It is inaccurate that these prescriptions are any more expensive or onerous to offer than diabetes medication, sleep aids, anti-anxiety medication, or any other medication that is taken long-term or for the lifespan. Many service members have meds they take every day. Further, most people will have some kind of medical intervention in their lives. The cost of providing someone with affirming surgery is far lower than the cost of supporting that person in psychological distress if they are not able to transition. And in neither case is the cost any more or less than providing care to any other service member.


How has the rise of transgender celebrities and prominent transgender YouTubers affected your patients? Do role models actually matter or does having a community (online or in real life) have a greater impact?

shiruken

Hello! It's Cei!

I would say that the rise of transgender celebrities has absolutely affected my patients. YouTube and the ability to find other people online who are sharing the entirety of their transition in real-time is an unprecedented benefit for so many of my patients. For myself, I did not meet another transgender person until I was 21. Though I had been "living full time as my gender" since I was 12, I didn't even know how to tell people that was what I was doing until I was 17. Now I see 11 year olds and they know all kinds of very detailed words to explain their identities and are familiar with how they might go about better aligning their bodies with their gender identity. Simultaneously, I'm seeing a lot of patients who are thinking about gender as far more expansive than a traditional masculine and feminine model. I do think online role-models have helped these patients to more quickly identify what they need and seek out appropriate treatment.

I think role models matter enormously, and I would even go so far as to say that it is important for a community to have visible public representations of themselves in all areas, not just high celebrity. It can be clarifying to have someone in the world who identifies the same way you do, but who is very different, or with whom you disagree, so that you can articulate your own identity more clearly.

Having a community is also hugely important for a great many people. No matter how inclusive, nothing can compare to knowing other people who can empathize with your lived experience and share with you the unique challenges and joys of that experience. Especially for younger people who are starting to explore their identity, community can be critical.


Hello I'm a front line health care worker. I was wondering, post SRS do trans people risks for infections such as Urinary Tract Infections stay the same?? Another popular thing that I often hear but cannot find adequate information on is the claim that the new genitals constructed function identically to the biological ones. Lastly, I find it hard to wrap my head around three notion of removing or re-constructing healthy tissue, is this simply another method of harm reduction?? Thank you

BrownKhalessi

Hi there, Alexis Drutchas here, I am a Family Physician at Fenway Health. There is limited data on post-operative UTI risk for both transfeminine and transmasculine surgery. As in any surgery, the risk of UTI depends on the type of surgery and any post-operative complications. For transmen who have had phalloplasty, there can be an increased risk of UTI due to catheter use, instrumentation during surgery, if urethral elongation was done, bladder retention, and if there are any post-operative complications such as stenosis or stricture. For transwomen who have undergone vaginoplasty this occurs with urethral shortening and thus can increase UTI risk. As above this also depends on any post-operative issues such as prolonged use of catheterization, bladder retention, strictures, etc. It is important to counsel your patients on hygiene and hydration. Colonization after surgery is possible as well, so it is important to check a urine culture if any symptoms are reported.


What are some of the unique challenges facing transgender patients in a primary care setting?

kerovon

Hi there! Cei here.

One of the biggest challenges for gender diverse patients in a primary care setting is having equal access and equal affirmation. Often a clinic will have providers who are happy to serve the transgender community, but what about the front desk staff? Are there ways for all staff members to know the name this patient uses? When called in the waiting room, will the patient be assured that their correct name is called? In the office visit, many transgender patients in primary care receive substandard care because the provider is unsure of how to broach the topic of gender identity. We advise a very direct and honest approach. Ask someone how they identify. Ask them what words they would like to use to describe their body. When asking about screening and testing, take an anatomical inventory and use the words that the patient uses for their own organs. The most ideal structure has these questions being asked of every patient. It's a lot less work than it sounds!

Another challenge in primary care is the "transgender specific program" of care, which, in it's ideal form, is integrated into primary care, and in it's more destructive forms, isolates and singles out gender diverse individuals from the rest of the patient population. An example would be an office that seeks to be trans inclusive, and so makes a three page transgender intake form that they only give to patients they "think" are transgender, causing multiple negative outcomes: the patient is singled out and has more work to do than other patients to receive care, it is up to someone else to "decide" who is transgender who walks in the door, it can be outing for the person filling out the paperwork, and it may obfuscate the reason why the person is in the primary care clinic. We advise asking all patients about their gender identity and sexual orientation (and, in fact, if you are a federally funded health center, you are now required to do so), and then to be open, honest, and willing to listen in visits.


Hey, I just want to say Fenway Health Center turned my life around. I am a transman, who transitioned with medical help from the Fenway health center. You guys do wonderful work and helped me to overcome a lot of self doubt, self hatred, depression and anxiety. I have since moved farther away from Boston so I no longer am a patient at Fenway, but I was able to find a PCP close to me who was a former member of your team. I feel so fortunate to have a medical team that understands my needs and issues and I weep for those in other parts of our country that are denied access to the care they need.

Because I must ask a question... What's your favorite sandwich?

Voteforcondit

Hi! This is Cei.

Thank you for your kind words. It means a lot to us to hear that we were able to support you in your journey. If you ever have other questions or move again and are looking for providers, don't hesitate to reach out!

My favorite sandwich is roast beef on toasted thick seedy bread with whole-grain mustard, sharp-sharp cheddar cheese, arugula, and mayo. :)


When a person says they feel like they should be the opposite gender, how do we differentiate between feeling like they should actually be in a different biological body and simply desiring to do things we associate with the opposite gender?

Edited for wording.

vatreehugger

Hello! Cei here.

I think that the distinction here is more about the person receiving the information than about the gender diverse person themselves. Why should it matter whether they feel like they want to be in a different body or if they want to do things that are gender atypical for their assigned sex at birth? Gender is a social construct that relates to physicality, and all people who are gender diverse have slightly different experiences. For some trans people, their bodies do not make them feel dysphoric, but it is important for them to be perceived by society as their gender identity. For others, it is less important that they are "read" as their gender identity than that they are able to better align their physicality with their gender identity. For most people it is a combination of the two. It is impossible to completely disentangle the behaviors we have assigned to specific genders and the ways in which people choose to perform their gender in society because of their internal identity.

It may be helpful to think of gender more of a myriad collection of infinitely variable elements, rather than a binary with fixed physiological and social expressions on opposite ends.


My question is towards both transgender individuals and the doctors here.

How do you "know" you're transgender? The thing I will likely never understand, because I don't feel it, is how can you know you are one way before actually being that way??

It's different with gays - they have an attraction towards same sex. They already are what they claim to be. But claiming to be something that you are currently not? Surely there must be some false positives, and then what? Is there a way to go back?

And just as a side note to prevent the triggering of overly defensive individuals : I have no discriminating thoughts towards what I don't understand. Just a lack of understanding.

Miseryy

Hi! Cei here.

There is no way to "know" you are transgender, other than through self-exploration and introspection, and likely social exposure that can give you words and frameworks to contextualize and explain how you feel. I am of the opinion that people are probably transgender for more than just one reason. Perhaps there is a genetic code that results in some people being transgender. Perhaps there are several. Perhaps someone feels that their sense of social identity is most appropriately affirmed by being transgender, though their understanding of their own gender may be far more complex. It's a somewhat controversial statement, but I personally don't think it matters if there is one or dozens of reasons why people are transgender.

To tie-in to your comparison to sexuality, two things: one, it is offensive to refer to gay people as "gays". People who are gay are not exclusively their identity. They are people with a sexuality and that sexuality is sometimes called "gay". Two, I actually think the process gay people and transgender people have to go through to understand their sexuality and gender identity is similar. In both cases the challenge comes not inherently from having a gay or transgender identity, but because society does not affirm, support, or provide models of, those identities. For this reason, identity formation becomes a matter of introspection, social discovery, and often the seeking out of affinity groups that can help make sense of the way someone feels their identity is perceived by society. Transgender people are not claiming to be something they are currently not. They are claiming to be exactly who they are, and are asking for resources that will allow them to be themselves in a world that is largely intolerant of difference.

Regarding "false positives", I think it's important to acknowledge both that there are few people who transition who seek to transition back. I am not here to say that people who de-transition are wrong. Their story is their own. But I will say that in over a decade working with the community, I have never met someone who regretted transition or who wanted to de-transition, even if their lives had been extremely hard. In terms of "false positives", that implies that someone else is making a judgement about whether or not a person is trans, and no one can make this determination except the person themselves. In very rare cases certain psychological disorders can present with symptoms of gender dysphoria. In cases with individuals with complex psychological conditions, we work very closely in an integrated team of medical and behavioral health providers to ensure that a) we are addressing the psychosis and b) that we are not assuming that just because someone is psychotic, they cannot also be transgender and deserving of gender affirming medical treatment. An excellent article on this EXTREMELY RARE situation, by our own Dr. Alex Keuroghlian, can be found here: https://www.ncbi.nlm.nih.gov/pubmed/27824636

As for whether or not someone who wishes to de-transition can "go back", that depends on which of the permanent effects or surgical interventions they have experienced if they have chosen to go through medical gender affirmation. Hormone therapy has both reversible and irreversible effects. Surgery is typically permanent, and revision or reversal is not covered by insurance.

In sum, trust that people will know who they are. We are all different and part of what makes us a robust community is sharing our identities across groups without judgement or fear. Almost no transgender people are wrong when they decide to come out, though gender, like most aspects of identity, is something that fluctuates and changes over time. People may come to different understandings of their gender, but rarely do people transition and then want to de-transition.


I am a closeted trans person, and just turned 32. I have a (very very long) post about my history here for anyone that is interested.

I have 2 questions, but the first is the one I really hope you might answer.

  1. I have never touched hormones, which I feel would make me a great candidate for studies. Is there anywhere I can volunteer to get an MRI scan to see what extent if any my brain may have more in common with a genetic females? This would give me a lot of peace of mind.

  2. Can you give any insight on the extent to which neo-vaginas can self-lubricate, and to what extent the body treats them as a wound? This is a major hangup for me going further and transitioning.

Zurlly

Hello! Cei here.

  1. I do not know of a study currently ongoing. Here are a couple places you can keep an eye out for clinical trials for which you feel you may be a good fit: https://clinicaltrials.gov/ct2/search/index https://www.nih.gov/health-information/nih-clinical-research-trials-you/finding-clinical-trial You can also reach out to the Boston Medical Center for Transgender Medicine and Surgery, which may have an interest in supporting such an investigation, though few medical institutions will work with a single patient for a study. The number for BMC is 617-618-1833.

  2. There are two main methods for constructing a neo-vagina: the first is penile inversion, where the skin and tissues of the penis are inverted into a created abdominal cavity to create a vagina. Scrotal tissue is used to create labia and the glans is used to create the clitoris. This method is more and more preferred worldwide because it produces a good aesthetic result and has far fewer complications than the other method which is: the colon-section vaginoplasty. In this procedure a portion of colon is removed and used to line the created abdominal cavity, and the clitoris and labia are created in the same fashion as the penile inversion technique.

The trouble with option a: penile inversion: is that the vagina does not self-lubricate. Most women find that they have satisfying sexual intercourse using their vagina with the aid of lubricant, which I personally would highly recommend to anyone and everyone regardless of their natal organs and what kind of sex they're having. Extra lube makes everything better. The trouble with option b: colon section vaginoplasty: is that the vagina is ALWAYS lubricating. just as your intestinal tract is always producing mucus, so too will a section of colon constructed into a neovagina. This comes with its own set of challenges, as you can imagine. Further, a neovagina constructed from colon is far more fragile than one made using penile inversion, and penetrative intercourse can be challenging because of the delicacy of the tissue.

At the end of the day there are tradeoffs to each surgery, and you'll have to decide what is your biggest priority. There are excellent surgeons who do each of the procedures, but it can be challenging to get in and get insurance coverage.


What in your opinion, is to blame for the high suicide rate amongst transsexual patients? The last statistic I saw was around 50%.

dragons5

Hi there - Julie responding. The high rates of suicide among this population are more than alarming and unfortunately due to many overlapping factors — transphobia and discrimination leading to high rates of abuse and violence, underemployment and homelessness, financial difficulties, lack of insurance and access to health care.
And most disturbingly, the highest rates of suicides attempts, by far, are occurring in the population who is 13yo and younger. 92% of trans individuals who reported attempting suicide did so by the age of 25. This means we are not listening to our children and supporting our youth through a time when they need adult guidance and love. For a comprehensive look at the experiences of trans people across the United States, please check out the 2015 US Trans Survey. This report heard from 2700 trans individuals from across the country — all 50 states — and reported their experiences with employment, housing, health care, with police and incarceration, mental health, and substance use. It is very, very important to understand the vulnerabilities and disparities in a population to be able to do work on the other side to help raise this population up and care for the community.


For a future med student who wants to help transgender kids transition, what are things I can be doing now to get there in the future? Thank you for all you do.. my transgender friend used your services

DarklingThrush4

Hello! Cei responding here.

I would focus both on understanding cross-sex hormone therapy and puberty blockers. If you have a chance, take a residency somewhere like Fenway, Whitman Walker, Children's Hospital of LA, Callen-Lorde, or any of the many other clinics who will be offering these services soon. I would say there is no substitute for an immersive experience in a clinic with experienced providers.

As of right now, such residencies are few and far between. Another way you could pursue your interest is to advocate at your medical school for there to be more such opportunities made available.

Other things to do: attend a WPATH or USPATH conference and focus on the pediatric/adolescent track. The conference can be costly, but you may be able to make a case for school funding it. Contact Dr. Johanna Olson-Kennedy at Children's Hospital in LA and just listen to everything that comes out of her mouth. Attend the Philadelphia Transgender Health Conference (coming up in September!)- this conference is much more community oriented and there are a million things you could immerse yourself in and lots of people to talk to about your future ambition!


How do you feel about prominent Scientists and Dr’s still believing ‘Trans’ is a mental illness? Is it still up for debate?

For instance despite pioneering Gender Reassignment Surgery the John Hopkins Institute stopped performing it decades ago.

This article spells out their argument:- http://www.thepublicdiscourse.com/2015/06/15145/

DrDarkMD

Hi there, Alexis Drutchas, MD here from Fenway. I appreciate your question. in 2013 "gender Identity disorder" was taken out of the DSM-5 and replaced with gender dysphoria. I think this signaled a large shift in our country and in the medical community. Overall I think the medical community has greatly moved away from feeling that "transgender" is a mental illness, and instead viewing that gender dysphoria is something that can and should be treated. As a few point out below, I also think many more medical centers are increasing their access to transgender care. The Huffington Post, while not medical, did publish an article in 2013 about this shift in the DSM5, and I think it has some valid points that might be helpful in this discussion. http://www.huffingtonpost.com/2013/06/04/gender-dysphoria-dsm-5_n_3385287.html


What are the main challenges and differences of female-to-male in regards to genital appearance and function? I realise it's much simpler to take away than to rebuild i.e.: male to female, so surely this process is largely ineffectual, or am I wrong?

Hardcore90skid

Hello! Cei answering here.

Masculinizing genital surgeries can be more complex for all the reasons you cited. That being said, the surgeries are improving all the time, and for most guys who choose to have these surgeries, they are satisfied with their results.

One of the hardest parts of the surgery is actually maintaining reasonable expectations. These surgeries are complex. They often include microsurgery and are comprised of multiple stages. It can take a good couple of years to get to a place where all the procedures are done, especially in the case of phalloplasty. Re-enervation and sensation can take even longer to return.

The surgeries are actually highly effectual, though. They require patience, diligence, and persistence, but they can be very fulfilling and effective for those who choose them. For people who choose metoidioplasty, they generally retain excellent sensation and have a satisfying appearance of a natural-looking small penis. In the case of those who choose phalloplasty, the final result is a larger phallus capable of penetrative intercourse that is generally outfitted with an erectile prosthesis of some kind. After the healing process many people who choose this procedure have good sensation.

There are still many challenges for both feminizing and masculinizing genital surgeries, and happily many surgeons are working on advancing the field and improving techniques all the time.


I have a pretty basic question. Are transgenders biologically different than what we associate with a male or a female? If yes, how much and in what ways? If not, what makes them different.

cdhawan4314

Hello! It's Cei.

Two things: First, it is offensive to refer to people as "transgenders". People can be transgender. Some people have a transgender identity. But their personhood is not subsumed by their transgender identity. An appropriate way to phrase the question might be "Do transgender people have different biological characteristics than the characteristics seen in individuals whose gender identity matches their sex assigned at birth?"

In brief, the answer is we don't know. There has been a lot of recent research that has shown a variety of possible ways in which transgender identity is biologically linked. For example, Dr. Joshua Safer at Boston Medical Center has shown that the brain of a transgender woman has the same pattern as a cisgender woman, and the same for transgender men: http://www.medscape.com/viewarticle/840538_3 However, it's highly likely that there are many different reasons for gender diversity, and that biological difference may be only one of them. Further, there is dramatic biological diversity within people who identify their gender as being the same as the sex they were assigned at birth. People have wild ranges of endogenous hormones. People's phenotypic expression is almost infinitely variable. So it is challenging to say whether transgender people are biologically highly variant from their cisgender peers.


A lot of trans people avoid medical care, because outside of dedicated community health centers like Fenway it can be very hard to find medical providers who are willing and able to provide competent care. Not just transition related care either, so many doctors either assume that every health issue a trans patient has is due to being trans ("trans broken arm syndrome"), or outright refuse to treat trans patients at all.

What can be done to change this? Are medical schools starting to cover the medical needs of trans patients at all?

tgjer

Hey! It's Cei.

I think what we're doing right here is certainly one of the things that can be done. Talk widely. Disseminate information. Get at the meat of people's questions in a safe space.

Many medical schools (at least in the Boston area) are starting to wake up to their lack of LGB, not to mention T education throughout their curriculum. Many schools are working hard to eliminate this gap-- some are offering electives in LGBTQ medicine (we are happy to host HMS students at Fenway as part of such an elective), and other schools are bringing in educators (like myself) to workshop, train, and educate their staff. Other schools are working on multi part solutions including MOOCs, training modules, and rotations.

Keep bringing it up! The more it is demanded, the more likely it is to happen on a grander scale!


[deleted]

[deleted]

Transgender people are neither inherently "distracting" because of their gender identity and/or transition, nor is their healthcare burdensome compared to any other service member. https://pbs.twimg.com/media/DFqqfbDVwAEVzmx.jpg


I have seen studies that there are a lot more people transitioning from MtF than FtM. Can you confirm this and if so what do you think is the reason for it? Do you think if society became more accepting of men expressing themselves outside of their gender norm the number of people who want to transition would go down drastically?

doryby

Hello! This is Cei.

We were just discussing our Q2 numbers yesterday, and we really do have a pretty even split. Different places have slightly different proportions-- it varies widely and changes all the time.

I do think there is some validity to the idea of masculinity being more acceptable to perform than femininity in terms of cross-gender expression, but at least on the clinical side, we're seeing ~ 1/3 masculine, ~1/3 feminine, and ~1/3 who identify as non-binary (agender, NB, genderqueer, masculine of center, feminine of center, demiboys, demigirls, nutrois...).


Are transgender people just intersex without knowing it? I know you can have an X and a Y sex chromosomes thus being genetically male, but being insensitive to androgens and therefore have female anatomy. I also know there are a few other ways you can be genetically male or female and physically the opposite.

saareadaar

Hello! This is Cei.

While some transgender people identify as intersex, or discover that they are intersex later on, it's actually not all that common. The vast majority of our patients are (to our knowledge) not intersex, and most intersex conditions present with genotypic or phenotypic signs. That said, there are certainly intersex conditions that exist only on the chromosomal level, and if someone has no impetus to get chromosome testing done, they probably won't. So it could be that more people are intersex than we know, but that still doesn't mean that those people will identify as transgender. There is a robust intersex community, and intersex people may choose to identify as intersex or as the gender in which they were raised.

In your specific example-- being insensitive to androgens and having female appearing anatomy-- there is a very famous example of this being true for an olympic runner without her knowledge. When she found out that she was intersex, she advocated for the restoration of her awards on the basis that androgen insensitivity was, if anything, a detriment to performance, and has identified as female her entire life. She is an woman who has an intersex condition-- in no way transgender. She also came of age in a country (Brazil, I believe) and a time when she wouldn't necessarily have had the medical care needed to find the androgen insensitivity. For most babies born in the United States, such conditions would likely be found early on.


Is there any validity to the argument that medical expenses are costing the military a lot? On the surface the argument makes some sense, but I get the feeling that it's a load of crap and would appreciate a professional being able to clarify for me.

eryant

Hey there! This is Cei. I've provided the link to the RAND study in an above answer. You're feeling is correct- it is a load of crap.


What advances have been made in FTM surgery recently, especially phalloplasty? Is the inflation method still widely used? While I'm not trans myself, I am curious as to how the procedures work.

-dorian-gray-

Hello! This is Cei.

A lot of advances have been made in phalloplasty, and continue to be made. A big change is that most surgeons performing the procedure now acknowledge it as a microsurgery procedure, and for this reason many microsurgeons are now looking at being trained to do this work. Hand surgeons are particularly good at it, since they are used to reconnecting very small vasculature and nerves. Different types of phalloplasty (radial forearm, pedical flap, abdominal flap) all have upsides and downsides. I've found that managing expectations is actually one of the biggest components influencing whether or not people are satisfied with their surgery. If a person expects everything to be done and for them to feel all better and to have full sensation in only a couple months, they will probably feel that the surgery was ineffective. These are multi stage procedures and it is not unusual for the process to take two years. It also takes a long time for nerves to regrow. People may believe they've lost sensation when in reality it will come back, and in most cases be very satisfying. It is still the norm to assume a pretty high risk of fistula, stricture, or other complication with phalloplasty. In general these issues resolve on their own and surgeons are better and better at fixing them.

Metoidioplasty is also always improving, with surgeons getting better at creating aesthetic results, adding girth to the phallus, and improving urethral lengthening procedures. Another great feature of metoidioplasty is that for most of the kinds people would have, it still leaves the possibility of phalloplasty later, if that is what the person feels they need.

As for the inflation method, if you're talking about the inflating erectile prosthesis, then yes, this is still a very common choice for phalloplasty. Most people have good results and are satisfied with this method. Flexible rod erectile devices are also used, but have a slightly higher likelihood of needing to be replaced or slowly rejecting from the tissue and poking out.

Overall, I think we have seen incredible advances in all gender affirming surgeries in the past five years, and I think the next five are going to be extraordinary.


Do you agree with Joshua Safer, from Monday's AMA, that there is data that determines gender identity as biological and not psychological?

bowloftea

Hello! This is Cei.

I agree in part with Dr. Safer. I do think that there are biological markers showing us that gender identity may have biological underpinnings. The brain studies certainly make a compelling case. I absolutely believe that this is likely the truth for some transgender people.

I do not believe that all gender diverse people have a biological underpinning that explains their identity. I feel that there are likely many reasons why people are transgender, and I fear the idea of a biological "test" that would dictate whether or not someone is transgender. It may cut off access to resources for people who are absolutely legitimately gender diverse but who do not have the markers that were decided needed to be present to confirm their identity.

Gender dysphoria is what we are treating with medicine. The distress that comes from the misalignment of gender identity and sex assigned at birth. Gender diversity, transgender identity, intersex identity, genderqueer identity... these are all diverse human identities and it is no more appropriate for medicine to dictate membership in such communities than it would be for medicine to dictate membership in a religious group, racial identity, or linguistic identity.


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