Transgender and Gender Diverse Care

Announcer

Welcome to the Academy Exchange, HIV Today and tomorrow. In this podcast, we discuss the latest advances in HIV prevention care and treatment, as well as examine the societal and systemic issues facing people with HIV. Thank you for joining us.

Bruce

Hello and welcome back to our listeners. My name is Bruce Packett and I am the host, along with my organization, the American Academy of HIV Medicine, of this podcast called the Academy Exchange: HIV Today and Tomorrow, where we want to talk broadly to listeners everywhere about the clinical and social aspects of HIV and what's coming down the pike.

We have a really important and interesting conversation today. I'm really excited because I have with me Dr. Michelle Collins Ogle, who is the sitting vice chair of the Academy's board of directors. But that's certainly far from her most important position. 

Dr. Michelle Collins Ogle is a pediatric infectious disease specialist who has spent her career providing comprehensive care for infants and young adults living with HIV. She is currently the medical director of the Montefiore Adolescent and Youth Sexual Health Clinic in the Bronx, New York. She is associate professor of pediatrics and faculty at Einstein College of Medicine in New York.

And what we'll be discussing with Dr. Ogle today is gender affirming care, what it is, what it isn't, and why it's a critical linchpin to ending the HIV epidemic in the US.

Dr. Ogle, thanks so much for being here. And I'm really looking forward to talking with you about all the great work you do in your practice with youth and adolescents.

Dr. Ogle

Thank you. For us, it's nice to have this conversation with you.

Bruce

Absolutely. Now, I want to start with a sort of disclaimer, because somehow in some unfortunate turn of political events, individuals, lives and decisions about themselves right down to their most intimate, subjective expressions like gender have become really painfully divisive political fodder. And we're going to do our best today here to absolutely avoid the politicization of gender expression, gender diversity, and transgender people generally.

We will approach this topic, we hope, with as much deference, care and humanistic attitudes as we can, in part because I identify personally as a cis-man, he/him pronouns, but also because we need to understand from a clinical perspective how to provide compassionate and affirming care for this very stigmatized population. And of course, each of them with different stories, feelings, expressions, traumas, and on and on.

Again, we won't approach this conversation as some kind of political debate. This is about human beings and also about public health and we will very much frame this topic around health outcomes. All right, Dr. Ogle, let's get into it. 

There's a well-known gender non-conforming American writer named Alok Vaid-Menon who wrote that the gender binary exists to create division and conflict, not to celebrate creativity and diversity.

So just to kind of grease the wheels for our chat today and just sort of reflecting on this quote, I thought I'd start by asking you what you think of the stigma. Do you agree with it? And how does this gender binary they're referring to have an impact on a person's health and then also on the public’s health?

Dr. Ogle

Great. That's a wonderful question for asking. And I think it would really be helpful for our audience to know a little bit about Alok. So, Alok, is their gender non-conforming name. It's a non-binary name. And Alok is a very young like entertainer, activist, poet, who is gender non-conforming and who embraces their feminine side. They also refer to themselves as trans-feminine.

This is a very popular person, and I totally agree with that statement. That gender binary system is set up to say that this is the only way our system works. There's a he and a she and there's nothing in between, and there are no other ways to identify people. And that does create divisiveness within our society. It does affect individual at the health care level and also our society.

So if I tell people who are gender non-conforming or may see themselves as gender fluid, that you don't matter, that you have to fit into a box, you're either woman or man or girl or boy. Of course, that impacts them mentally and socially, right? And in terms of our, you know, our social wellbeing, we're also creating a system that is oppressive to people who don't see themselves as binary.

And so in this context, I totally agree with them, Alok, and I really admire the way that they address this head on.

Bruce

Yeah, it's a great it's a great quote. And I think it's really important to make sure that we're clearly defining all of our key terms for our listeners, Some listeners who may not be as familiar with this population. Maybe as straightforwardly as you can put it, what is transgender and to what individuals would that term apply? And then and then what about gender diverse or gender diversity is another phrase that is commonly used.

Dr. Ogle

Great. That's another good question, because we throw those terms around and everyone doesn't necessarily know what they technically mean. So before we define transgender list about define cisgender. So cisgender individuals are people who identify with the sex or the gender that they were assigned at birth. So, for example, Bruce, I'm like you. I'm female. She/her. I identify with the gender sex that I was assigned at birth.

Transgender individuals are those who are assigned a certain gender or sex at birth, but they do not identify with that gender or with that sex that was assigned to them. The people who are more gender diverse and gender fluid are those who sort of embrace their feminine and masculine side and don't necessarily want to be constricted or put into a box in terms of how they see themselves or how they identify.

And people who are of trans experience or transgender individuals often, they're not in just one space. They are often gender diverse and express their feminine and masculine sides and at the same time as well.

Bruce

Right. Absolutely. Thanks for that really succinct definition or series of definitions. And I also want to define another phrase and try to connect this conversation to health care. There's a phrase being broadly discussed and I would say even cynically debated in popular and political culture in this space of transgender, gender diverse individuals, as it applies to the health care arena. And that is this phrase gender affirming care.

And I'm really hoping that today you can help us clear up any mythology around this term. What is your understanding of what gender affirming care is in the clinic? And specifically, how do you provide it? And maybe you can use that question to just kind of talk about a day in the life that Dr. Ogle’s clinic.

Dr. Ogle

Thank you for that question. Gender affirming care is actually a better way to define what it is we provide for our patients who are of trans or gender non-conforming experience. Let's start with what gender affirming care is not. 

It is not anyone who walks in the door having hormones shoved at you or  told that you need to have hormones in order to live in the body that you want to live in, or live how you see yourself. So it is not hormone therapy. It is not anyone telling people that this is the way you can live in the body or in the way you identify.

So gender affirming care is a term that I like to use and I'd like for everyone to use, which basically means that we affirm the person that's in front of me. I affirm who you are, how you identify yourself. And my job as a health care provider is to make sure that I help you live your best life in the way that you identify. That does not always equate to using hormones. So when people say they want to limit gender affirming care or transgender care or have some idea about what it is we do, they don't understand that a lot of what we do is not built around hormone therapy.

There are at least three or four main pillars that we associate with gender affirming care, and one is social. So I have young people that come in that have socially transitioned, which means they have a preferred name that they like to use. They have preferred pronouns that they like, and also a way that they might want to dress that does not conform, again, to the gender that they were assigned at birth.

Also, there's a behavioral aspect to gender affirming care we provide that we provide a way for people to kind of talk through this journey so that they have an understanding themselves of what it is they're experiencing and this gender that they were assigned at birth, but in a way that they don't see themselves or want others to see them.

And then there's the medical piece to gender affirming care, which we talked about a bit here, and that's hormone therapy for those people who want to physically appear and physically be the person that they identify with and how they want others to see them, which is extremely important. So a hormone therapy is a component of that as well.

So those are the main pillars that you use when you're talking about gender affirming care. It's very comprehensive. And so that's how I approach this discipline and my practice every day. When people come in our door. The first thing that's asked of them at the front desk is what is their preferred name and what are their pronouns?

That in itself puts people in a comfort zone where they know they're affirmed. And then we proceed to talk about how they came to this decision how they appear and how other people see them as incongruent with who they really are. And then from there we decide based on what their goals are and what they tell me they want and what they need. Then we talk about the best way for those things to happen, right?

Bruce

So important and you kind of covered this, but I did want to bring up SOGIE. It's an acronym that many people working in health care are probably familiar with. But for our listeners, it's maybe their first time hearing it. SOGIE stands for Sexual Orientation, Gender Identity and Expression. And we really know that sexual orientation and gender are often conflated, but they aren't the same thing.

And again, I think you kind of covered this, but why is it important for health care providers to understand this information about their clients or patients? And then what other sort of common misconceptions do providers need to overcome in caring for this community?

Dr. Ogel

That's an excellent question, and that's why I'm also glad we're having this conversation. So it's really important. And when I'm educating fellows and residents and other providers that I work with on this subject is to understand that gender identity is not your sexual orientation or has anything to do with sexuality. Your gender identity, again, is how you see yourself and how you want others to see you.

And their sexuality is maybe who you're attracted to or what people or what types of people that you're attracted to in a physical sense. Those are two different things. And one of the things I think that's conflated and I think we need to do a better job of understanding is that, again, in this non-binary space that we're talking about because people are it transgender woman or transgender man, does not mean that they're attracted to people that are of the opposite gender. So transgender women don't necessarily identify by their sexuality as being attracted to cisgender men. 

Some transgender women also are attracted to cis-women, trans-women or men who have sex with men and all of those in between and gender diverse people. 

I would say right now, in my younger population, about a third of the people that I provide care for identify their sexuality as pansexual. And I find young people now are just not having it. They don't want to be put into this box that they have to be attracted to a certain gender or a certain kind of person. And sort of like, I like who I like. And it doesn't matter like what I like. I like who I like. If they're kind to me, I like them or I have attraction towards them. 

And I think we need to do a better job of that. And why is that important? It's important because it helps me have conversations with my patients about how to keep you safe, how to protect you from sexually transmitted infections, how to decrease your risk for HIV and other sexually transmitted diseases.

It also helps me have a conversation with them about sexuality, what it is, and make them feel comfortable in that space. So in that context with we talk about sex education in the schools is heteronormative, right? It's boys and girls. It's talking about pregnancies and heterosexual sex. And that's not the case for many of the students in this space.

So I think as providers, we have to provide that space to have that conversation so that, for example, young gay men who I provide care for, sometimes they're conversations with me are about being attracted to other men who are anal receptive, or bottoms, and they’re bottoms. So being able to identify a person's sexuality and who they are attracted to allows you to have a safe conversation in a safe, non-judgmental space where you can also provide appropriate information to keep them safe and to also make sure that they have a decreased risk for sexually transmitted infections.

Bruce

Yeah, it really all completely underscores how important gender affirming care is. And I'm really interested in one sort of outer aspects of the political conversations, which is, what is it that providers could do to provide gender affirming care in those parts of the country that are desperately trying to basically completely out all the practice of providing gender affirming care, especially to youth.

Dr. Ogle

It's a very important and timely topic. And I feel in these United States that your care should not be based on where you live in this country. And so if you live in certain states, you get a different level of care than if you live in other states. And so what people can do, if we go back to what I defined as gender affirming care, it does not necessarily mean hormones and it doesn't necessarily mean hormones for a lot of these young people.

Sometimes young people want to just have some affirmation that they're okay in the space that they're in and that they're okay being a transgender kid or a gender nonconforming kid. So we go back to that social piece.

So, for example, transgender boys, speaking with the parents about letting them cut their hair short, not wearing makeup or not having your eyebrows contoured, wearing gender non-conforming clothes, allowing them to use the pronouns that they're comfortable with and a preferred name.

And there are also states that are trying to put restrictions around that as well. But at this point, that is something that we can definitely help parents with and also kids. That while providing hormones or puberty blockers may have some restrictions in these states, you can certainly, from a social aspect, allow them to live in the body that they want to live in.

The other pillar that I talked about is behavioral, some providing counseling, some therapy, a way for young people and families to talk through what this means for them, how they can experience their gender identity in a way that does not put their families and themselves at legal risk.

Bruce

Absolutely. All really important information. I want to kind of get into the history of the movement and the history of transgender people in the United States and how we got to where we are through the historical context, how transgender health care got to where it is today in the U.S. And I'm hoping you could share a little bit. I know you're a history buff, too, about Harry Benjamin. Who was he? What did he do? How did he inform modern American understanding of transgender health?

Dr. Ogle

Great. I love history. I think it's important for us to understand how we got here. We need to understand where we came from. And I think it's really important for our audience to understand that contrary to what a lot of people say, being a person of trans experience, it's not new. It didn't just crop up a few years ago. It just didn't crop up ten or twenty years ago. 

Being a person, what we now call of trans experience, is as old as civilization itself. But we didn't have terms to divide people into a binary way. So one of my favorite things I like to bring up or points I like to bring across in a historical perspective is for people to understand thousands of years ago as a civilization, there were people that were not put into a woman or a male perspective.

Our Native Americans, the original Americans, the people who originally inhabited this country have celebrated gender diversity, the way we term it, forever. And people who understand two-spirits, two-spirit concept, in our native culture, two-spirit people were celebrated. And two-spirit people were people that had a feminine spirit and a masculine spirit.

And if you read about two-spirit individuals from a historical perspective, they were celebrated. And these were people who are often the people within their communities who were looked up to and also, again, celebrated and really welcomed into the community. So they may dress or appear physically as a more feminine person, but biologically they were men. So these two-spirit, individuals, that type of celebration, was done through cultures throughout the world.

It wasn't until Western civilization and namely White men, White heterosexual men, decided that they would reeducate various cultures on what it means to be a man and what it means to be a woman. And it wasn't until White civilization or the colonization of a lot of different cultures, particularly in the United States. It wasn't until colonization that we really started having this term cisgender, transgender, or people who were called, you know, sissies if they were boys that were a little feminine or girls that were more masculine, referred to as tomboys or boyish. That is a Western civilization term that was created, created to have a binary system that had people who were in a hierarchal way oppressed and those who are oppressors. So I'm now telling you what the definition of a man is, doesn't matter what your culture has said for centuries, I am now telling you what the definition of a man is and how you should behave as a man.

Out from that has come to this place where we are now and what it means to be masculine or male and what it means to be feminine or female.

In the midst of all this, in the early 1900s, there was a man, Harry Benjamin, that you brought up who was a German born American in the late, late 1800s. And so remember, he was German born. So in Germany, he sort of became fascinated with this whole concept. Now, Harry Benjamin was a physician, an endocrinologist who at that time also was referred to as a sexologist, but not in the terms that we think about sex. It was more of like hormones, sex hormones. What made a person who was biologically female appear masculine to want to identify more masculine or vice versa. So he was one of the early pioneers as an endocrinologist and to understanding what we've now termed as transgender individuals. 

And he celebrated it. He thought that this was very normal, that this is something that we should make happen in society and really did a lot of his work in that. When he came to the United States, he continued this work and started to work with other people that also had problems with understanding what transgender individuals, who they are, what they are. And many of these people and we know even then modern society thought that these people needed psychological care. They needed to be talked to, that there was something wrong with them.

And he said, no, there's nothing wrong with them. What we need to do ,and again, we're talking back in there now, maybe 1940s. What we need to do is provide surgical intervention so that people look like who they identify with. So he was one of the original thinkers about gender reassignment surgery. The 1950s, early 1950s, a transgender woman by the name of Christine Jorgensen, before they became a woman, was referred to Dr. Benjamin. And Dr. Benjamin immediately said: You need to go to Europe. Here's where I think you should go. You should have gender reassignment surgery and be the person who you are. And so Christine Jorgensen is probably the most famous person no one's ever heard who came back to this country in the 1950s after having surgery, gender reassignment surgery, and became this icon. She was all over the news. She was interviewed about what it was like to once lived as a man and now through surgical means, be a woman.

The other piece to Dr. Benjamin is Dr. Benjamin created an institute called the Harry Benjamin Institute for the Gender Diverse Association.

Remember, these were men who were working and creating these systems. His board of directors for this institute were all cis-men, advocates for the community, but didn't really have real experience living as people at part of this community. What we now know as WPATH, the World Professional Association for Transgender Health, that is what the Harry Benjamin Institute has now become.

So WPATH is now primarily staffed by, directed by, guidelines that come from WPATH are by people who are actually transgender individuals, gender non diverse people from all over the world who have different cultural experiences, who are now head of this organization and set the guidelines that we use today to provide gender forming care.

So that's really a long way, but really giving people an understanding of what transgender is, how we came to this place and who was responsible for us really being put into this binary system where now we are in a place where people who don't understand, those who are not in this binary box, how we've we come to this place to provide care for them and the guidelines that we use.

So some of the misconceptions that are that people just come into our office and we just go, Yeah, here, you want to be feminine?  Here’s estradiol. Or you want to be masculine? Here's testosterone. That's not how it works. We actually have guidelines that we use. There's a whole system that educates us on how to provide this care in a safe way that does not harm our patients or their families.

Bruce

It's all such interesting and important historical context that usually gets erased or even pathologized, as you pointed out. Denee Mallon is another trans woman who in the 1970s at 73 years old, sued Medicare for not covering gender affirming care and actually won. We see these kinds of legal and political fights continuing to this day.

What is the effect on a group of people when their access to health care has to be fought for at the Supreme Court, for example? What does that tell people about how their fellow Americans value their health and their lives?

Dr. Ogle 

So, you know, I first want to just give a shout out to her. She was I excuse my time. She was a badass and in her seventies, decided that this was care that she needed, this was medical care that she deserved. And she sued Medicare and won. And it is this a travesty, right, that we have to go to this extent to say we deserve the kind of health care that we desired and that the health care system offers that it should be paid for and we deserve access to it.

But when you have a system set up, again, let's just step back a minute and think about who sets the rules. Who decides what insurance companies will reimburse and what they won't reimburse, what they do consider medically necessary care and what they don't consider medically necessary care. And those are White heterosexual men. Those people that are making the decisions about how care is rendered, about how insurance companies reimburse physicians or hospitals, institutions that provide this care. These are not people that are actually in the community or of the community or that require this medical care and deserve it. But these are people who have no real understanding of what it is to provide this care. So those are the people making the decisions. 

I do want people to understand it's not like Medicare, Medicaid, and these third party insurances just, you know, develop this compass, this moral compass and said, oh, this is the right thing to do. They had to be sued to do it. And we have to really jump through hoops. And there are a lot of barriers put in front of us to be able to provide this care for people in a compassionate, meaningful way where their insurance company pays for the services that they deserve, the medical care that they deserve.

And it goes back to what we were talking about earlier, that now we have a health care system that is basically telling people you're not worthy of this type of care or that you don't deserve this type of care or me. And 99.9% of the times a White heterosexual man that is healthy and in their thirties or forties is dictating what is acceptable and not acceptable medical care.

And again, you have individuals looking at themselves saying they're not worthy of receiving medical care or that the judicial system has to okay me being able to receive this type of care. And it's hurtful. And I think people really don't have an appreciation for… You know, I realize that for young people who are hearing these messages day in and day out. And because I'm in the great state of New York, doesn’t mean that the people that provide care for young here, what's going on in other states in this country. Utah, for example, that have now actually legislated its law for people, particularly young people, who are not currently getting puberty blockers or hormones, they don't be allowed to. They hear these messages all over the country. They have a very strong network and they constantly hear society saying, you're not worthy. Who you are, we don't affirm you. The person that you identify, it's not correct and you need to change it. They constantly hear these messages. And I think the worst place to hear it is from the health care system. We're here to do no harm and we're here to provide people the best care possible that we know how to give. And it is the insurance company’s responsibility to make sure that that care is rendered in a way that does not financially make it impossible to do it.

So it's harmful at every turn to have to fight the judicial system to get health care. And we are still having that fight in a way that I think is very, very harmful. Not only to our children, but to their families and to our society as a whole.

Bruce

Yeah, 100%. And you actually gave a really great webinar to some of our member clinicians at the Academy. And you actually talked about Susan Streicher, who's an American author and historian, and she wrote that medicine and the medical field has the power to determine what is sick or healthy, normal or pathological, sane or insane, and to turn human differences into oppressive social hierarchies, just like what you're saying.

Assuming she's right, how are people coming into and working in the medical field being prepared for this responsibility that they're finding themselves with?

Dr. Ogle

Well, first, you know, I 100% agree with Susan Streicher. She's right, because I was just saying. Who are the people making the decisions for communities that they are really aren't even a part of? It's White heterosexual men. They're making decisions for communities that they aren't a part of have no real relationship to. And they're saying what is appropriate or inappropriate.

It's what she said, what's sane or insane, what's sick or what's healthy? And it's harmful because, again, we're in this system where I'm the one dictating to you what should be the norm. And that's inappropriate, right? Because and we're saying people who don't fit that norm, there's something wrong with them. They're pathological in some respects.

It's not helpful. And it's not how our society and how our country grows or it comes together as a community when we look at people in that manner. There are people back in the day, Bruce, before we could even have patients come in our clinic to even talk about hormones, they had to go to a therapist, they had to go to a psychiatrist, no less. We had to get a letter from the psychiatrist saying that this individual was mentally sound and able to have a conversation and able to come to me to receive gender affirming care. That's in my career span. I actually had to have those letters before I could even talk to people or even have anything to offer them. That's ridiculous.

But who decided that, right? Certain not people who are non-binary or people who are gender diverse of people for chance experience, they didn't decide that. And that was such an issue that that DSM classification has been removed. So we don't have to do that to that extent. We do have to have letters, though, from therapists to provide to surgeons to say that people are not crazy and that they can consent to procedures that they want to have. We don't do that for any other type of surgical procedure, but we do it for gender affirming surgical procedures. 

So I do agree that the health care system plays an important role and we're doing better. We have a long way to go, but I think we're doing better. We are now training. 

When I was in training, there was not gender affirming care. There was no real discussion or education about gender diversity within our curriculum. Now, at least I have people, residents, medical students come to our clinic all the time wanting to shadow, understand what gender affirming care is, how we deliver it. We now have that included in various curriculums across the country it’s certainly that way at our institution that Einstein.  Sexual health curriculum is gender diverse curriculum are available now to really give people a space to understand the community that they'll be providing care for.

And I'll say the other thing on that really quickly is, after all that, our medical students, nurses, residents, anyone that is in the health care system, this is also a way of affirming them. You know, they're people that are in our health care system, that are gender diverse, that are trans experience, that are gender non-conforming, that are providers that are nursing, that are all sorts of clinicians and support people within our health care system.

This is also a way of affirming them and saying that we welcome you into our health care system. We need you in our health care system to help be a voice and also be a sounding board for the way we deliver this care. So I think we're doing a lot better. We have a very long way to go, but I think we're doing a lot better and understanding our society and that we are not in a binary world and that we're not in a system that only male and female can be appreciated and celebrated.

Bruce 

That's right. And very unfortunately, Michelle, we do have to talk about violence. I didn't wake up this morning wanting to talk about violence against innocent people, but it is part of public health that it's part of this conversation. The number of trans people murdered in the U.S. nearly doubled between 2017 and 2021. And while only 13% of the whole transgender community is estimated to be black or African American identified, the UCLA School of Law's William Institute reports to us that black trans-women account for nearly three quarters of known victims in these murders.

Even these horrifying statistics are undercounting the real magnitude because often trans victims of crime are misgendered by police officers and others in authority. So the numbers, unfortunately, are probably higher. And I with that, deep breath. Right? Taking all these horrible numbers into our understanding, what can people do, what people working in health care, but also all people what can people do to protect and support people who are trans or gender non-conforming? And, in your view, what would it take to reverse this terrible trend of murder and violence against people who are trans or gender diverse?

Dr. Ogle

Yeah, it's a great question. Is very loaded. We could talk about that for an hour. And that I deal with this struggle with every day. And I think that what kind of sheds light on something I want people to understand. Whether it's a child and adolescent or an adult that's seeking gender affirming care. These people go through a lot.

I have a lot of compassion and empathy for families that bring their kids to see me, to discuss what it looks like to provide gender affirming care for their child. These families are often ostracized by their own family members. They're ostracized by their community. They're ostracized by their church or whatever religion that they identify with because they're not conforming to society's idea of how you should raise your child in this binary world. Like, they're either male or female, and doggone it, you're going to be male. If I say it and you're going to be female, I say it no matter what. 

So these families go through a lot. Kids who are transgender, they go through a lot. They're bullied. They're told by society, they're told by the judicial system, they're told by their health care system, you're not worthy. And that how you identify, there's something wrong with you.  It’s a phase. Health care providers need to stop telling kids that it's a phase. I hear that way too often. It's not a phase that's not how it works. I mean, like I was sort of a tomboy. I used to hang out with my brother, but I'd never wanted to be a boy. And then when I started liking boys, I decided I needed to wear dresses and stop wearing baggy jeans and sweatshirts. 

We send these signals to kids that and families that this is just a phase that it's not really real who they are. So this goes way back when we're talking about violence against families and kids, adults who are transgender. And it's very sad topic for me.

I will say this, not only and these statistics, 40: not only are more transgender women of color being murdered, but they're being murdered at younger ages. So the average life expectancy for a transgender woman is somewhere in her mid to late thirties.

So young people, young transgender women of color particularly are being murdered at younger ages. Why is this happening? It goes back to what we started talking about. It's an oppressive system. And if you don't conform to my idea of what a woman is and if you don't conform to my idea of what a man is, then you don't count and I'm not going to affirm you.

So as you said, transgender people, particularly women, are being murdered at very high rates at younger ages. And it's undercounted because even the system won't acknowledge that they are atransgender person. They still want to use their dead name. And the biological sex that they were assigned at birth. And that's not who that person is. So of course, those numbers are undercounted.

And any society where you have marginalized, oppressed people, you're going to have the situation.  This isn’t new to transgender people. We can talk about black and brown people murdered, right? Hung from trees, shot down for registering vote. This is the history of our country.

Bruce

A bloody history. Absolutely.

Dr. Ogle

Is that we commit violence against people who are marginalized, that we don't agree with, or that we want to keep oppressed. People want to wipe out the notion that they are transgender individuals.  Well that’s never going to happen. It's never going to happen. What we can do, and what I really, if I could wave my magic wand, Bruce, I would ask people who don't understand what being gender diverse, being a transgender individual, what it is, before you pass judgment and before you decide what it is, how about educating yourself as it is and what it isn't?

And I think when you start to understand it, nobody understands what it's like. When I hear a child that's like 11 year old, 11 years old, say, I couldn't understand why I'm this boy. But man, I really identify with girls. I want to look like them. I'm jealous of them. I want to be with them. But somebody told me that that's not acceptable or tried to talk me out of who I really am and how I identify.

And then those kids go on to have, like, you know, mental health issues struggling with that. They harm themselves as well. Suicidality among transgender kids is extremely high. And now we're looking at increased numbers in these states that are restricting gender affirming care and criminalizing parents. So the suicidality and the suicide rate among these individuals is extremely high, particularly in kids.

And we find in communities, states where gender affirming care is provided, the suicide rate among those kids, it's lower. These kids are happier, they're very productive, they're in college. They do great things when they’re affirmed and being accepted as who they are. We can do a better job of just educating one another on what being gender diverse is and that it's not pathological.

We need to get out of this binary thinking that men are men and women are women. The society and certain members of this society are really hyping up what it is to be a man. You know, he's got to be gun toting and that's their concept of a man. And if you don't fit that, then I'm going to make sure that you're not seen as a man.

So that's something we really, that's something we as advocates, even though I am a gender heterosexual woman, I'm a staunch advocate for people of gender diverse experience for transgender kids. We have to be the ones to help have a voice for them. They are voiceless. Having this conversation that you and I are having now I think is helpful to give people some insight as to what it means to be gender diverse, gender nonconforming, transgender, and to accept these people as who they are.

I want to just, before I forget this, when I was a teenager, I fell in love with the song and I like to, I fell in love with this song called The Greatest Love of All. At that time, it was sung by George Benson, singer of The Greatest Love of All. Whitney Houston remade it in the nineties, and that first paragraph starts off about talking about children.

I believe the children are our future. Teach the world and let them lead the way. And I think if we held our children to some high respect and some high regard in that manner, that as a society we’ll do better. I never thought as a health care provider, I mean, I'm a pediatrician. I'm an advocate for kids.

I never thought I would be in this place where we make kids victims of our own ignorance. And I never thought that I would be in a place where we would vilify families who are trying to do the best by their kids and keep their kids happy and keep the kids safe. I never thought we would pick on kids and make them out to be bad guys.

It really, deeply disturbs me that we do that. So my George Benson song, The Greatest Love of All, is something I like to go back to, and I think if people really value our children, value their abilities to be who they are, I think as a society we’ll live up to trying to make this a perfect, more perfect union, I just think tolerant and accepting.

Bruce

It's such an important message and so well said. Thank you for saying that. You know, we are an HIV organization, an organization of medical providers who treat and hopefully prevent HIV transmission. Can you spend and then just talking about the HIV risk profiles for transgender and gender diverse people. And when you do that, can you talk about if there's a difference in the risk profiles of, say, transmasculine and transfeminine, And why do you think transgender individuals are at such a high risk for HIV?

Dr. Ogle

Great. Thank you for that. And, you know, that's the work that I'm doing now that I've dedicated myself to in the Bronx is looking at transgender youth of color. And what are their specific social determinants of health that increases their risks for contracting HIV, being exposed to HIV, as well as other STIs.

I first like for people to understand that because you are a transgender woman, a transgender adolescent, particularly if you're a transgender person of color, that itself is not a risk for HIV. You're not a risk factor because you're transgender and people get those confused. Well, listen, I've even had some of my trans kids say, well, I'm, you know, especially my trans girls, when the transgender girl, I'm going to get HIV. That's ridiculous. And that's not how this works. 

Being trans experienced does not itself puts you at risk. There are particular social determinants of health, and we're actually looking at that again in our adolescence in the Bronx, that these young people have to deal with that actually create barriers to them being able to prioritize their sexual health.

So we're looking at specific social determinants that are particular to transgender adolescents of color, and that would be what I've termed the four U’s. It's my terminology for the way we should look at this. This is kids who are under or uninsured and in New York being uninsured is not so much a problem. The state of New York has done an excellent job in fully implementing the Affordable Care Act.

But in states where that's not the case, being under or uninsured is a risk factor because you can access health care. Being unemployed is a risk factor because you can't get meaningful employment. I think people know many states in this country, people can be fired or not hired because they are transgender, gender nonconforming or gender diverse, and it's legal and that's ridiculous.

So being unemployed, under or uninsured, unstable housing is very common among transgender adolescents in general, particularly transgender women and adolescent girls of color. They're often kicked out of their homes if they choose to live that way. Or they're put in situations where their housing is not stable, they do a lot of couchsurfing and living from place to place. And then the last U in there is substance use disorder, I've had kids often say to me, particularly trans kids of color, that they do drugs to sort of dull the pain, they do drugs to sort of escape the reality that they're living in.

And no kid, no person should need to feel like they have to do drugs in order to dull their pain and in order to just cope with the ignorance society puts upon them. So those particular U’s, those particular social determinants of health are very common among transgender youth. And it's not just my work in the Bronx.

I also did this work when I lived in North Carolina. This is universal and creates barriers for these young people to prioritize their sexual health. It's not that they don't care. I would like to get rid of that myth. They do care. They care about their health. But listen, even in the health care system, transgender individuals are denied health care because they're transgender.

It doesn't even have to do with sexual health care. If you come in because you have asthma, you can be denied health care because you have asthma and you're transgender. It's ridiculous. But that happens in our health care system. So not being able to access health care and a safe, nonjudgmental environment creates the environment that puts these young people at risk for sexually transmitted infections.

I have a number of young transgender women who have to turn to providing sex in exchange for money, in exchange for a place to stay. You know, our society is what it is. It takes advantage of people who are vulnerable. And many of our young people are put in those situations where they have to make decisions to survive. 

And you ask me about what it what it is being transfeminine, transmasculine, how there are differences are going to go back to our society. Men are valued more in this society than women. We see that right with the reversal of Roe and this post-Roe where, the judicial system, a small group of people, decided that women have no longer have agency over their own bodies in their own reproductive health. You see in trans people. Transgender women have the same issues that cis-gender women have. Transgender women are also discriminated against just as being women, just as cisgender women are. 

So in this society, men are valued more. They have an upper hand. I take care of a lot of transgender young men. They have their struggles as well. But they're accepted a little bit more by society than transgender women. So I think that goes back to, again, how we value men and women in this society. And that's why transgender women of color particularly. And also, what it is to be a black or brown in this country, it's also an issue. So when you put being a trans experience, being a person of color, and then if you're in poverty, when you put that all together, you put these young people in a position where the decisions that they have to make or the environment that they're in puts them at increased risk for HIV.

Bruce

Right. And I do also want to talk about pre-exposure prophylaxis or PrEP, because some of these folks may choose or want to avail themselves of a medication that essentially prevents HIV transmission. What are the options for PrEP for transgender people who want to protect themselves from HIV?

Dr. Ogle

Great question. And it's one of the things again, and we're looking at our social determinants of health and our transgender adolescents. We've actually looked at why we have such a low uptake of PrEP in that particular group of vulnerable adolescents. The prevalence of HIV among transgender women overall is about 9%. But in transgender women of color, it's about 15%.

So why is that? We talked a little bit about that, but what can we do about it? So one of the things we're looking at is how to restructure our program and provide gender affirming care. We have what we call status neutral approach. We have a take care of people living with HIV. Those are at risk.

Provide PEP, PrEP, sexual health counseling, testing, treatment. We do all of that in under one umbrella. And the reason for that is that in providing gender affirming care, you’re also bring in kids into the system and you can provide sexual health care as well, counseling and offer them ways to stay safe. So PrEP options are available. I will say the first PrEP option that we have that's available to everyone, adolescents, if you're transgender or gender diverse, cisgender men and women is the blue pill.

Well, if it's if it's the brand Truvada, there's also generic available works just as well. We have a lot of people on generic TDF/FTC, which is the combination pill for Truvada. And it works really well when it's taken. Remember, I talked about those for U’s, some kids we have start PrEP and because of these other social determinants of health they might stop taking it or it no longer becomes a priority in terms of preventing their risk for HIV.

So the blue pill, Truvada or the generic TDF/FTC is available for all kids. Anyone who wants to protect themselves against HIV, exposure to HIV or infection with HIV.  There's another formulation of tenofovir. That's a component of the pill called Descovy that the formulation is TAF/FTC or tenofovir alafenamide. That pill has restrictions. So for Descovy, and again, I have a hard time trying to make sure people understand the difference.

That formulation of tenofovir, TAF, versus Truvada, which is TDF, it works a little differently. The studies and data that were needed to okay that drug to be used in cisgender women or transgender men if they have a vagina, they don't have the data. So that particular PrEP option is not available for cisgender women,  I will say question of men who have a vagina, still.

There are a lot that do, they don't after surgery, which is another myth. A lot of trans gender individuals do not want gender affirming surgery or bottom surgery as we refer to it. So there are some restrictions on that pill. I will add the caveat, Ido have cisgender women on Descovy.  Women who have hepatitis, chronic hepatitis, active hepatitis, or have other co-morbidities that might cause them problems if they take TDF/FTC or Truvada.

We do have to go through an authorization process, but we can get that for them as well. You have to look at the risk versus the benefits. And for me, the benefit of you taking that pill certainly outweighs the risk of you contracting HIV. And then finally, we have lately this this year actually FDA approval for a long acting injectable PrEP option.

It's known as Apretude and Apretude is known as long acting injectable cabotegravir. And there are restrictions on that as well. You cannot use long acting injectable Apretude in women who are pregnant, who may want to be on PrEP.  Truvada or TDF/FTC is totally safe and pregnant women who may want to protect themselves and people. So why would you want to do that?

Well, if you're in a relationship with a partner who is living with HIV, this is just an extra layer of protection for you and your unborn child during that time. So TDF/FTC is totally acceptable and appropriate for pregnant women.  Descovy in not.  Apretude is not.  It is available for cisgender women, men, transgender people, people of gender diverse experience. Whether you're on hormones or not, it's a viable option. 

Apretude works for the first two months. You get an injection once a month for two months, and then after that it's every other month. And that is for people that are over 77lbs or 80lbs, somewhere near the weight restriction. But again, it's a viable option for transgender people who may not want to take a pill daily.

So those are the three options. And of course, condoms are always on the table. But the fact that we have the problems that we do with STIs and HIV transmission, people can wear condoms, but of course that's always an option and should be used as well to prevent HIV and STI transmission.

Bruce

That's all such really important prevention information. Thanks for going into detail on that. I'm sure our listeners will really appreciate it. Understanding PrEP options for trans individuals better. For my last question for you, I just want to ask, do you believe it's wrong or harmful to tell, let's say a 14 year old who wants to start hormone therapy to wait until they are 18 or 21 or whatever age you pick to make sure it's what they want to do?

Dr. Ogle

Great question and even a great topic of debate among those of us who provide gender affirming care right? They are people in both camps and the spectrum of those camps who believe that young people are able to make those decisions and that they should wait until they're 18. Although I don't know what's so magical about between 15 and 18.

I know a lot of 15 year olds that more mature than 18, 19, 20, 21 year olds, and that have a better understanding of their health and who they are than people who are older. But that is a great topic of debate. I happen to fall in the camp that I think that's very harmful and detrimental to adolescents and pediatric patients who clearly, clearly have gender and body dysphoria.

I think we don't, among those kids where that ideology exists, that they shouldn't be allowed to have any sort of gender affirming care. Again, does not always mean hormones, but sometimes it does. And also in the form of pubertal suppressors. And let me in answering your question, let me just talk a little bit about that.

Pubertal suppression, again, debatable. People are, you know, we don't have enough data long term, whatever, whatever. But what I do know is that I take care of these kids that I provide pubertal suppression for. And what pubertal suppression does is it does not, again, another myth, take this moment to educate. It does not prevent puberty. It does not It's not a hormone that you're giving to feminize or masculinize someone. So pubertal suppressors do put puberty on pause, hold right where it is. The value in doing that is that it gives the kid a chance to live in the body that they're in without any further development of secondary sexual characteristics. It also gives the family a chance to kind of see if this is working for them, how this is, how they process this.

Because remember, I tell kids, I'm your advocate, what your parents want to do the right thing by you. I don't know any parents that don't want to make the right decisions for their kids, to make their kids happy and healthy people. So I think puberty suppressors are very valuable and allowing kids that space to live in that body that they're in so that they really grow and figure out this is really what I want. Also gives parents that time to live with that kid in that space with those pronouns and that name for them to also understand if this is really if this is really who this kid is and who they identify with. 

So I think that is important. And I think when we withhold medical therapy from patients who truly need it, that's harmful. 

Again, if you look at the literature, the data is clear. Kids who do not receive that sort of affirming care or received that medical needs to sit medically necessary therapy, suicide rates are higher, behavioral issues are higher, harming themselves, in those patients are higher. Substance use is higher in those populations. So I think that withholding care till you're 18 is ridiculous. 

And it also says that I don't think that 14, 15, 16 year olds know what they're talking about. And it's totally not true. And I will say to the audience, when these kids come in to have consultation about gender affirming care or to discuss their gender identity, they've done more homework. They know more about this conversation. A lot of times than I do, sometimes the kids and tell me something. I'm like, now I need to look that up.  

They do their homework. They truly, truly understand what it is that they want and what it is that they need in order to be nice, healthy kids, which is what we want, right? We want them to be happy and healthy, I want them to be happy and healthy. So I happened to be in the camp that if the family, these are their kids, I don't think that I have the right to deny families or kids the kind of help or the kind of medical care that they deserve and that they're asking for, I don't feel that I have the right to deny that.

Bruce

Yeah. And one of the human truths that people tend to forget is that gender identity is born at a very young age. Little boys and little girls have a sense of their own gender from ages, even as young as three and four years old.

Dr. Ogle

So it’s true. And actually, you know, Bruce, when I'm having those conversations with kids, sometimes I have, you know, and again, I want to get rid of this myth that somehow parents are forcing this on kids and they're bringing them in saying, oh, this kid is acting like a girl, so here, make them a girl. That's not true. I don't know any parents that do that.

Most of the parents are like, well, this is what they say, but we don't want to rush. We want to have a conversation. We want to take our time. Parents are very deliberate and how they help their kids make this decision. But what I do want to say to that is when I start talking to these kids and you start them to tell their story, they can tell you as early as four or five that they didn't understand, but they weren't seeing themselves like they were literally looking in the mirror. If they were I don't know if they were assigned female at birth. They were literally looking the merit themselves and saying, I'm a boy. 

The youngest child that I started following was seven. And again, this is what gender affirming care isand what it is not. I love this kid and their parents. I've been following that for a couple of years. The family realized very early on that this kid was identifying as a boy, identifying as a boy, wanted to look like a boy, called himself a boy. You don't teach kids that, right? He knew that. That he called himself a boy. They brought him to me at seven. We started having this conversation about social transitioning. Let him have his hair cut short. He wears boy clothes, clothes and identify boys. He is called by his preferred name and they use his preferred pronouns.  And we are waiting as he's older to talk about when he will be at a good age for pubertal suppression.

But this kid is the happiest. He's a great kid. He's on the honor roll. He's involved in all these different debate groups. He's just like this wonderful boy who's grown up as a boy, his family affirms him. They are loving, wonderful people, and all of his friends know him as a boy, so they don't have this opportunity to assign him, label him as a female. And then now, you know, you're not really a boy. You're really a girl. They know him this way. 

So to your point, this is why I say people really need to educate themselves on what it means to really be a person that has gender incongruence with who they were assigned, who they were told they were birthed. Remember, you're told that you're told that you're a girl from early on.  You don't know that, you're told that.

And whether you identify with that or not at a very early age is very, very common. And when you talk to those kids, particularly transgender women, because they understand what being gay is, a lot of them think they're gay.  And they'll say, well, I, I like boys, I identified, I'm more feminine. I kind of identify with women. So I just thought I was gay. Till they start educating themselves or kind of broadening their network or talking to other kids who have the same type of experience that they say, Oh, no, this is really who I am. I am a transgender girl. I am this girl, even though I was assigned this and even though I like boys, I'm attracted to boys. I'm not really gay that this is this really who I am? 

I hear that from kids all the time. And so what you're saying is true. Again, it's not it's not pathological. There's nothing wrong with them. This is exactly who they are. And I and I wish we would take the opportunity to really learn and understand that and support these kids and affirm them and not treat them like they're like somehow or another, they're crazy as some sort of deviant.

Bruce

Absolutely. And thanks for sharing the patient case of your young patient. I think it's really important. It's such a heavy place where we work. It's just constantly. So I like to end these podcasts on a more of a happy note. And I think we've managed to do that. So I really hope throughout this conversation that we were able to paint a picture for our listenership as to why it's so important to provide compassionate and I would say even joyous, gender affirming care in the clinic as we've seen that this is quite literally one of the most vulnerable populations in the country. They're very bodies and cells are under attack conceptually and physically. And it's going to be really key that this message spreads, if we are ever to truly find our way out of the HIV epidemic, it's really the only way to go. Dr. Ogle, I could talk to you all day about this, but we have time constraints, so I will have to let you go.

But thank you so much for being here and sharing your expertise with our listeners today.

Dr. Ogle

Bruce, thank you. Thank you. Thank you for inviting me and giving me the space to have this conversation. And you're right, I could talk about this all day at night. There's so many different aspects to provide this care, but I appreciate you giving voice to this and allowing to have this opportunity to hopefully shed light on this really, really important aspect of providing this type of health care to individuals who deserve it.