en English

In this episode of the GenderGP podcast Helen and Marianne are joined by stef shuster (they/them), an assistant professor of sociology at Michigan State University. They discuss stef’s research on how healthcare providers respond to their trans patients – in both good ways and bad – and imagine what excellence in trans healthcare might look like.

If you have been affected by any of the topics discussed in our podcast, and would like to get in touch, please contact us via the Help Centre. You can also contact us on social media where you will find us at @GenderGP on Twitter, Facebook and Instagram.

We are always happy to accept ideas for future shows, so if there is something in particular you would like us to discuss, or a specific guest you would love to hear from, let us know. Your feedback is really important to us. If you could take a minute or two to leave us a review and rating for the podcast on your favourite podcast app, it will help others to discover us.

 

Links:

Doctors treating trans youth grapple with uncertainty, lack of training | The Conversation

Why We Need To End Gatekeeping | The GenderGP Podcast

stef shuster is on Twitter @stefshuster. Their book, Trans Medicine, is available from NYU Press.

 

Get access to the care you need today

 

The GenderGP Podcast

Excellence in Trans Healthcare

 

Hello, this is Dr. Helen. Webberley welcome to our Gender GP podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman, herself and our head of therapies.

 

Helen:
Hi everyone, Marianne and I here we have Stef Shuster here today with us, um, as our guest and as usual, I’m going to hand over to them and let them introduce themselves, tell you all about them and why they might be here and what their passion and their energy is in this area of conversation. So welcome Stef. Lovely to have you.

Stef:
Yeah, thanks for having me. So I, um, I a, an assistant professor of sociology at Michigan state university, and I’ve spent the last decade or so studying how medical providers learn to work with trans people, um, the challenges they experience, the uncertainties they have and how gender plays out within medicine itself.

Helen:
Okay. So that makes you someone that I’m really, really excited to talk to for the next hour. <laugh> so you’ve worked on this for some years. What have you found?

Stef:
Yeah, I mean, a lot of course <laugh> um, so I guess I began my research going to the Kinsey Institute, which is located at Indiana university and looking at their archives and reading through medical correspondence between providers who are working in the 1950s and 60s. Um, and so I guess one of the findings from the historical work is that they really struggled. Um, knowing how to work with trans people, how to make sense of trans people, the role of therapists, um, wasn’t immediate. So for some time they thought that for example, trans people represented a form of schizophrenia, right. Um, because they thought that trans people were delusional for identifying as a gender that was different from their assigned sex. And so for me, what was interesting was to begin in the archives and then to interview providers right now, working with trans people and to hear some of those similar concerns.

So I think that one of the biggest forms of uncertainty that has just carried through over the last 70 years is really that medical providers are not usually trained to work with gender, right. They’re trained to work with illness and disease. And so that way of thinking about what their job is supposed to be does not map easily onto working with trans people. And so I think that just creates a lot of uncertainty for them. And it’s not the uncertainty of how do I administer hormones, for example, instead, it’s more like, how do I make sense of this person in front of me? What happens when I feel like something’s not quite right? So they talk a lot about gut instinct and like flags and asking them to explain a little bit more about what they mean when they say that is when they start having trouble. So I think a lot of the ways of understanding trans people has carried through and so have their own certainties. And I think sometimes that’s hard to imagine because doctors have been working with trans people for so long. Now.

Helen:
That’s really Interesting. I wanna say so much and I know Marianne will want to, but I’m, I’m not gonna let you yet. it’s interesting is that as you were talking, I was thinking, okay, so right at the beginning, it wouldn’t, it be great if trans people could see a trans doctor cause at least that trans doctor would have some experience of what it might be like to be trans. But then I was thinking, well, actually, do you know what, if you have diabetes, you don’t have to see a doctor who has diabetes for that doctor to understand what that person, patient, client might be going through or how they navigate the world of living with diabetes. So what is the difference? Why can’t we, what is the big problem that doctors can’t understand trans, but they can understand living with something like diabetes.

Stef:
Yeah, no, I think that’s a great question. At first, as you were talking, I was thinking about a lot of the social science scholarship shows that patients tend to trust doctors who share similar demographic profiles. Right? So, um, white cisgender, straight women have higher trust in doctors who also are white cisgender, cisgender straight women. And so there’s a part of it that was like maybe, maybe it would alleviate some of the challenges that trans people face and, and, you know, trying to find doctors, but there’s so few doctors who identify as trans binary, it would make, it would make healthcare access even more difficult. So why is it that the everyday family provider has concerns about trans people or it feels challenged from working with them? I do still think it goes back to the gender component and doctors training. Like if I had a legal problem, I would go to a lawyer. Right. And if I had a toothache, I would go to a dentist. So if I’m working within my gender identity, it’s a little weird to think about, like I would go to my medical provider and I think providers feel the same way. Right. Um, so I think it, it is partly the lack of training, not a lot of experience, not a lot of interfacing with trans people, um, that just creates all of that uncertainty and anxiety.

Helen:
Yeah. That’s a really good point. It’s it? Marianne it’s that, it’s that age old thing, isn’t it? That being transgender is not an ill, this a disorder, a disease. And yet that you do sometimes need, or want some medical or therapeutic intervention

Marianne:
Years and years ago, I was on a forum and it was talking about how being trans isn’t a mental health issue. And there were some people, some trans people, uh, uh, arguing, you know, ferociously that it, it has to be. And I was struggling to understand why anybody would think that, but actually as the conversation unfolded, what they were saying was, you know, if it’s not a mental health issue, the NHS aren’t gonna help us, what is it, if it’s not a medical issue, then how are we gonna get help? Who do we go to and I think that’s actually driven, certainly in the UK, it’s driven a lot of the, um, the healthcare that trans people have actually bowed to the idea that it’s a mental health issue when actually personally I and a am hoping Helen will agree with me that it’s it’s preventative care. There are issues around being trans that can develop into mental health issues that didn’t need to given the right support at the right time. But that must be a dilemma for, you know, agencies that are going to offer funding, our insurance companies, that the, what, the justification for this help, if you’re not ill ill, why would we be paying type of Thing?

Stef:
Yeah. I, um, it’s a really tough sticky question. I think a lot about the spillover effects of continuing to name and understand being trans is like a mental illness or not as a mental illness, but something that needs to be labeled as such in order to get insurance coverage. And I, you know, as a sociologist, I think a lot about symbols and the, and how they’re powerful and having that in the DSM, it still, I think, signals something of about how the medical community understands trans people, but Marianne, as you were talking, I was thinking about like people who are pregnant can still get their healthcare needs met, can still be reimbursed through insurance. And it’s not understood as like being pregnant as an illness or disease. Um, I mean, certainly historically at some point it, it did, but I don’t know, like I just wonder how to shift the frame, um, to stop thinking about trans people as mentally ill. I think we can look to other examples such as pregnancy, right?

Marianne:
Interestingly, um, you could almost argue one, one of the issues again in the UK and I can’t speak from the US. I’m working with people now that have got what I think are pretty severe mental health issues. And actually the being turned away because they’re not serious enough. And we’ve almost got this thing now where if somebody could go to a doctor before they developed depression and get a little bit of therapy, then they may never develop depression and may never need to go to mental health services. But actually they will probably, you know, what you coming to me for, you’re not depressed a and maybe this is just something that as a society, you know, uh, you’ll know more than I do working in sociology that, you know, we’re developing as a society and there are other factors playing in our lives that cause mental health issues. And that actually, if we could catch them early, then we wouldn’t need, but where would we turn? So, yeah, I don’t know this isn’t just about where the trans is a mental health it’s about actually going and preventing conditions rather than going and getting a cure for a condition that’s developed.

Stef:
Yeah. I mean, in that way, it almost, what I’m hearing you say is like, instead of thinking of any illness or disease is like a problem to fix, right? Yes. It’s like we have to shift the entire conversation about medicine and mental health, um, to stop thinking in those terms. So

Helen:
Marianne you’re right. Health promotion is something that we do all the time in healthcare. You know, we check blood pressure to stop you having high blood pressure that might go on to cause heart attacks and strokes or kidney problems. We do your family planning, um, with hormones and implants to prevent or to prevent unintended pregnancies and to plan your families, to improve your mental health and improve your life satisfaction. So there’s lots of health promotion that we do. You’re right. We shouldn’t have to wait till people are desperately crawling at the walls to get help and interesting, isn’t it because the um classification of disease disorder has changed or is changing from mental health into conditions related to sexual health. And maybe that is just the right place for it. Um, who knows? I agree. It has to be somewhere. I don’t agree that we have to wait until someone’s desperate in order for them to get help. And maybe sexual health is a really good place to, to house it.

Stef:
Yeah. I mean, I guess one of the things I, like I worry about in listening to, you know, I, I interview providers, um, I observe them in healthcare conferences, how they were teaching each other. And one of the things I worry about that um, is that like some of the language they use, it was a fantastic session. And I learned so much from providers at attending this particular session. It was, um, gray cases in trans medicine. And so they were going case by case and, you know, presenting like the scope of it and why it presented ethical ambiguities. And one of the cases the providers started talking about how, um, she had a trans woman who was maybe in her mid forties and had, uh, co-occurring conditions. And I was sitting there and I was thinking about what is the co like, because very implicitly, what that is suggesting is that providers thinking about, you know, this trans woman is trans. And also I think the case was about having depression. And I was like, that’s really interesting to think about the co-occurring rather than just, I have a trans patient who also has depression. Right. Um, so it, it does, I think of like, it still signals that like a lot of what we’re talking about.

Marianne:
I just think from, um, you know, my experience of medical care is that it’s almost, I feel like I’m a hot potato. Nobody wants to hold onto this and take responsibility. And, and it just gets passed around very quickly. Uh, because a bit like you were just saying there, Helen, maybe it is under the wrong department now. I think it was, uh, chairing cross was a mental health Institute and they lost the commissioning for gender, um, the gender clinic, because it was declassified, it isn’t in theory classified as mental health. And it just kinda fell between the cracks. And I think that throws more uncertainty out to anybody that’s not involved, but actually if it could just move over to the sexual health clinic and interestingly enough, I’ve got a client who lives in Illinois, believe it or not, God knows how he found me, but in Illinois, they went to the family planning place to get their hormones. And I just thought that sounds the nice kind of place to go to that he doesn’t have to be any more complicated than just speaking to a healthcare professional that knows about a hormones and accept you for who you are. I don’t know. Maybe that’s the fantasy.

Stef:
There are some people who specialized in gynecology that I spoke with. And even they, they express concerns, right? Like this, this notion of, I don’t know what I’m doing. Like I just, I don’t know what I’m doing. And I’m like, but you work with hormones every day. Like you work with ES I mean, maybe not testosterone, um, often, but like you work with estrogen. So what do you mean when you say you don’t know like you, you do right. But I think it’s just that fear of the unknown. Sometimes that can make people feel, I don’t know, put out or like they’re not experts. Right.

Helen:
And which bit of it is unknown because certainly the estrogen therapy and the testosterone therapy and the effects that that has on a person’s body is really, really, really well known. The unknown is having those hormones. If you have a different set of chromosomes, um, or a different set of gonads and then have those hormones. And in that I was reading your article and you were talking about the trans woman who had, I think it was, um, heart disease. I think something like that. And, and there was a concern, oh my goodness, is it going to be safe for this trans woman to have estrogen? And the way I always look at it is, well, if it’s safe for all those cisgender women who also have atrial fibrillation or a regular heartbeats or blood pressure or heart disease, or a family history of strokes, if it’s safe for all those cisgender women, uh, to have it, why isn’t it safe for transgender women to have it because actually hormones are so bio identical, you know, the ones that we make in the laboratory are the same as the ones that we make, um, in our bodies. Why is it, what is that fear all about?

Stef:
Yeah. I mean, at least the providers I spoke with were concerned about that their colleagues would deem what they’re doing as, so outside of the balance of like medical consensus that they feared for their licenses. And I think others, one person described it as like wanting a handrail to hold onto. Right. And I think for at least the providers I spoke with that handrail was if they didn’t have the clinical experience, they wanted to be able to look at like evidence based medicine and practices. Um, there’s so little of it for all of these particular situations, right. They felt a little unmoored. So I think it was like partly a, will I lose my license? Will my colleagues cast me out right. As like engaging in so called quackery. Right. But also for some providers, you know, I think that sense of needing to be anchored and knowing that the decisions they were making were in the best interest of their patients.

Helen:
But you see, they say that those words don’t, they best interests of their patients. And it’s, it’s almost like, yes, my car’s got an MOT. And so it’s safe. I dunno what you have in America. But we have this annual MOT motor ordinance, um, test to make sure our car is safe, but you might have passed that test last, last week, but it doesn’t mean your car is safe this week. It’s that best interest of the patient. And it it’s like a tick box done that best interest, but have we. And one of the other analogies I’ve been thinking about recently is if you are a young person, um, and you have a medical condition, which means you have testicles, which aren’t going to work. And in those situations, we would induce puberty to around 12 years old. Um, if you are a young person who, who does have testicles that are going to work, but they haven’t kicked in yet. It’s like, hang on a minute. Why, Hey mum, why haven’t I gone through puberty? Everybody else has. And for those young kids, those young boys, um, they’re late puberty. We, we start puberty off at 14. That’s the kind of guideline, hang on a minute. Now, if you’re trans boy and you definitely haven’t got test pills, they’re not gonna work. They’re not gonna produce, um, hormones at all, but you are not allowed to start your puberty until you’re 16. Now, where is the rationale for, for those three different clinical scenarios? It’s just not fair. Is it?

Stef:
Yeah. Right now in the US state legislators are passing all of these anti-trans youth pills, forbidding providers from offering puberty blockers, even making recommendations to other medical providers. So I don’t know. I just think there’s something like, at least in the US, I think there’s like this protectionist stance that comes through, right? Like we must protect the children. They’re so vulnerable. And yes, like I’m not, I’m not dismissing that kids like, of course kids are vulnerable, but like the justification that the way to protect trans youth is to prevent them from, um, being able to access transforming medicine just seems, it’s such a disorienting logic that it’s hard to like wrap my head around the best way to protect trans youth is to not let them be in their trans bodies.

Marianne:
Like I think it’s the dilemma that we have in that there is not yet a societal acceptance that some people are trans and some people aren’t that this fear that a cis person might get it wrong. And the, you know, the reality is I, you know, I speak to lots of parents and they come in, you know, what, if it’s a mistake, what is this? You know, and I kind of say, this just, isn’t gonna go away. whatever you do now, they are always gonna be trans that you can fight it and you can worry about it, but they will always be trans because no cis person would ever go to that extreme of believing they were trans whatever age they’re at. What I would say is there are some trans people transition in for all the wrong reasons because they weren’t given good advice.

They weren’t given good therapy that they thought by just getting the right hormones, that all their problems and depression would lift, you know, bad care, breeds regrets. But actually if the starting point was, oh, you trans, how can we help? Uh, uh, uh, we talk about that phrase all the time. How difficult is it just to ask them, what do they know? How can we help, what you’re hoping to achieve? What do you need from us to be able to achieve that? It would just be a reframing, but society’s acceptance that there are just happen to be some people that are wired it’s slightly differently. And, uh, yeah, if you’re not trans, you’ll never understand it. So don’t try to,

Helen:
I was thinking Stef, that you I’ve been a doctor for quite a long time now, 30 years, and I never really considered that. It might be someone’s job to be sitting in an audience and listen to me teach or watch me interact with patient, um, and to study, uh, or, or to interview and observe my practice. I’m fascinated that love to have been part of that. And I’m interested as well. Cause Marianne said something very brave there. And if I know doctors, doctors are not that brave. So Marianne said, mums come in and they’re worried. And I Marianne says they will always be trans. And if I know doctors, doctors very really don’t like using that word always or never, there’s always, there’s always, there’s always seems to me to be some caveat, some kind of like probably got this the most likely the cause for this, uh, you’re very unlikely to experience that side effects. This is the most likely outcome and doctors don’t like saying always or never it’s that your experience?

Stef:
Yeah. I mean, I think that that is where that ambiguity comes in, that, you know, the providers that I was observing and interviewing were really just struggling with, um, because even, even in the healthcare conferences, which are spaces for them to ask each other questions and draw on each other’s experience and knowledge and expertise that you could have one case presented, and the provider came to one conclusion and you might have someone else in the audience, who’s like, I’ve had something similar, but I, we did this instead. And so, yeah, I think it’s, it’s not like it’s not formulaic. Um, but I think the way that the knowledge has been passed down from the 1950s on has been first, this happens, then this happens, then this happens, then this will happen. And by trying to standardize a process for transitioning, it doesn’t serve trans people. Well <laugh>, if you don’t fit within those steps, but for providers who are experiencing patients who are like, yeah, I want, I want to try hormones. I’m not sure if they’re gonna work for me. Let’s check back in, in a couple months. Like, that’s like, no, like you have to know, you know, I will not let you be on hormones until you can assure me that you will definitely always wanna be on that. It’s strange that some providers ask trans people to make such a commitment. Um, when disease suggests a lot of providers, don’t like those residents, So

Helen:
I remember when I was learning, I had a, a teenager at my early twenties, they had difficulties with social communication. They would say to me, my gender is not male, but everyone thinks I’m male, but this isn’t right for me. So I’m like, well, what is it? And they were like, I don’t really know how to say it. And I’m like, well, how can I help you if you don’t know? And they were like, I wanna try estrogen to see if that will work. And I was like, well, okay. But that might make you grow breasts. How will you feel about that? They were like, I don’t know. And it was, I, I felt really bad when I think back in it. And I think I didn’t do that patient the best that I could have done, but it was really hard for me to well hard for them. Cause I was trying to squeeze them into my boxes of clarification and understanding, and they couldn’t, how could they, they didn’t perceive it. And they couldn’t reassure me in my language, not their language. And so we never got anywhere. And I often think, oh, well, I wonder what happened to that person. And I often feel regret there. I didn’t do a good job and you’re right, because I was squeezing them into my narrative or trying to, and they couldn’t, it just didn’t work. I dunno. Marianne, do you have experiences with

Marianne:
That just to kind of follow on what, with what Stef said, um, I, I, I think I’ve spoke about this before Helen, that the model was flawed back in the fifties. What they haven’t done is gone away from that model. They’ve just tried to massage that model. So if you start making a cake and you use the wrong flour, and then you started adding more ingredients to bring the flour back, back in line, you’re gonna end up with a poor cake. It’s never gonna be the best cake. It can be. If you set off with a flawed medical model of transness, and then all you try to do is massage it to fit 70 years later, it’s still a flawed model. And I think that’s the situation that we’ve had. And interestingly enough, Helen, and I’m gonna put myself in this category as well.

We’ve had a bad narrative by Hollywood and by the media about trans people, if the medical model of care was flawed to start with, even I’ve bought into that model, that even, I believe that there was a hierarchy of transness that we needed to meet before we could transition. It’s only with the privilege of working at Gender GP and in my own transition that I’ve learned otherwise. But the truth of the matter is you as a doctor, unconsciously have bought into that narrative and have bought into that model of care and that we need to go back to the 1950s. And, you know, if, if we could have a back to the future, you know, if we could go and slap Harry Benjamin around the chops and say, no, you’re wrong, Harry, this is what we know about trans. Then we may have been in a different position now. I don’t know what you think to that Stef.

Stef:
Yeah. I mean, so, you know, in the archives I was playing in, um, a lot of it was Harry Benjamin’s letters and watching his thought process unfolds over several decades. And, you know, at the beginning he really, he kind was just making it up <laugh>, you know, and then somewhere along the line, he started being asked to like, by colleagues, like, well, how, how do I do this? I have a, trans patient, like, you know, how to work with this population. So like tell me, and I think the knowledge just kind of accumulated where it became canon. Um, and it kind of started with, he was more or less making it up. Right. Um, based on what he thought might be the best thing to do. And now it just see, seems like it’s become standardized. And when you have a way of thinking about the worlds or about how you should practice medicine or be a therapist, I think it’s really hard to break out of that, that model. Right.

Marianne:
I was gonna, uh, mention Freud there as well, because what I know about counseling and therapy and psychotherapy is, you know, Freud was making it up because there had never been any formalization of mental health, you know, and the asylums were full of women and suddenly, you know, Freud come along and he was at ground zero and he was trying to develop. And yeah, a lot of it might be argued that it was flawed. What, how up and then is other people come and studied him and developed away from it and, and found that there were other models of care with Harry Benjamin that doesn’t seem to have happened. It’s almost like he just set off down a road and everybody else just kind of joined that road without anybody challenging it and it’s just a pity. We didn’t get the same kind of support as you know, mental health got in general.

Stef:
I do see a little bit of a tug of war, at least in the US, between like the WPATH model and the endocrine society and a little bit of legitimacy wars over, it just feels like, um, trying to claim jurisdiction over who should be in charge of trans medicine. And so it’s just, it’s interesting that the endocrine society is also like bringing psychiatrists in like psychiatrists are the better people that you should go to. Whereas with WPATH, I think it’s more like psychologists. So I still think there’s some unresolved tensions between psychiatrists and psychologists and endocrinologists and like primary care family care providers. We, the guidelines that they each offer, right. Are, are not all that different. They’re like some small differences, but you’re right. Like they, it, both of these models, even if they try to pretend like they’re vastly different, they all kind of stem from the same core, which is Harry Benjamin.

Helen:
That’s really interesting because, um, I was, I attended a, um, a WPATH conference a couple of weekends ago on, um, child and adolescent, uh, health. And they were discussing, uh, patient scenarios. And so the, the, the fictitious scenario that they were discussing was a 12 year old assigned male at birth, who was wanting to start hormones. But again, some, some social difficulties in talking, I think, you know, had had some bad experiences with therapists and doctors. And the 12 year old had said a couple of things, which I’m talking. I think we it’s probably Stef what you were saying about red flags. And so the red flags that were being identified were things like 12 year old had said, you know, when I have children, I want X, Y, Z. And they didn’t like talking to therapists. And actually the, they had been told to go to the, but they didn’t turn up.

And these were the red flags. And so there was an endless discussion about, we cannot allow this 12 year old to start puberty. I ego to the endocrinologist until we’ve sorted out this mental health stuff. The, you know, what if they got unreal expectations about, you know, be getting pregnant, um, they’re not going to therapy. And there’s the, was this big tug. And, you know, I’m a physician. And I was just thinking, this kid wants to start puberty. You know, maybe when got that over and done with then maybe there would be some space for some therapeutic work around talking and the journey ahead of them and their life ahead of them. And actually checking the understanding as to whether this person who hasn’t got a uterus would be able to carry a child or, or not. Maybe that’s a discussion that does need to be had certainly. But why is that something that’s going to make this person have treatment withheld from them? And there was a big endocrine psychology battle going on, uh, with that fictitious case, which is why we were discussing it, of course. But, um, it was really interesting.

Stef:
Working in archives can be difficult, especially when it’s like difficult material, you know, like you’re, you’re in this little room, you’re looking at old letter, like handwritten letters day after day, hour after hour. And thinking about like, how could these people writing these letters have medical degrees, right? Like, but it’s not fair. Like it’s not fair to apply current understandings of how bodies work to historical moments, right. Because they didn’t have the knowledge base, but one of the more difficult things, and I really sat with it from the archives providers were very concerned about trans people, not having families. Like they were discouraged from having families. They were encouraged to leave their families. And it took me a while to really sit with like, why was that? Why did they care so much about the reproductive capacities? And also the, like the idea of trans people raising children.

And I think it came from, I think it came from your classic kind of deplorable eugenics way of thinking that trans people are. So the scare quote, like unfit and unworthy, and they will, you know, tarnish any future generations that the best thing possible is to ensure that they just never have children. Um, and so it is interesting to think about how that is changing right now, where, um, like people starting hormones have convers, like they have conversations about fertility and, you know, like freezing their eggs or their, you know, sperm donations. It’s interesting to think about the role of trans people in the imagination of providers and thinking about like, I, you know, social fitness, um, and who’s worthy to raise. So

Marianne:
I was what I was gonna say as well, kind of link into that because when you were talking about WPATH and all these different areas that are all kind saying the same thing, but in conflict with each other, the thing that comes to my mind continually is who benefits, who benefits from in a gate keeping system and the people that benefit are those that make the money. There are people that, and I hate the label, gender specialists, cause they’re just, I’ve yet to meet one. If I’m honest, there are people that specialize in this area, but they don’t come across a specialist to me. But actually if we’ve gotta go a psychiatrist purely by inference that we are mentally ill, you don’t see a psychiatrist unless you’ve got a mental condition. And even if that psychiatrist was then to sign you off as transgender, you’ve being signed off by a psychiatrist that when you then go to adopt a child, why did you see a psychiatrist?

You had a mental illness. I, you know, it just follows you right down the line. The parents do not want the childs getting a diagnosis of autism because that label will follow them down the line. There’s lots of areas in this country, but who benefits? And the psychiatrist benefits, he gets, you know, $500 or 500 pounds to sit there and tell you what you already know about yourself and endocrinologists, you know, you’ll pay them to just stay there, say the bleeding obvious. That’s kinda how I experience it, so to speak. But, but then I’m bloody minded as well. I have to say,

Stef:
<laugh>

Helen:
Nevertheless, you said about you, <laugh> it is, isn’t it. Um, and it goes back to that idea of who who’s protecting, what the gate keeping who’s protecting, what’s going on. And Stef you, you were talking about the, that some in some way that trans people might be unfit and unworthy. Um, and therefore we’ve gotta curtail their fertility in the past. And you talked about social fitness. And I think sometimes the, the, the word that I hear quite often is they’re a vulnerable group of patients. Therefore, I gate keeping is allowed. We must be careful. This is a vulnerable group. And I just wanna say, hang on a minute, we’re all vulnerable. Equally trans people are no more vulnerable than cis people, what they have to go through sometimes. And the barriers and the, and the, the sociological barriers that are faced them, make the access to what they need, uh, vulnerable, but they’re not a vulnerable group of people, but yet these words are used in order to justify policies and barriers. I mean, did you see much of that? The vulnerable word really gets on my nerves. I have to say, that’s my extra grind barrier.

Stef:
<laugh> yeah, no, I think that’s real. I just use underrepresented. Now. I think it still signals that smaller groups of people that are not populating, like, you know, everyday life in the ways that other groups might, or, or they don’t have the same access to resources and institutions. For me, the clearest example that comes up is when providers talk about risk and concerns about risk and pointed this out earlier, Helen, that the so-called risks of being on estrogen for trans women, for example, may be no greater than for cis women who produce estrogen. I think like where, where it gets a little tricky is if you are a provider and you’re reading someone’s blood labs, and you’re looking at their cholesterol level, for example, I’m not sure it’s really been figured out yet in a clean, neat way for a trans woman. Are you supposed to be looking at baselines for assigned males or baselines for assigned females?

Right? And so those small, but significant logical leaps, I think, I think that that plays into the concerns of risk. And I think that also feeds further the idea that some providers and I don’t, you know, this is clearly not all providers, but some providers who then feel compelled to gate, keep to protect trans people from themselves. And I think we can think of many examples of lots of other groups, of people where like, that just never works out. Right? You, you don’t protect people from themselves. Um, especially if you’re not a part of that group,

Helen:
I could not agree more because the situation that we have at the moment, if you look at the, if you look read the newspapers, read the medical journals, read, read the analysis, that’s going on, it’s all about does trans exist? Is it okay? And then you, you get a groundbreaking paper that comes out, which says, Hey, gender affirming surgery improves mental health in trans people. It’s like, why are we focusing our research on that? Why can’t we just believe that? Because you’re right. If we’ve got a budget, why aren’t we looking at cholesterol levels? And which should we be using? Should we be using the assigned male range? Or should we be using the assigned female range? Cause that’s really important. And there’s a blood test that you have done when you have someone thinks you’re having a heart attack, it’s cardiac enzymes and the blood test comes back.

And if it’s high, you might have had a heart attack, but the levels are different for male and female levels. And I wanna know if I’ve got a trans woman who, who swapped her hormones really early on like age 13, 14 when, when it should happen, I believe, and this a attack’s now happening at 60, which enzymes should I be using? And these are really important questions and research ideas for the future. But it seems to me that we’re so far away from that because we’re still trying to prove that it’s okay to treat trans people with hormones. And it exasperates me. We’ve got some really, really important medical questions to ask, and it’s not, is it okay to treat a trans person and switch their hormones?

Marianne:
There’s a lot of research goes into, you know, is this person trans, you know, not what is the best way to look after this trans person just continuing on with the research as well? The, the one thing I’ve witnessed is poor research to justify gatekeeping gets a lot of attention. And the good research that shows that good affirmative care helps gets very little attention and just gets dismissed from a social media perspective that people want to believe that we are mad that we are vulnerable, that we need gate keeping. And if I was a psychiatrist trying to justify my gate, keeping role, am I gonna want to read the paper that said, actually, you didn’t need to speak to a psychiatrist. You’re gonna want to read the bit that said, oh, you know, that boost my ego. That makes me feel like I am the expert in the room. So medical research is what we need.

Stef:
Mm-hmm <affirmative> yeah. It’s interesting to think about, I think both of you raise really interesting points that a lot of the research offers justification for medical providers, not focusing on like, what is helpful for trans people to know. Yeah. That is, I’ve never thought about it that way, but that is interesting. It’s like to assure themselves, right? Like I’m, I’m doing the right thing.

Helen:
It goes along and it goes along with your risk, doesn’t it? You know, you said earlier that medical providers are in fear for their license and the risk and the risk of give this person hormones and the risk of switching hormones. And what if they have a high cholesterol, what is the risk? And it’s like the risk to who is it, the risk to the doctor or the risk to the patient. And, you know, certainly what, you know, what you alluded to that’s happening over in the states at the moment, uh, with, you know, criminalization of providing affirmative care with she’s horrendous. It’s just gonna make that worse, but we’ve only got a few minutes left and I’d love to finish on something really positive. So in your research, because we’ve hopefully come some way since the fifties mm-hmm <affirmative> are you seeing some patterns emerge in terms of positivity of healthcare provider provision, um, in your observations?

Stef:
I know that it’s sometimes easier to focus on like all the horrible, terrible stuff and like, well, how did that person say that? Or think that I actually ended my interviews with providers on a similar up note. So I would ask them, um, can you share with me, what are some of the joyful aspects of working in trans medicine and it, and for me, like as a non-binary trans person, of course, like it’s hard not to somewhat selfishly be like, oh good. Like there are some good people out there. Um, but like they being asked to reflect on that question. I think that a lot of providers talked about how working with trans patients, may present challenges that they were not trained to work with, but that by slowing down, by trying to listen to what their patients needed, that it made them better doctors for all of their patients.

It almost sounded like a cognitive shift of having to think about what assumptions might I be making about this patient. And then that started translating over to their care with other patients as well. Right? So it almost sounds like for some providers who have humility, um, that they can lean into that and it translates to, to their patient care with other people. And, you know, I, I think for the therapist that I spoke with, a lot of them really detest the gate keeping, and it’s not a part of the orientation of therapies to prevent someone from doing what they need. And so they talked a lot about how they found workarounds, like strategic workarounds to fulfil whatever thing they needed to fulfill, but to try to work with their patients in ways that align with their therapeutic values. So I do see those as moments, those pockets of resistance and strategizing, and also like a lot of deep self-reflection about who they are and who like how they want to be in, in their medical practice or their therapy.

Helen:
Marianne, have you anything to add to that lovely, positive thought?

Marianne:
I mean, despite everything we, you know, we can sit here and gripe a little bit and I still think we’ve got a lot, a lot of work to do. We’ve, we’ve gotta loosen the grip on that gate keeping. But one thing that I am seeing is, is greater understanding. And, you know, we shouldn’t underestimate that, Helen, you know, you sat here, you’re not here by accident. There are people up there now starting to challenge this. And I know I’ve got a mind that does like to always simplify everything. And I don’t say that that’s right, but I think if we start off with very simple goals, then we can work out the complexity of achieving them goals. Uh, and I think it’s happening. And 20 years ago, I wouldn’t be sat here. Do you know, I, I wouldn’t have got access. People like me didn’t transition. Um, or that was my belief. You know, working class ordinary people just didn’t get the opportunity. And the fact that I am sat here and that the fact that there are more people like me who could be sat here, it does come and show there’s a shift and clinicians have got to catch up because there’s an avalanche coming. If they’re not careful.

Helen:
Thank you. And thank you to both of you. I mean, I am a medical provider who for the last five years, know an investigation will be concluding at the end of this year to know whether I’ll get my license back or not. And I can honor to say, I have never worked in a more rewarding field of healthcare in terms of the opportunity for education, the opportunity to change the balance of access for affirming positive, helpful healthcare that can really make a difference. And to be honest, this patient group is just incredibly rewarding to work with. And as another plus, I get to do podcasts like this, talking to people from all over the world, sharing their experience. So thank you so much, Stef, for joining us today in a really eye opening. Anytime I lecture in the future, I’m going to just keep an eye out for the person at the back. Who’s observing me <laugh>

Stef:
You might not know. I, I get dressed up in formal conference gear and, and most people just thought I was like a medical students. Thank you so much for having me. This has been a real treat.

 

Thank you so much for listening. I really hope you’ve enjoyed our program today. Please go ahead and subscribe to future episodes if you haven’t done so already, if you or anyone else who have been affected by any of the things that we’ve talked about in our podcast today, and you’d like to contact us, please visit our website Help Centre and contact us while we’re there. We are very happy to accept ideas for future episodes and future guests. So let us know if there’s anything, think they’d like us to cover. You can also visit our website, www.gendergp.com for a multitude of information about transgender health and wellbeing issues. You can follow us on social media ID is @GenderGP, and you can sign up to our monthly newsletter. Full details can be found in our show notes on our podcast page. Thanks for listening and see you soon.