Anita Rao 00:03
In the summer of 2019, I came across a book that took me into the fictional world of a family on a fascinating emotional journey. "This Is How It Always Is" tells the story of a liberal, middle-class, Midwestern couple named Rosie and Penn. They have five young children: four boys and a transgender girl who starts socially transitioning in kindergarten. The story is based on the life experience of the author, Laurie Frankel, and it follows the family as they navigate their daughter's social and medical gender transition — sometimes with grace, other times with some big fumbles. The book made me realize how few stories I'd heard about the experiences of really young folks navigating a gender identity transition. Kids who — before they hit puberty or in their teenage years — can articulate to their families and society that they don't connect with the gender they were assigned at birth. I started to wonder how parents of all stripes respond when children express discomfort with their anatomy or a desire to be seen in a way that aligns with how they see themselves. As a relatively new aunt and frequent presence in the lives of my friends' little ones: Are there things I can do to support as big decisions are made about things like puberty blockers or gender-affirming hormones? Are there existing resources family should know about in our hard-to-navigate health care system? This is "Embodied." I'm Anita Rao. I want you to meet Max Brown. I did recently. He's a transgender teenager living in western North Carolina.
Max Brown 01:54
The interesting thing is a lot of trans people have their awesome coming out story, and it's so emotional and all these other things. My coming out story actually isn't that interesting. I actually — it was really abrupt. We were in the middle of grocery shopping and I was like: Mom, I think I'm trans. And she's just like: Let us check out, and we'll talk about this in the car.
Anita Rao 02:19
Max is really close with Frances — his cool, cucumber of a mom. She's been advocating for Max as his body and social presentation have started to change. But before all of that, Max had to learn more about himself so he could ask for what he needed.
Max Brown 02:36
How I found out I was trans was —well, first I came out as gender fluid in fourth or third grade. And I still felt like — it still didn't feel right. And so I ended up finding this YouTube video of this transperson and their experience of, of just being trans and their journey through transitioning and having gender dysphoria and surgery and hormones and things like that. And when I saw that — I had felt a connection that I felt I had never felt before. I would honestly go with like: I felt like I was touched by Jesus.
Anita Rao 03:17
The Williams Institute at the UCLA School of Law estimates there are about 150,000 transgender teens between the ages of 13 and 18 in the U.S. And about 1.3 million trans adults. Those numbers are probably low. After all, not every trans person is out. And like Max said, trans folks don't have a lot of role models.
Max Brown 03:40
I did a lot of research. I read a lot of articles. I reached out to a lot of people. And I was... I was like: How does gender dysphoria work? How does transitioning work? How does all this work? How does being a trans person work? Or, what's the experience of being a trans person? And after hearing all these stories and reading all these articles and watching all these videos and hearing different stories, I truly felt like: This is me. This is what I've experienced. This is what I feel like. This is how I want to move forward with my life. And that's kind of the steps I took. And the surprising thing is I read so many articles and I was only 13 or 12 at the time.
Anita Rao 04:21
If only we all had that same initiative to educate ourselves on gender expansiveness. But the truth is, there's also just not enough research yet on the trans population. There's a knowledge gap that becomes pretty relevant and urgent when a transgender person becomes someone you're responsible to teach, protect, defend, or treat.
Max Brown 04:44
I had to stay overnight at a hospital. And I remember that I was with another trans patient. And I experienced that — One of the one of the nurses or one of the doctors that were treating him kept continuingly misgendering him, and I could just see, or I could feel the pain of, of being misgendered. Especially since they were there for their own medical needs. And I, I remember, I got misgendered from a nurse, as well, constantly. And it's just. It really doesn't help your situation. If anything, it makes you feel worse, because you're already there, and you're feeling kind of — feeling kind of bad or feeling kind of hurt. And you get misgendered. And it's just another level of pain, or it's more of internal pain.
Katherine Croft 05:42
What that really speaks to is a lack of education among healthcare providers as to how to treat trans patients.
Anita Rao 05:48
Katherine Croft is a nurse navigator and program manager at the UNC Transgender Health Program. She says it's not uncommon for transgender and gender expansive people to have bad experiences when they're going to the doctor.
Katherine Croft 06:02
So healthcare providers are often not taught — during their medical school during their residencies, and nurses are often not taught the same — that trans people have slightly different care needs. And that gender-affirming care is something that should be provided to our patients as a baseline. So when trans patients try to come in and get care, they may be going to providers who aren't trans affirming or don't know about trans healthcare in the way that they really need from their provider. So there's a instance of a lot of trans people feeling like they have to educate their doctor when they come in on how to treat them. And trans people will therefore spend a lot of time self advocating and looking up information and trying to do their own research about their treatments, because they feel like when they go into their provider, they may not get a provider who's understanding and knowledgeable about what they are dealing with.
Anita Rao 06:56
Well it's interesting, because you mentioned this term, gender-affirming care. And I'd love for you to unpack that a little bit, because I think, you know, when people may hear the term transgender healthcare, people may be focused really on medical transition and surgery and hormones, But gender-affirming care really includes so much more than that. So give us a sense of the variety of things that you're talking about when you say gender-affirming care.
Katherine Croft 07:17
Absolutely, yeah, when we talk about trans healthcare, generally, what we focus on on is transition-related care. So that's, you know, what you would expect it would be: hormone therapy, mental health care, surgical options, those kind of things. Gender-affirming care is a lot more all encompassing, because our trans patients have the same medical needs as any other patient does. And what the issue is with the trans community is when they come into a provider for something that isn't transgender related — such as a broken arm, such as routine gynecological care, such as, you know, an infection in the emergency department — if they don't have providers that are versed in gender-affirming care, then they won't be treated appropriately. And a lot of trans folks have had either negative experiences with providers because they were trans or are afraid to go into the doctor because of negative experiences they've had reported to them by their community and the people around them. So gender-affirming care is really about focusing on providing comprehensive health care to patients in a way that supports them as an individual and recognizes and acknowledges their gender identity and their gender expression. So it doesn't bio-essentialize them by breaking them down to what sex designation is on their birth certificate, it looks at the whole picture. And to be versed in gender-affirming care means that you have to be aware of trans healthcare. You have to be aware of what it means for hormone therapy to be taken by a patient and what that affects. You have to be aware of what, you know, organ configuration they have after surgery and what their risks are. So there's a lot to it, and it really intersects with every day needed healthcare that anyone would try to get but that trans people tend to have a much harder time obtaining because their providers are not educated enough to provide this kind of care.
Anita Rao 09:09
Katherine Croft says the lack of cultural competency in healthcare is so widespread, many trans folks decide it's not even worth the risk to go to the doctor.
Katherine Croft 09:20
When it comes to transgender patients seeking health care, you have to understand that as much as 30%, or one third of trans patients delay necessary health care because they're worried about having a bad experience at the doctor. And what these experiences tend to be, are not necessarily intentionally misgendering or intentionally not gender affirming, but out of ignorance or not having the appropriate training on gender-affirming care, it can lead to a lot of situations that trans people are extremely uncomfortable with and sometimes feel dehumanized by. Another good example of the way that trans healthcare works in comparison to everyday healthcare is surgery. When a transgender person is seeking surgery for alleviating gender dysphoria, then it's required that they meet certain standards that another person seeking surgery who's not transgender wouldn't have to meet, such as letters of support from mental health providers that have assessed and made sure that they're good for the surgery. We do the same surgeries on people who are transgender and not transgender, but the transgender folks have to get these letters and be assessed and have multiple steps through multiple providers even just to get in the door. Whereas, you know, a cisgender provider or someone who's not transgender would just go into the doctor and, you know, get the assessment from their provider, and then get the surgery that they need.
Anita Rao 10:46
Well, tell me about the UNC program, because you all have set up an environment in which you're trying to provide comprehensive care where someone may not need to go, you know, to a mental health professional to get these letters of recommendation in one place, and then bring it and talk to a surgeon and deal with maybe some confusion around what they want. So talk to me about the setup of this unique program. It's only about a year old, I guess?
Katherine Croft 11:07
Yeah, yeah, we started in 2019. And the goal was to really expand and make more efficient the health care for trans people at UNC. So what we do is we kind of have a top down approach where patients are able to contact us at the trans health program. And then we work with a network of providers within the system, and sometimes even without the system, in order to get them the care that they need with providers that they can count on who have been trained either by our program or by other training resources to handle gender-affirming care. So if a patient comes in and has multiple different needs, they speak to me or my team. We assess those needs, and then we determine the best providers to send them to. And our providers through that network and through the trans health program are able to collaborate a lot more. Before we started this program at UNC there were a lot of providers who are doing fantastic work for the transgender community. But a lot of trans patients have difficulty accessing those services. They were not necessarily made easily accessible to them. And what a lot of trans people have to do when they're seeking medical services is just kind of call around and, you know, hope you get someone that's going to be trans affirming or have some experience in trans care. So we take that out of the picture. Where you call our program, and then we match you with the providers that you need to get the services that you're looking for.
Anita Rao 12:42
For trans and gender expansive folks, their gender can sometimes be such a distraction for doctors, that it's hard to get proper care for a typical health issue. That was the case for Nick Smith of Raleigh who experienced a phenomenon well known in the LGBTQ+ community.
Nick Smith 12:59
Trans broken arm syndrome: You go into the doctor's office complaining about something that's wrong, and they don't necessarily not know about trans things, but they often are like ignorant of different kinds of experiences. And so they may just like try to blame what it is that you're experiencing — that's completely unrelated — on just the fact that you're trans, or like, you're taking hormone medications, or you've had this surgery, so obviously, this is going to happen, when it's not necessarily a side effect of what it is that you came in to have treated.
Anita Rao 13:32
Nick said they've tried to reduce the stress and potential harm of an upcoming doctor's visit by doing some recon.
Nick Smith 13:39
A lot of the times I'll try to call ahead just so that they will like understand and know in advance that they're going to be dealing with someone that's transgender, just so that like I can avoid some of the frequent awkwardness that might happen. But a lot of the times what's running through my head is: Are they going to be able to like match up my documents correctly? What is it that they're going to refer to me as? Am I going to have to explain my name to everybody that I interact with? What kind of medical history are they going to need access to? Are they going to ask me about like any kinds of surgeries or anything else that I have going on? Am I gonna have to stop my transition-related medications and stuff is a larger concern when it comes to anything like that might be serious that's going on, like car accidents or anything like that when recovering and such.
Anita Rao 14:27
Being othered at the doctor's office — at work, school, home — doesn't always look like overt abuse. Even frequent microaggressions can increase stress on trans kids developing bodies and take a toll on their mental health. Those include being misgendered, or being asked unnecessarily-invasive questions, or dead naming: The non-consensual use of a trans person's given name before they transitioned. Rebby Kern sees this happen a lot. They direct education policy at Equality NC.
Rebby Kern 14:59
It starts when we know that educators are not fully equipped with language and inclusive curriculum to be able to educate their classroom community to support young people. We're also understanding that 72% of transgender and gender-expansive young people report hearing their families making negative remarks about LGBTQ people. And that usually goes up when we look specifically at transgender people. And so, if the climate is not safe for gender identity and gender expression for young people, then that's a huge aspect of their social experience where they're gaining negative impact. And young people who are transgender or gender non-conforming, the data is showing that they're more likely to engage in self harm, to experience anxiety and depression overall.
Anita Rao 15:49
Rebby says it's important to normalize learning about gender, as well as race, for people of all ages, including little kids and the people who care for them.
Rebby Kern 15:58
We have folks that are transitioning as young as kindergarten, and so, we need to have age-appropriate responses for our folks as well. And at the peak of this time, to understand that anti-racism work is embedded in this. Our young folks of color are experiencing even higher marginalization when we really truly stack the data together. And so, all of this work is intersectional. It's continuous, and the more we educate ourselves, we can educate others.
Anita Rao 16:37
It's a beautiful thing to be seen and supported by a medical provider. Morgan Givens is the creator and narrator of the hopepunk storytelling podcast "Flyest Fables." I could go on a long tangent here and try to define what hopepunk is, but a better use of your time would be to just check out "Flyest Fables." It's awesome. It even has original music. Morgan is a black, transgender man who grew up in Charlotte, North Carolina. He now lives in Washington, D.C.
Morgan Givens 17:29
I didn't get any solid, you know, real health care by a doctor who truly made me feel seen until I came to D.C. And I found a clinic through research and word of mouth in the community. And they were like: Whitman-Walker has been around since, you know, the AIDS epidemic first started — since before that, and they focus specifically on, you know, queer, LGBTQ health — on making sure folks without homes, homeless folks, have adequate health care — undocumented folks. So they're really community oriented.
Anita Rao 18:06
Yep. Whitman-Walker Health is a nonprofit clinic-turned-community health center that's been around since 1973 in our nation's capital. Their tagline is: We see you.
Morgan Givens 18:18
And they have a doctor there, my doctor, I've had her since 2013. I found her, and I'm never leaving her: Dr. Lynsay MacLaren. I'm like: You're my doctor forever. But Dr. MacLaren specifically went to school with a focus in transgender health care, which is incredibly rare. But when I go to her — if I go see my doctor for my physical, it's like, okay, like, it's a regular physical. And then she knows the additional questions to ask like: Okay, have you been feeling well? Are you seeing any issues? [Are you] noticing anything when you take your hormones? Oh, also, let's do your bloodwork to make sure everything is — so she just really takes care and actually sees the person, and it's not this show. Like you can always tell when someone's trying to put on a show to prove how like progressive and accepting they are. And I'm like: I can see right through that man, you don't like me! So, why would I trust you with my health? Um, you know, especially because as trans folks, and as a black trans man, we're already ignored when it comes to getting any type of health. And then when we have issues, we have to push much harder to get our medical needs addressed. You know, ovarian cancer runs in my family, and I had a moment when I was not with Dr. MacLaren, ad these people at the other hospital would not take me seriously. I'm like: Look, you don't understand. My mom got it at 28. I know it's rare. I'm telling you: You need to run these tests, because my body isn't right. Um, and thankfully [it] ended up being nothing, but I was not truly heard. And so I think, you know, as a doctor, that's what I want is somebody who kind of just sees me, and I don't have to explain my humanity, because that's just a conversation I'm nor gonna have. I'm not gonna debate the the undebatable, if that makes sense.
Anita Rao 20:13
Makes perfect sense to me. On every other episode of "Embodied," you've heard from my parents, brave souls they are. But for this show, I thought it was important to hear it from the parent of a trans child who's living through the experience of helping someone they love dearly feel supported through what can be a uniquely uncertain and challenging period of youth development. You met Max Brown at the beginning of this episode. Now let's hear from Max's mom, Frances, who says her family was lucky to find doctors who knew how to help or to reduce harm.
Frances Brown 21:00
Well, we've been incredibly fortunatate. His pediatrician a few years ago, when we presented this to her, you know, she was very upfront about like: This is out of my wheelhouse, and gave us some materials as far as, you know, where to find more information. And then as luck would have it, they had a new physician that joined their team, and this physician was well-versed in transgender care, in LGBTQ care in general. That was incredibly beneficial to have as a family, because all of our questions were able to finally kind of be answered. And, you know, every parent goes through so many feelings. There are so many emotions to unpack with this. You know, you don't know what's right. You're not sure if if this is a completely true feeling for them initially. And that's all part of processing that as a parent, but what we learned eventually is letting them lead the way, informing ourselves, educating ourselves is what helps us get through this and having supportive medical care has been a huge, huge leg up in this process for us.
Anita Rao 22:20
Grant Holub-Moorman, Charlie Shelton-Ormond and Rebecca Martinez produced this episode. Thanks so much to them and to our sound engineer Jenni Lawson. Lindsay Foster-Thomas is our executive producer and content director. And Quilla created our original theme music. "Embodied" is a production of North Carolina Public Radio WUNC. When you give at wunc.org. it helps make more episodes of this podcast possible. Thanks also to Weaver Street Market: a worker and consumer-owned cooperative selling organic and local food at four Triangle locations in North Carolina. Now featuring online shopping with next day pickup: weaverstreetmarket.coop. I'm Anita Rao on an exploration of our brains, our bodies and taking on the taboo with you.