Connecting trans youth to gender-affirming health care
Connecting Trans Youth with
Gender affirming health care
Izzy Lowell, family medicine physician and founder of the Transgender Health Clinic. queer med, once had a patient come to her for hormone therapy after 11 other health care providers turned her down. Each had not come with rude comments. Lowell was the first to treat them with respect, use her preferred pronouns, and offer help.
Health care for trans and non-binary people is not rocket science, says Lowell. But there is a shortage of accessible and gender-affirming health care for transgender patients. And political forces trying to block access to hormone therapy, an essential life-saving modality for those who seek it, threaten the long-term well-being of trans and non-binary youth.
In her practice providing transition services for transgender and non-binary people in the American South, Lowell has seen what comprehensive care and an affirming doctor can do for a trans patient: “It’s the best thing to see a patient come back three months after no change. , not different, but more trusting and fair themselves.”
A question and answer session with Izzy Lowell, MD
Gender dysphoria is the feeling that your body is the wrong gender for you. The word “dysphoria” means extreme distress and discomfort. I love my job because I can see people relieve themselves of this anguish that they have been trying to cope with all their lives. People who go through this process develop further into who they are.
There is a wide variety of people who come to us for help. Sometimes people come to us in a position of strength. They are ready to go and excited about the transition.
Unfortunately, many teens come to us after a suicide attempt, school failure, self-harm, or extreme depression, with families who may not accept them. They’re like, “We don’t know what else to do, so we’re going to try this.” We have patients who are in their 50s and 60s who come to us saying that they have wanted this all their lives.
Transgender medicine has a lot in common with medicine for all, with several broad categories and some key differences.
First is primary care. Everyone should have access to primary care, but many people, especially those in marginalized populations, including trans and non-binary people, do not. When we talk about primary care for trans patients, people get caught up in gender. The approach I use is simpler: if you have it, have it examined. If someone has breasts, they need mammograms. If they have a colon, they need colonoscopies.
Then there’s hormone therapy, which is what I do. Someone who is male but was assigned female at birth would need testosterone to help her body better match her identity. Someone assigned male at birth who identifies as female would be given estrogen. For adolescents who are in puberty or have not yet reached puberty, we might use puberty blockers to allow them a few more years to clarify their gender identity before starting hormone therapy.
Another category of care we think about is surgery, which is often first and foremost on people’s minds, but is a relatively small part of transgender medicine; many transgender and non-binary people do not choose to have surgery or may not be able to access it. Mental health care is also very important for many people, whether they are transgender, cisgender, or non-binary.
If a patient is ready and clear about their gender identity, they should be allowed to begin the transition as soon as their body begins puberty; that way they go through a single puberty to the correct gender at the same time as their peers. For those patients, that is the ideal way to practice trans medicine.
But not everyone is ready to transition at the age puberty begins, which can be as early as age eight or nine for people assigned female at birth. In that case, we use puberty blockers to delay puberty until the patient knows what they want to do next. It’s a misconception that puberty blockers, which have historically been used when someone starts puberty too early, necessarily cause permanent changes. Puberty blockers are safe and reversible.
That said, puberty blockers are not a complete solution. Let’s say someone assigned female at birth starts puberty at age nine, so we put puberty blockers on her and wait until she’s a legal adult: 18 or even 19 in some states. What we’re doing is keeping someone a preteen until she’s potentially in college. They are completely alienated from their peers. There could be potential long-term problems with keeping someone on puberty blockers for much longer than intended. For example, it affects bone density, which is completely reversible after several years on puberty blockers; however, these drugs were never intended to be used for a decade. Also, puberty is not just about changes in the body. It is also about the emotional and intellectual growth that makes us adults, and testosterone or estrogen play a key role in that brain development.
Quite often I see young patients who have already gone through puberty. For them, the process is more like an adult transition, except we slow down, gradually increasing their dose to mimic puberty.
For the first few years, things were quiet. No one really knew my practice existed. More recently, we have expanded into states where there is a lot of controversy surrounding trans medicine, such as Alabama and now Texas. They are reintroducing bills to make trans hormone therapy and puberty blockers illegal for minors. It has been stressful. For my own sanity, I don’t listen to the news or go on any social media. I have people do that for me so I can do my job.
I would also like to address the mental health therapy that is required prior to transition for adolescents. If everyone had access to affirmative, affordable, geographically accessible mental health care, I think that would be wonderful. What is short-sighted about the effort to make therapy a requirement is that access to care is a major problem and a major obstacle. In my practice, we strongly suggest therapy. I had a patient in Mississippi who was under 18 and she called five different therapists trying to find someone to see her. She was rejected because she was trans. It was a traumatic experience for her. She came back to me and told me that she couldn’t find anyone. Therapy is great for everyone, but it doesn’t make sense for therapy to be an absolute requirement for care if the therapy isn’t accessible, practical, or gender-affirming.
Parents’ main concern is that they don’t want to do anything permanently if they aren’t completely sure if this is the right thing for their child. There are also other questions about the reproductive organs and side effects.
Almost all children have done a lot of research these days. They know all about hormone therapy and what changes to expect, so they often already know most of what I review at the visit.
Teens with supportive parents, or whose parents are catching up wherever the child is, are often very excited and don’t want to delay anything. They want to make sure they start as soon as possible. Patients whose parents don’t support me but end up in my office anyway are hopeful but not necessarily excited, because they don’t know if they’re going to be able to start the transition or not. In general, the more parents learn about the effects of hormone therapy and how gradual the changes are, the more comfortable they feel supporting their teen’s transition.
Izzy Lowell, MD, MBA, is a family medicine physician and the founder of Queer Med, a telemedicine clinic offering hormone therapy for trans and non-binary patients. Previously, Lowell started the Gender Clinic at Emory University. She is a member of the World Professional Association for Transgender Health and the Gay and Lesbian Medical Association. Lowell regularly lectures to educate doctors and students about transgender medicine.
This article is for informational purposes only, even if and regardless of whether it presents the advice of physicians and medical professionals. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.