BU Today: Okay, so what do some of these services look like in practice? Regarding endocrinology, what does hormone therapy entail?

Cohen: A lot of it is helping folks get the hormone therapy that they want. You’re giving estrogen or testosterone in different forms and in different amounts based on what people are coming for. So, if I’m seeing a new trans masculine patient who is seeking testosterone therapy, we’ll work together and go over medical history, risks, benefits, and what form of testosterone they want, i.e., transdermal or injection. Similarly, if I see a new trans feminine patient, we’ll go through their history, explore their specific goals, discuss risks and benefits of hormone therapy, and initiate treatment based on their preference of estrogen (oral, transdermal, or injection).

I usually see folks in follow-up every three months for the first year after initiating hormone therapy. The purpose of these visits is to check in to see how people are feeling, reassess their goals, and monitor for any side effects. Based on an individual’s goals, blood work may be done on those visits and testosterone or estrogen doses may be adjusted. Once folks have reached their goals with hormone therapy, I usually see them twice a year or annually in follow-up.
 
My other job is to assess what else people are looking for besides the effects of the hormones. I might be their first avenue into gender-affirming care; maybe they haven’t yet met a behavioral health provider who they feel comfortable with. Or maybe they’re seeking behavioral health because they need a letter of support for a surgery they want. So I often send folks to my colleagues, too.

BU Today: And what about GCC’s behavioral health offerings?

McGrath: Ellen, myself, and Micha all hold behavioral health clinics. A lot of that is related to identity work and understanding what patients’ goals are, or maybe dismantling internalized transphobia. 

Ellen Ijebor: Something I’ve been noticing in my time working with this population is that a lot of [what we talk about] is just life stuff in general. Identity, or coming to terms with one, isn’t the end-all and be-all. For some folks, that aspect definitely spills into other things. But it’s not this big struggle.

McGrath: That’s a very crucial point. As behavioral health providers, we do hear a lot [from patients] about discrimination and harassment and stigma. But, there’s also a whole lot of joy in this population. And I think it’s super important to lift that up. Our work is really all about meeting folks where they’re at—and that may or may not be focused on their identity. And I think it’s important for those who are new to this type of care to not assume that just because someone has a trans or gender-diverse identity, that that’s their whole focus. 

Pam also hosts something very beautiful, from my perspective. There’s a specific support group for neovaginoplasty. To be invited to it, you either have to have your surgical date set or have already had your procedure. There are women who show up five years out from surgery just because it’s this place of support and of information. I think it’s a really beautiful thing that we offer.

BU Today: Speaking of surgery, are there hoops patients have to jump through before they can undergo some of these procedures?

Carl Streed: Yes. A lot of them are insurance-dictated. Some of them are holdovers from prior standards of care that end up being more gatekeeping. In general, insurance requires letters of support that attest to somebody’s gender identity, that they are in fact stable in this gender identity. And, that surgery is in order to treat quote, gender dysphoria, unquote, which not everybody has—they can actually have gender euphoria, and be happy with their gender and be pursuing treatment to further align their gender identity. But insurance requires dysphoria to be what we’re treating. 

There are certain parts of the letter that are helpful, and which arguably should be applied to all surgeries. Like, what’s your support system? If there are other behavioral health issues you have, how are we going to address them, regardless of what the surgery accomplishes? But I think it’s worth noting that for some of these procedures, if you’re cisgender, you don’t require a behavioral health evaluation or a letter of support. You can get breast augmentation, you can get facial procedures.

Bensley: There’s also a waiting list. Part of the reason why wait-lists are longer for non-trans or gender-diverse care is because there are limited resources [compared to other kinds of care].

Streed: Right—10 years ago, if you wanted to be a surgeon who does gender-affirming care, there wasn’t a way to do that, unless you knew the surgeons who were doing it and sought them out to receive special training. Now, there are a few fellowships in different places in specific specialties, such as plastics, urology, and so forth. BMC is one of the places where, if you access urology services, you will have exposure to gender-affirming care. That was not the case 10 years ago. That’s why you have this bottleneck: many surgeons and clinicians know nothing. And the ones who do are new and still growing their practices.

BU Today: It seems like there are a lot of misconceptions about gender-affirming surgery in particular, and especially around the speed and frequency of people “suddenly” seeking surgical services. Can the team explain why some of these beliefs are misguided?

McGrath: No one wakes up, [decides they’re trans], and then tomorrow is seeking surgery. I would say most people have had a through line, maybe not through to childhood, but to when they first had the freedom to consider themselves. It takes, from my perspective, a lot of courage to choose to access this care. 

Bensley: And, sometimes those realizations are more sudden, just because someone hasn’t had the space or capacity to dream or really connect to themselves. Maybe they needed to not think about that part of themselves in order to survive within their contexts. And then all of a sudden, they either get access to a community, a therapist, or a friend that gives them that space. And then they’re like, “Oh, okay, there are more possibilities.”

Streed: Also 10 years ago, no insurer was required to, or would even think about, providing coverage for gender-affirming care. So if you needed to use insurance [for desired procedures], you couldn’t. And there was no incentive for the healthcare system to provide coverage. When people say, “There’s an uptick in surgery these days”—that’s because payers actually started paying for them. And therefore more surgeons could actually get people in; healthcare systems could make it make sense for their bottom lines.

BU Today: What else do you wish people understood about your work?

Pam Klein: What always resonates with me is that the care we provide is judged to be gender-affirming care, when it should just be care. I don’t want to be the only person who can do what I do because I have this specialized training. Maybe someday, people will be able to go to their primary-care providers or to any endocrinologist and get hormones or go to any plastic surgeon for at least some of these procedures.

Streed: Gender-affirming care is not a new phenomenon. And we’re practicing evidence-based care. There’s research to back up everything we’re doing. And patients, in larger community outcomes, do better when it’s the clinician and the patient and their support systems making decisions, not politicians.

Cohen: In [my speciality] endocrinology, there’s so much joy. People are not coming to you because they’re sick. They’re coming because they need your help to get them to where they want to be. Oftentimes there’s this change, where at first, someone might be worried or sad or really anxious and unsure. And then over time, you see them become more confident or really just more themselves. For me, there’s a lot of joy in being on the other end of that.