Transcript

Russell [00:00:02] Let's get stronger. 

Gates [00:00:04] Healthier. 

Prickett [00:00:05] Calmer. 

Russell [00:00:05] Smarter. 

Gates [00:00:06] Better. 

Russell [00:00:07] Living a healthier life is a journey. Not a destination. 

Gates [00:00:10] You can always get better. 

Prickett [00:00:12] Let's get better together. Hi. I'm Dr. Michelle Pickett. 

Gates [00:00:21] I'm Dr. Khalilah Gates. 

Russell [00:00:23] And I'm Dr. Susan Russell. 

Gates [00:00:25] All right, ladies. So, I am super excited by the topic of gender-affirming care. And so, as we approach that topic, I just wanted to kind of chat and see now what we're thinking as we're preparing and gearing up for this podcast. 

Prickett [00:00:39] I'm glad that I get to talk with you all, as well as our expert, to share this information and just shed light, inform people, so that we can provide the best care to the transgender community and let everyone in, just all of the community, understand how important it is to be sensitive and to know that there's options out there. 

Russell [00:01:01] I would like to come away knowing what terminology I should use, what things I should be thinking about, and how to be more thoughtful as a provider with transgender patients. 

Prickett [00:01:13] Let's get this conversation started. Transgender and gender non-conforming people have long faced inequities in health care. The Northwestern Medicine Gender Pathways Program, co-led by today's guest, Dr. Sue Jordan, is working to end those disparities by providing gender-affirming care. Thank you for joining us today, Dr. Jordan. 

Jordan [00:01:43] Thanks for having me. 

Prickett [00:01:44] So, how long has the Gender Pathways Program existed? 

Jordan [00:01:48] The Gender Pathways Program has been here since 2019, when we hired our first program coordinator, and it has really grown — actually tripled in size — since then. In the director role, I really just try to gather as many gender-affirming, trans-competent providers as I can muster from the system and try to coordinate our care and make sure that we have as many services available as possible. And if we don't have a service available, I go and find it. 

Prickett [00:02:12] I'm really interested to understand, you know, what led you to this career choice? 

Jordan [00:02:16] I was pretty lucky. I grew up pretty, you know, privileged. And I knew I wanted to become a surgeon. And the choice came. I became a plastic surgeon because I wanted to restore people and give them quality of life. And I didn't really actually think about gender-affirming care. And I came here, to Northwestern, for my residency, and I was really lucky to have some early exposure to the beautiful community that is the transgender and gender diverse community and how resilient they are and see what an impact that gender-affirming care can make. It's kind of an obligation. I have to be able to use those skills to help the people that are in front of me right now. As a plastic surgeon, I perform top surgeries and bottom surgeries. Top surgeries are surgeries on the chest, so it may be breast augmentation for trans women, or it may be a mastectomy, for breast reduction for trans men. Bottom surgeries are surgeries on the genitalia. So, maybe creating a new vagina, creating a new phallus. Frankly, from a pure technical standpoint, there isn't anything more quintessentially plastic surgery to reshape somebody's body, and it's technically challenging as well. There are so many parts of plastic surgery that are wonderful, but gender-affirming surgery is like a different level. 

Prickett [00:03:22] You're literally helping someone be themselves in ways that they couldn't otherwise. So, I can only imagine. So, we've heard you say "transgender," "gender diverse." And so, these are terms that we may not all be familiar with. So, before we really jump in deep in this conversation, we want to make sure that we're all on the same page with terminology and background. And so, with that in mind, can you give us an overview, and our audience as well, of a handful of terms that we'll be using today as it will relate to gender-affirming care, but also how we interact with people in our day-to-day and the terms that we really need to understand?

Jordan [00:04:07] So, it's really natural to be uncomfortable with the new terminology that's floating around. And I'll even admit, there are new terms that I learn every day as well. You know, everything is evolving. This is a part of society as we grow as a people. And then we're trying to intersect that somehow with medicine and the people that we come across with in our practice. So, just really briefly, we can start with "transgender." So, "transgender" is an adjective to describe any person who identifies as a gender other than the sex that they were assigned at birth. So, "cisgender" would be anybody who does identify as the same sex that they were assigned at birth. So I am a cisgender woman, for example. 

Gates [00:04:44] How about you define "gender"? 

Jordan [00:04:46] Oh, well, that's a good question. So, "gender" or "gender identity" is that deeply held sense, that internal belief of who you are and what gender you are — whether that's female or male, or somewhere in between. And then, the sex assigned at birth is the sex that, you know, the OB declares that you are. And that's often determined by body parts as a baby. So, that may be male, female or intersex. 

Prickett [00:05:09] And what about the term "nonbinary"? 

Jordan [00:05:11] Nonbinary, thinking about gender as a spectrum. So, most things in nature occur along a spectrum, rather than zeros and ones that computers kind of live in. So, "nonbinary" may mean that somebody doesn't feel completely a female, may not be completely masculine, but may be somewhere in between, or it may change depending on the situation. They could be gender-fluid. They could be agender, for example, and not identify as either gender. And all of those kind of fall under the umbrella of nonbinary. "Gender diverse" is a big umbrella term that encompasses that, you know, folks whose gender doesn't necessarily match that with which they were born. Another common term you'll see is legal sex. That's the little letter that you see on your driver's license and your birth certificate and your health insurance card. And those are things that can be changed according to the state that you may live in. Those are the big ones. You know, as I said, language is changing all the time. 

Prickett [00:06:03] What are your thoughts when people say, "Why do it? Why is it important for me to know? Why? Why are pronouns important? Why is this an important thing in my day-to-day life?" What are our thoughts on that? 

Jordan [00:06:14] I mean, we all have an identity. You know, we have a number of things that make up our identity, whether it's our hometown, our profession, our race or ethnicity, whether you are. Chicago pizza lover or New York pizza lover? I mean, we all have an identity. There's a lot of things that make up what we are, and gender is a part of that, and it's a big part of that. And so, you know, when you walk around town, you want to be respected for who you are. When you are interacting with another person, you want to be called where you want to be called. You know, if you call me Mrs. Jordan in some context, I may do a little, "You talking to me?" That's great, okay, because that's not generally what I go by. And so, it's important to address the people in front of you by how they want to be addressed. And gender is part of that, and pronouns are part of that. So, I use "she/her," and I think as society goes on, we may start to normalize introducing ourselves that way. "Hi, my name is Sue. I use she/her pronouns." And I totally get it. It can be hard at first. 

Prickett [00:07:09] I think the other thing I think about is how it can be fluid and it's one of the concepts that I think we can all relate to is, you know, "I've always thought this would be my life," or "I always thought this would be a part of who I am," and how that can change over time and with different circumstances. The transgender community may have felt that all along, and now they have an opportunity through different medical interventions, and it's our responsibility to reflect and respect those identities. 

Jordan [00:07:36] Nobody wants to hide who they really are. There's a little anxiety that comes with that, right? When you're trying to pretend who you're not?

Gates [00:07:42] Can we kind of elaborate on other pronouns that we may see, and we need to respect? 

Jordan [00:07:48] Yeah, a really common one that I get asked a lot about is "they/them." You know, people are like, "Well, it's plural and I can't change my sentence structure, and it's just not correct grammar." But we actually use "they/them" all the time. We haven't even thought about it, you know. "Oh, you know, whose backpack is that over there? You know, they better come back and get it, or somebody is going to steal it." Or somebody you've never met, "Chris is coming to relieve you." Well, if we don't know if Chris is a man or a woman like, "Oh, they'll be here in about five minutes." We've been using it all along. When we put that emphasis on making sure that you use that, all of a sudden people get nervous, and you're afraid to say the wrong thing and it's okay, you know, we're going to make mistakes. We're going to say the wrong thing. And I think that's another big point to make, is we're going to mess up and we should say sorry, and then we should move on. You know, this isn't about us messing up. It's about trying our best, getting it right. And if we get it wrong, try better next time. 

Prickett [00:08:38] Well, I think it kind of goes to what I've learned from Dr. Gates on implicit bias and intent and impact, too, right? Like so our intent is good, and we can have good intentions, but even with the best of intentions, our impacts may still hurt. We need to come at it with grace and apologize if our impact is not, what our, does not align with our intention. I was hoping that we could all just share a little bit about why gender-affirming care is so important. 

Jordan [00:09:06] Perhaps, you know, the most vulnerable time for folks is during transition, when they may be expressing their true gender identity or making steps towards medical transition, or even surgical transition is probably the flashiest moment. And so that all falls under gender-affirming care. But really, you know, health care is for the life span. And we all have cardiovascular needs. We all have cancer screening needs. We all have just our regular "I got COVID" or "I got the flu" needs and it's all gender-affirming care if we're doing it with respect for the individual's identity. "Trans-competent care" means that having that little extra bit of training or knowledge about, you know, the specific circumstance of the individual. So maybe addressing them appropriately so you don't alter their mental health by misgendering them. A big part of gender-affirming care, if you want to start from the beginning, is getting people in the door. It's really, really hard for trans people to come to the hospital because they don't know if they're going to be mistreated. And so, the first step is getting in the door. And then after that, you know, respecting somebody identity, understanding their hormone status, just like we would understand a post-menopausal woman's hormone status and how that affects our decision making, understanding their organ status. You know, "Do you still have a prostate? Then you need prostate cancer screening." "Do you have breasts? No? Then you do not need a mammogram." That sort of thing. 

Prickett [00:10:27] You're providing medical care to a very diverse population, and you want to be gender-affirming. What's an easy way? 

Jordan [00:10:34] Be open. So, start off, again, introduce yourself and your pronouns. Ask the patient what they would like to be called and what their pronouns are, and the same stuff you do. "What's your chief complaint? What can I do for you today? Do you have any specific concerns?" And that may open up some dialogue about. "Well, I'm really concerned about blood clots because I'm on estrogen." For example. "My friend told me this to ask you." I think one of the things that's difficult is patients feeling like they're going to have to educate us on what trans-affirming care is. But the thing is, you know, we've gone through a ton of school. We actually know all the science and evidence and stuff. It's in there. We just have to apply it to the situation that's in front of us and not treat anybody any differently because of it. 

Prickett [00:11:13] I think being open and asking everyone is really what I had learned early on in my career. I saw a very large LGBTQ population and it really put in a light how important it is to really normalize these conversations, that people do feel able to share and feel like they're an inclusive, safe environment. 

Jordan [00:11:31] Yeah, I mean, back in medical school, I remember being really nervous asking about like, you know, these little old ladies to use I.V. drugs? We ask everybody, to ask everybody the same questions because it may affect our decision making. And we want to make sure we don't miss anything. It becomes part of our checklist. 

Gates [00:11:44] And so along those lines, at Northwestern, we have Epic and then Epic, in the upper left corner, we have pronouns and I believe it's gender there as well. And so, what are the other things that health care can do to promote practicing gender-affirming care? 

Jordan [00:12:00] Letting people know that you're open and you're having these conversations is a great start. We are doing your best to educate the entire workforce. We have non-gendered bathrooms available because bathrooms are, you know, are a very big source of, well, frankly, discrimination if you don't have a bathroom available for your patients. Epic is a great tool for recording name and gender identity, sexual orientation as well. Pronouns, that's, you know, readily available. Patients can enter it on MyChart ahead of time if they feel comfortable. You know, at the end of the day, gender identity is self-reported. It is not something that we impart on somebody. They tell us what it is. And so, it's nice to have that that record up there. 

Gates [00:12:39] Earlier, you said that it was important to acknowledge and obtain information to prevent altering the mental health of this patient population. What is the impact that gender-affirming care has on those groups? 

Jordan [00:12:55] Yeah, well, the common statistic — that is just heartbreaking — is that 40% of transgender and gender diverse individuals have attempted suicide at one point in their life. That's almost half, like, every other trans person that you meet has thought about or tried to take their life. And it is overwhelmingly a much bigger number than the general population and even, you know, a larger number than the kind of, the broader LGBTQ community. Aside from that, we all know that minority stress can have a big impact on chronic health conditions like cardiovascular disease and susceptibility to other illness. So, gender-affirming care really gets at the root of that, right? So, we are accepting people for who they are. We are supporting them with mental health to help them explore their gender and how that may be impacting other mental health symptoms. There's been a number of studies that show that hormone therapy and surgical therapy, improved depression, anxiety and overall quality of life. That's undisputed. 

Gates [00:13:54] I think it just highlights the importance of acknowledgment and acceptance and pathways to actually deal with some of the challenges that different groups actually face, and not just ignore them or pretend that they don't exist. 

Prickett [00:14:08] And 40% is such a, oh my gosh, it's such a mind-blowing statistic and just, kind of, encapsulated how much trauma there is. It's a really low bar to bring that number down, and it could be just simple things and so grateful that there's a program like yours. 

Jordan [00:14:23] We have a really great team. Nobody that I have approached has ever said no, you know, like, "Oh, yes, how can I help? This is great." We need to bring more inclusive care to our institution and really make sure that everyone's welcome here. And we have a great team of primary care doctors and endocrinologists, psychiatrists and psychologists. We have great OB-GYN, urology, social workers, voice therapists. I could go on forever, but you know, it's, a lot of people have really embraced it. 

Prickett [00:14:49] Not everyone requires all those services, so not everyone that needs surgery might need hormones. Is that a true statement as I'm learning here? 

Jordan [00:14:57] Yeah, everyone every individual's transition journey is a little bit different. Some people may not want any of the medical or surgical transition services, and some people want all of them, for example. There's no one path, there's no one order. But everybody has their goals to make the external appearance match what they know to be true inside. And really, we're here to be a central resource, you know, knee pain or something. We can find a orthopaedic surgeon that we know is going to be affirming for you. 

Prickett [00:15:24] Is there a story that you could share with us to help us kind of summarize and understand the impact that this may have on patients? 

Jordan [00:15:32] Think back to kind of where it all began, for me anyway, and seeing trans youth during residency come in for top surgery, and top surgery is removal of the breast tissue to make the chest nice and flat and more masculine-appearing. And what you see is a nervous teenager, you know, come back after surgery and they've been able to turn the lights on in the shower for the first time, and they can look at themselves in the mirror and not look away. And it just never dawned on me until that day. "What do you mean? You were showering with the lights off, like, you can't even stand to look at yourself in the shower." And that was it was a big impact.

Prickett [00:16:11] So, Sue, what are some of the biggest obstacles your patients face for navigating health care? 

Jordan [00:16:15] Honestly, picking up the phone is really hard. And then, once they get past picking up the phone and finding a medical provider and then navigating insurance. Just finding that provider that is familiar with all of the available therapies. is hard because there still is, you know, a scarcity of providers. I am just so impressed every day about how resilient my patients are and how incredible the community is and how rich and diverse the community is. People really enjoy opening up to know new communities that they hadn't been part of before. 

Prickett [00:16:49] To know that there's a community that has been feeling this for so long, and there's things that we can do to help, not just medically, but also in the mental health venue to really make things better and to alleviate some of the stressors and concerns. Getting the pronouns right is a good first start but having the tools and access to folks that are understanding and can put those tools to use and apply them to what patients are asking for and within the needs of patients is so heartwarming because that's why we go into medicine, is to help people be their best self, whatever their best self is defined as. So, with that, thank you. Sue, Dr. Sue Jordan, for joining us today in our podcasting endeavors. 

Jordan [00:17:31] Thank you so much. Was a lot of fun. 

Russell [00:17:37] Thanks for listening to Get Better. 

Gates [00:17:39] We hope you leave this podcast better than when you started. 

Prickett [00:17:42] For more information, visit NM.org/healthbeat.