This is 20-Minute Health Talk. I'm David Reich-Hale. in recent months, more states have debated and even passed legislation that limits how health care is delivered to transgender individuals. In the last year alone, more than 20 such bills have been passed Nationwide in part 1 of this special two-part conversation, we take a closer look at the impact these laws are having on transgender care with a panel of experts at the local state and federal level.
In part two, we discuss PrEP injectables the newest treatment for HIV. The injectable received FDA approval in December Here to discuss these topics are Dr. David Rosenthal. Medical director for Northwell's Center for Young Adult Adolescent and pediatric HIV. He is also medical director for the health systems Center for Transgender Care.
Joining us remotely are doctor Demetre Daskalakis, who serves as the CDC's Director of the division of HIV/AIDS prevention, as well as Dr. Charles Gonzalez, who serves as the medical director for the New York State Department of Health's AIDS Institute. Thank you all for joining us Dr. Rosenthal, when you appeared on the show in 2021, we spoke about legislation in various states restricting, medical care for Trans youth. Sadly, we are having some of those same conversations today.
Most recently with a controversial law in Alabama, attempting to criminalize gender-affirming treatments, like puberty blockers. With that said, how can healthcare professionals help patients and their families feel safe? Dr. Rosenthal: So, I think that this whole concept is very, very complicated. I want to take it apart into a few pieces. One is that I think that it is critically important that the medical relationship between a doctor and their patient remains sacrosanct.
And I think that what we need to do is we need to make sure that we can provide the best kind of medical care to individuals to figure out what's going on. I take care of a bunch of trans youth and a bunch of trans youth from communities of color.
And I think it's essential what we're able to do is, is there were Able to realize that we're treating them along their Journey because everyone who has gender diversity, everyone, who has a gender identity that's different than their sex assigned at birth, is on a path and has a journey. And what we need to do is we need to make sure we're finding out what their journey is and we're helping them to be their authentic self. While at the same time, we're doing things that make sense.
Looking at the the impact both on their physical and mental health currently and into the future, because both of those things are really important. And so we need to talk about the importance of the high rate of unfortunately of suicidality that we see in transgender youth, we need to talk about the self-harm and the self-cutting that occurs within transgender youth.
We need to talk about the fact that we need to make sure that we're helping people provide a direction and steps that help them see themselves as being authentic. And making sure they can be happy and healthy and the work that they're doing. And one of the really important points that we talked about with this is that you know the first step for a lot of individuals is a social transition. It's cutting someone's hair.
It's wearing a binder, it's being called a different name that they were assigned at Birth. These social and identities are very important in creating supportive environments for teachers and families and schools. That endorse these things that let the young person develop and identify as themselves is, critically important.
Following up on that actually, Alabama's new law attempts to among other things, ban hormone therapy and puberty blockers. A federal judge has issued a preliminary injunction blocking most of its provisions from going into effect, stating that appears to be discriminatory Dr. Rosenthal what are puberty blockers and why are they a necessary treatment for some transgender youth?
Dr. Rosenthal: Hormone blockers are puberty, blockers is an early intervention that we can put into place for a lot of individuals and what this does. is it basically halts puberty where it is and stops it from moving forward It's sort of like an audio tape that you put on pause, or it's an MP3 that you put on pause. And what that does is it lets the young person determine more what's going on with themselves It lets them become their authentic selves.
It gives them a chance to do things and the advantages is these medications have been given since the 1970s for children and during puberty early, and they don't have long-term sequelae on fertility and other things like that that we've seen in the medical literature. Even through two generations that we've been able to see. So it's important to realize we're talking about doing interventions for transgender youth we're not talking about doing something that doesn't make any sense.
We're talking about really treating them for who they are, and helping them to figure out how they can develop through their life. And that's a really important piece, I think that's misconstrued and
misunderstood greatly by politicians and by communities. And the other piece that's very disturbing to me also, in the literature, and we've been seeing is that if you have two Mommies and you're in kindergarten, you should be able to talk about your mommies when you talk about what you do at school that day. You should be able to talk about what's going on in your life, and your home and your family. And those are important things for us to consider and to talk about as well.
So I think there are some certain challenges that we have, but I think providing Health Equity and providing appropriate, gender specific care to individuals is highly important and really critical in order to maintain that and really figure out how we're going to do that. And I think that that will help open the door to having healthier and safer youth. Turn into healthier and safer, young adults, as they continue to go through this Cascade.
Dr. Gonzalez thoughts, Dr. Gonzalez: I want to Applause, I really do. I think that that's absolutely beautiful, David. I would just add that no one in the history of the world has ever been forced to take a puberty blocker. Okay? This is something that's offered and no one is forced ever. Take it. I mean, just on the most basic level. And the discussions that one has if you don't if you are unable to trust your clinician, then you
have to get another clinician. But that trust is absolutely essential for any therapeutic, emotional or advice. That's given to a young person or someone transitioning at 70. It is a it has To be there. And if there is any fear on either the provider or the person in their cares, part that there were going to be legal repercussions or difficulty, that trust is blown up almost immediately, and very little can go forward.
What message would you have for patients and their families in areas of the country where these sort of laws are being? Debated. Dr. Daskalakis?
Dr. Daskalakis: You know, one of the things that people maybe don't know or haven't seen is the data that we have from our division of Adolescent and school health around what happens if you have a supportive environment for LGBTQ children or young adults in schools, what happens is that the depression scores and all of the other mental health indicators in those schools. Get better for everyone, not just for the LGBTQ kids.
So really creating an environment I think that is hard for any individual, especially an LGBTQ person ends up being detrimental for others as well. So, it's just, you know, that the sort of aggression there is one that rubs off even beyond the communities that are actually experiencing the primary aggression. And I think, you know, I can't really comment on specific legislation in jurisdictions.
But in terms of messages to people who live in jurisdictions that are restrictive in this way, it's to really keep that that that connection with your provider as strong as possible. And that you know, in the sort of medical environment, you know providers need to do what's right for the individual in front of them. And so don't hide from the providers. And from the people that care for you, even if there's an environment that makes you feel less comfortable.
I's not a perfect answer but it's the first thing that popped in my head which is that the attempt to silence should not actually result in silence Dr. Gonzalez what would your advice be? It's incumbent upon a health care provider to swing that bat in protection of his and her patients and their patients. It is absolutely necessary. That comes with your obligations to protect and to seek the best care for your patients. It's just it's just there.
The glib answer is always, you know, what was done in the 60s are Greyhound bus tickets, family moving to other jurisdictions, which will happen because parents will want to protect their children as much as possible. What Dr. Daskalakis was talking about was this opening up of the community discussion allows the betterment of the entire Community.
It is not just; the point here the political point that's made is to marginalize the marginal, the already marginalized, and that it has never been helpful. It has made, for example, the HIV epidemic for longest period of time go underground. It still has a little reasons for other sexually transmitted diseases and infections to go underground.
The idea that your marginalizing folks that are already feeling marginalized is detrimental to human health and to communities at large and to individual well-being Dr. Rosenthal: I think this ties into the data that we saw earlier with suicidality among trans youth, basically being somewhere in the 42 to 58 percent for ideation, we're seeing bullying that's occurring in 36 percent of individuals, based on something came out of vital signs
using 2019 youth population survey data. We're seeing about 2% of the population that identifying as transgender. So what we're understanding and what we're talking about is real people that are really experiencing these situations and how we need to make sure they get the care they need.
I was at South by Southwest talking about transgender Health, with a panel of individuals, really, an interesting conversation and someone from Oklahoma was telling me that they're already getting calls from individuals about how they can get the care. They need How they can make sure that they can take care of their transgender kids and how we can really make sure we need to do what we need to do.
I think just over the a couple of days ago in Texas, there was thankfully part of the law that came through was partially blocked by some work that was done by Lambda legal and the ACLU regarding some of the issues that were happening in Texas.
And and not being able to and finding people and bringing child abuse charges against those parents that were initiated by the governor and I think, what's important is that where we allow is as we allow for protection of children, using the standard modalities that we need to protect children through just like, we have always done so rather than politicizing this and rather than taking this to a political realm because I think that healthcare should be for everyone
children should be taken care of by everyone and we should make sure that we're not turning people into Political footballs for no reason whatsoever. How do we continue to message this? Because in some, in some parts of the country, this Barely acceptable or mostly acceptable but in other parts of the country, not so much. Dr. Rosenthal: I think culture and politics are making a big difference here.
And I think the problem is what we need to realize is that we need to identify the medical issues. And we need to let medical providers that want to take care of patients, provide the proper Medical Care using standards that are universal. That are there are substantiated by evidence, and by best practice, and guidance, both throughout the United States and through the world.
And I think that if we are allowing the conversation to occur between doctors and patients in letting that become the relationship by which the proper care is being delivered that is the key message how we can make sure that people are being taken care of properly.
And I think that, you know, Charles said earlier, Dr. Gonzalez said earlier, if you can't find a doctor that you can talk to about your sexual health, if you can't be honest about your sexual health, if you can't be honest, about your gender identity or sexual orientation with your provider, then find a doctor that you can. Because it's really important that you have that relationship where you can be your authentic self to the people around you, including your healthcare provider.
Dr. Gonzalez: And healthcare professionals were based on data and the science behind it and those are the decisions that should drive the discussions. And we need to stand on that as fact, not trying to come into arguments of political persuasion. That's not what we're there for. I mean, we can swing a good bat when we need to but Same time. It's when we are speaking. And to our patients, we're providing the best guidance based on evidence, based on data.
And based on reality, not someone's figment of what political reality should be Dr. Gonzalez... Dr. Rosenthal: Now I'm giving you snaps And Dr. Gonzalez, is there sort of hope that that will be able to educate enough of the public to, where these sort of conversations are no longer that political and are Or sort of tied to pure health care? Dr. Gonzalez: Well, you know We've come far. We haven't come far enough. I think that's fair.
And these, this is the intersection of what culture and politics get us to. But we have expanded that mindset to the point where you can now put You know, ads; perhaps not late night but reasonably on for The things such as PrEP, such as medications that will suppress your viral load. These are ads that essentially mimic the social acceptance of U equals U. What affects one member of our society. What determines one community in our society comes back and hits us all.
It's just even if it's only in terms of self-interest, if you make sexual activity illicit if you make pregnancy and abortion illegal, this will come back to every member of society this is always happened. And if you do it to one group, you will do a to another this is, you know, We have this melting pot idea. Our Canadian cousins talk about a mosaic and mosaics are what make culture and having different groups protecting each other and access to care is what makes it very beautiful Mosaic.
And tightens the links between communities, because communities; there, you know, you can consider yourself, you know, Hispanic and gay. But, where do you, which Community belong to? We are all multifaceted too many communities. And, you know, you start cutting off certain ends, you end up, you know, with no one in the community, there's nobody left, it's just very peculiar, but yeah, we've Advanced a great deal, but we have not openly discussed this for a while.
Okay, we have not openly discussed how members of brown and black communities are more affected by HIV which is part of less access to healthcare generally, which is part of equity. And those things are not, haven't been until Covid, front and center of our conversations.
As we've said, everyone said a thousand times that Covid has ripped that part of the facade or of the, you know, political pablum, if you will, off, Dr. Rosenthal: No, but I think with that, I think that that actually is a great lead in very much to the work that we were doing about six months ago when we were really talking about Health Equity and setting, competencies for healthcare providers for Health Equity.
And also kind of trying to set competencies to support those Healthcare institutions in order to create that Health Equity. Because if we don't necessarily find ways to address social determinants of Health, if we don't find ways to kind of equalize issues and making sure that we're able to address things across the board with poverty, food stability, housing stability all of these other social determinants of Health LGBT status.
We need to make sure that we're using, we're able to overcome these in a real substantial way to affect, not only ending the epidemic for HIV helping people get on PrEP that needs to be on it decreasing STIs. But also really to helping us have a healthier population as a whole. So I think that these competencies that we've talked about that we started setting out, really helped form the groundwork. And then the question is, how are we going to be able to move that to the next step?
How are we going to be able to continue to make sure we have healthcare providers that really can make that happen. Dr. Rosenthal you mentioned a set of Health Equity, competencies are issued by the New York State Department of Health. For context those four competencies include 1. Addressing social determinants of Health. 2. Taking an active role in community and institution. 3. Employing a person-centered model of care, 4. Seeking to avoid bias and provide affirming Services.
Dr. Gonzales, can you talk a little bit more about this? Dr. Gonzalez: Thank you for that lead in. You know, we did develop these competencies or what we discussed is, competencies for healthcare providers. That go beyond HIV, and STIs.
And we did it to try to be as practical as possible simply because, you know, for the vast majority of providers 65 to 75 percent of patients interactions are pretty easy It's the remaining, you know, 15% or so that provide most of our difficulty, whether it's social determinants of health or Or, you know, substance use or any of those. And those are the things that providers are, you know, essentially throw up their hands about not knowing what to do next.
And we come up with some very practical for points upon, which they can build on, you know, in terms of Engagement and to help someone through these interactions both on a person-to-person basis, but also a second set of competencies so that they may affect something within their organization.
But it really matters is that the clinician has a community responsibility and the need to convey engage with their community and to be known in their Community as someone who will protect both, their private medical issues, but also be issues and the needs of their Community. It's absolutely necessary for that to be done. It cannot be done alone. But to say that, we as, as clinicians that, this is not our Province.
It's just when eighty to ninety percent of all the chronic conditions and acute infections that were talking about are essentially determined by Often by your ZIP code, you know, in New York City We've looked, even if you go to the more prestigious academic institutions, your viral load suppression is more correlated with your zip code than where you're receiving care. That's extraordinary. That's extraordinary, same Health Care. Same thing.
We need to engage and have the community trust once again, the healthcare provider in years past the, the doctors word was was golden okay. We may not want to return to that level because there's a power dynamics that makes it very difficult to engage communities and to engage folks for their lived experience. But that's one of the things that we've sort of tried to do in our competencies to discuss, you know.
And to realize the difference in power dynamics and to engage what's important to that individual and to their care and their needs. Not just their physical needs, but their psychological needs. Whether that is fear of, you know, poverty or fear of developing diabetes. These things are incredibly important and underline the absolute need for a trusted and therapeutic relationship. This has been part one of our conversation with Drs. Rosenthal Daskalakis and Gonzalez.
In part 2, we discuss the newest tool in the fight against HIV — PrEP injectables. Thank you for joining us on 20-Minute Health Talk. I'm David Reich-Hale. Have a great day.