In this Exclusive Interview transcript, Joshua Safer talks with Diabetes in Control publisher Steve Freed during the AACE 2018 convention in Boston about transgender medicine and the role of endocrinology in treating transgender patients.
Freed: This is Steve Freed and we’re here at AACE 2018 in Boston. We have a special guest with us with a unique topic, who’s presenting here, and it’s Joshua Safer. Is that correct?
Safer: Yes, sir.
Freed: So, maybe you can give us the title of your talk. And then probably go into some of the details, what you would like medical professionals to take away from your presentation, so they can feel more comfortable with the topic.
Safer: Sure. My talk today relates to transgender medicine. I actually don’t remember the exact title of the talk, but the point of the talk is to frame the topic in a way that endocrinologists ought to understand it, so they can be the experts for hormone treatment of transgender people in their communities. The field has changed rapidly. We’ve certainly observed it in terms of public interest and such. But part of what’s happened also in the background that’s enormous is a recognition by the establishment medical community that gender identity is a biological thing and not just a passive thing. And that’s resulted in establishment medical organizations rising up and providing guidelines and thinking about what an evidence-based, science-based, approach to care for transgender people would be. And as we, the medical community, go through that journey and think that through, part of that includes endocrinologists knowing the hormone treatments, their logic pattern, the strategy, et cetera, and that’s what my talk today addresses.
Freed: So, what are some of the high points you’d like the medical professionals who’ll watch it to take away from…?
Safer: The main things that people should get out of my talk today are, first of all, understanding why the landscape changed. It’s not that we all became open-minded necessarily, although I think many of us hope we are, but it is more that even as somewhat skeptical scientific sorts waiting to see the evidence that it’s really happened, at least in the establishment medical communities where we have observed that. So, knowing what that evidence even is, so that as medical and scientific people we can be comfortable with what we do know and what we don’t know. It’s not that we’re bought into everything. It’s that we understand certain things and that we have a certain scientific approach, so that’s one. And two, is given that that’s true, what are some strategies for hormones? What’s the point? It’s not just throwing hormones at people. It’s thinking about why it is that the hormones even make any difference and how we’re going to use those hormones, so I would characterize that as two. And the third is something which should actually come easy to endocrinologists because they’re already using these hormones in similar ways for other conditions, how to monitor things and keep them as safe as they can be.
Freed: I was diagnosed with prostate cancer five years ago. And they put me on a female hormone to lower my testosterone and I wouldn’t want to have to go through that again.
Safer: Yeah. Sorry to hear that.
Freed: So, the side effects could be very drastic for people.
Safer: They can indeed. I can observe that transgender people are looking often to have the profile that matches their gender identity with the logic pattern being to have their appearance fit better with their identity. So people, as they walk down the street, treat them how they feel inside, and so that they feel that themselves. So, for them, it is not quite the negative experience that you just recorded but still, yes, it is profound and we need to educate our patients in terms so that they can anticipate the experience correctly.
Freed: What do you tell someone when they come into your office and they say that this is what they want and you’re the first medical person that they’ve seen?
Safer: We have no tests. We have no blood test. We have no brain scan in order to determine somebody’s gender identity. And so, that does make — that is a weakness. That said, most people who are otherwise sane and articulate can tell me their gender identity and be pretty accurate and pretty reliable with it, especially adults and even older teenagers. So, in my experience as a clinician, I don’t have any patients who are coming back to me and saying, “Oh, I guess, I wasn’t transgender after all.” When they’ve come to me and said they were transgender, it is pretty much it. It’s reasonably reliable. When I see somebody, I usually insist that they also have a mental health provider to help in case going through any of this is stressful which it can certainly be and can be in a surprising way even for the people who weren’t thinking it would be. So, I like to have that. Providers who are less comfortable, who see fewer patients than I do for example, might actually want that mental health provider to aid them with the diagnosis just making sure that it is really true. That there isn’t some other — that there isn’t a mental health concern that might be causing them to think they’re transgender when they’re not. But that’s about it. It’s actually much more straightforward than people recognize.
Freed: What do you see as far as the age of people? You get a transgender child, I would imagine it’s certainly more difficult, where an adult can make a decision for himself. Now, with the child, now you’ve got the parents you have to deal with. How do you handle that situation?
Safer: So, in broad terms, I divide people into three age groups. And so, the youngest age groups are those people pre-puberty and those kids don’t require medical interventions. So, my main message to parents is for the most part you can be relaxed about this because, one, we’re not going to do anything medically, so there’s nothing irreversible. And, two, you can’t brainwash your child to be transgender or not. And that’s actually the news to the medical community the past 10 years or so. We thought we could. We even tried. And our failure is part of the evidence that this is really some biological thing where we can’t change things. And that cuts both ways. And as much as we’re saying, “Oh, you can’t brainwash your kid not to be transgender,” if they are, they are — the flip side is also true. If you think your kid is going through a stage and they are going through a stage, and you say, “Well, okay,” and let them go to school wearing different clothes or different haircut, whatever — you won’t have accidentally let them become transgender. When they’re through with that stage, they’ll stop being transgender because it’s a biological thing and you can’t convince them. So, again, the point being somewhat trying to be reassuring to that kid’s parents of that age, just let them do whatever they want essentially. Next age, up, peripuberty. We have hormone regiments to delay puberty that we use for kids who enter puberty too early and we’ve used them for decades. And we can apply to transgender kids, so that we have time to think things through because we don’t have a test to know if they’re transgender or not, so that we can be thoughtful and conservative in our approach. And then the last age group will be the older teenagers or adults, where we’re quite confident where we stand and where we can start to implement hormones with confidence that this is the right thing to be doing.
Freed: As far as in endocrinology because you’re dealing with hormones, how many endocrinologists are really specialists in this field that you’re aware of?
Safer: The number of people who labeled themselves specialist in this field is very small. I’d say there are probably a dozen or so at this juncture. But part of my agenda and part of the reason why I’m talking here is because we all need to know this a little bit. Because wherever you are across the country, you are going to have primary care practitioners who are going to have maybe a handful of people who are going to come to them and say, “I think I’m trans,” or, “I think my kid is trans,” or whatever. And at some juncture that may be true and they may need some hormone assistance and the endocrinologist doesn’t have to be the big expert. If you’re just seeing the occasional person here or there, you don’t have to be the expert on the diagnosis or all the other pieces of it but you do need to know your hormones, that’s what you went through all your training for and that’s what everybody in the rest of your community is going to depend on you for and that’s the point of today’s talk.
Freed: So, if I wanted to get some — as a medical professional, if I wanted to get some information as to where to direct somebody, is there an association?
Safer: There is. There’s a professional association of transgender professionals called WPATH, World Professional Association for Transgender Health. There’s a US chapter which is actually a big chunk of the membership like you might expect, the US Professional Association for Transgender Health or US PATH. Those can be found on the web. And so, yeah, you can track people down. And then Endocrine Society has guidelines that came out in November, just the November revision along with AACE, the organization hosting today’s meeting which give some guidance and UpToDate, which is the online program that many physician use. It is [called] UpToDate, wouldn’t you know it’s not always up-to-date. And this subject though, it is up-to-date both with hormone therapy and with primary care therapy. So, for endocrinologists, those hormone chapters are current.
Freed: It kind of fits into the aspect of endocrinology because of the hormone aspect. Are most of these specialists endocrinologists?
Safer: Within the field of transgender medicine most of the specialists are still mental health experts and that’s because for so many decades this was considered a mental health concern. Mental health expertise is still important. These are very, very stressful situations. And part of our assessment, especially for kids, is making sure that there’s not something else going on. That it’s really just they’re transgender and not a mental health concern. So, mental health people have a big role but they’re still an out-sized fraction of the overall community from an era when we thought that’s all it was. And getting more medicine people whether they’d be primary care or endocrine specialists involved is actually an important thing. It’s an important gap in terms of being able to provide sufficient care for the people who are trans.
Freed: And most insurance companies are respectful in paying for these services?
Safer: In 2018, more and more insurance companies pay for these services. It depends on the state. I think we’re up to 18 or 19 states where insurance companies are obliged to provide transgender care. It would be considered discrimination if they did not. There are therefore a bunch of states where that’s still not the case. One thing I’ve noticed, living in two states where there is good insurance coverage for trans care, Massachusetts, where I’ve been working up until a few weeks ago, and New York where I just moved, that when that’s the situation, the insurance companies are not very worried about the cost. That is mental healthcare, primary care, endocrine care, hormones, are all relatively inexpensive interventions. The number of people who are transgender is much bigger than people realize but it’s still a relatively small fraction of the population. Even the surgeries that some transgender people have are not very expensive surgeries as surgeries go. So, the insurance companies that have come to me for assistance in their policies are pretty relaxed. It’s actually not a huge cost like some other medical concerns are. And so therefore, it’s just a matter sometimes of the states saying — it has to be and the insurance company saying, “Okay. Let’s get our wording correct, so we do the right thing.”
Freed: Do these hormones cause diabetes?
Safer: The hormones for transgender care are not known to be associated with diabetes. The literature says that people taking hormones in either direction, the conventional male to female or female to male, have increased rates of diabetes. Honestly, I wonder if they’re not just watching people age and accidentally observing that everybody has an increased risk of diabetes over time. I don’t know of any real specific evidence. I could invent some logic why it could be true, but I am not especially concerned that hormones in either direction should be causing diabetes or increasing the risk for diabetes.
For your patient with diabetes who is also transgender having diabetes per se is not a concern. The hormones do not interact with diabetes medicines and can be given safely to your patients with diabetes. The only concern is like with any hormone therapy when people sometimes have a change in their hormone profile, they have a change in weight. And if they gain weight, their risks of diabetes are increased. But if you can avoid that, this should be a perfectly safe thing to do.