Jessica Halem is on a mission.
“We’re thinking about recruitment of the next generation of doctors,” says Halem, an LGBTQ+ outreach and engagement director at Harvard Medical School. “Young trans people are such incredible advocates, and have learned so much about how bodies work. You can ask a trans person at the age of eighteen about the endocrine system and they know so much — these are exactly the people we want to see as future physicians.”
Halem is part of a three-year initiative at Harvard Medical School to change the way that doctors provide care to sexual and gender minorities. Recruiting more transgender physicians is just one aspect of a revolution currently underway in medicine, with the goal of providing the best possible care to young people who have questions about their gender. Over the last few years, numerous hospitals, schools, and clinics have established groundbreaking new programs to improve access to both information and treatment.
At a time when the Trump administration is stepping up attacks on LGBTQ+ medical access and patients still struggle to find affirming care, it’s never been more urgent for medical providers, educators, and activists to ensure that doctors can address the needs of trans youth.
“Traditionally, gender-affirming care has not been the provenance of primary care,” says Dr. Ethan Brackett, site medical director of Fenway Medical South End. Transgender patients often find themselves referred to endocrinologists or other subspecialists, particularly when it comes to pediatric care.
Brackett’s working to change that.
“Hormones and puberty blockers need to happen in primary care,” he says. “Families and kids should not have to wait six months to see a specialist.”
The teen years are a particularly crucial time to provide prompt, medically-sound care, experts say. “Puberty, regardless of gender identity is a time when young people can experience a lot of stress around the changes they’re experiencing,” says Lucinda Holt, a sex educator and the director of communications at Answer, a youth-focused education service from Rutgers University.
The stress of puberty is often compounded when a person experiences uncertainty around their gender, Holt says. “We know that so much of the discrimination that trans people expeirence can lead to higher rates of depression and anxiety, and that can be avoided when young people feel supported.”
Answer also launched a video series called AMAZE, featuring animated videos about sexual health for viewers aged 10 to 14. That includes a recently-added age-appropriate video about gender identity, expression, and medical options.
“The faster you can address dysphoria or stressors that kids and families are dealing with, the better the outcomes,” says Brackett. “Many of the kids we see are coming in with comorbid behavioral and mental health concerns, and we want to have a multidisciplinary team surrounding them as they go through an affirmation and transition process.”
That team-based approach to transitioning, which can include social workers, refill specialists, therapists, and more, is relatively new. So far, Brackett says, they’ve found that swift holistic care can mitigate suicidality, depression, or school failure.
“One of the more positive aspects of my job is ushering kids and families through this process,” he says. “It’s very gratifying. It’s one of the ways I feel effective as a caregiver.”
Another shift is a movement away from treating gender dysphoria as though it’s necessarily an illness, Holt says.
“Instead of making this about something that’s a problem, we approach it as, ‘oh this is how this person identifies, how do we support them?’” she says. That support could take the form of working with the young person to figure out whether they want to come out at school, if there are pronouns that align with how they feel, discussing how they want to dress, and whether puberty blockers are appropriate.
Social support systems are appearing in new forms as well. Georgia Messinger is a co-founder of The Trill Project, which created an app in which young people can find peer support. Though anonymized interactions, Trill allows users to follow conversations around particular tags.
Many of their users left Tumblr, Messinger said, due to that platform’s increasing problems with automated filters blocking discussion of LGBTQ+ issues as “adult.” In contrast, Trill conversations are monitored by actual humans, many of whom received training from crisis hotlines.
The Trill team is currently working with a research university on a study to more specifically identify the health needs of their users. Once that data is established, they’ll be able to apply for grants.“We can be a resource that has follow-up, and use the Trill content channel to see what messaging works best, or how people transitioning can best receive information,” Messinger says.
Better delivery of information is a key component of improving medical care. Although knowledge about transitioning is more widely available online than ever before, much of that information is incorrect, out of date, or from sources acting in bad faith.
For example, “there’s a misconception that puberty blockers are dangerous,” Brackett said. “I think they're actually a lot simpler than gender-affirming hormones. Their effects are reversible, and they don’t have nearly as many scary contraindications.”
In addition, he said, many patients expect their transition to be more rapid than is possible or advisable. “We’re engineering second puberties and puberty is a long process,” Brackett says. “An affirming puberty has to evolve at its own pace. It’s hard to fast-track it.”
Another misconception is that gender issues are simply matters of fashion and trends, says Mauro Cabral Grinspan, executive director of Global Action for Trans Equality.
But in truth, he says, there’s more discussion of transgender issues now because visibility has improved. “So they learn to put words to their own experiences,” says Cabral. “We have people saying, ‘how can someone be sure about your identity if you’re twelve?’ And one answer is ‘of course you can be right about yourself if you’re twelve.’ The other answer is, ‘who cares?’ If you’re not sure, and you try something and it doesn’t work for you, what is the problem with that?”
But, Cabral adds, America’s uniquely awkward healthcare system presents unusual challenges to improving care.
“The problem with the U.S. — it’s particularly hard,” Mauro says. “It has to do with how restricted access to healthcare is. It’s easier to de-pathologize in countries where people have access to universal healthcare.”
Nevertheless, momentum is unmistakably picking up at a remarkable pace.
“We started this feeling like, ‘oof wow we’re dealing with hormones, this is scary,’” says Brackett. “We haven’t lost that attention to detail, but the practice of doing it over and over has made us feel less gun-shy. Because we have so many more patient and family experiences under our belt, we can get to know the families and kids that much faster and meet them where they need to be in a medically appropriate way. We’re able to move a lot quicker than we used to.”
Innovations in care are likely to improve even faster as more openly queer people move into medicine. When Halem started at Harvard Medical School give years ago, she says, four percent of the incoming students identified as LGBTQ, compared to fifteen percent in the current incoming class.
Other institutions are focused on expanding trans-inclusive care to settings that are less focused on LGBTQ+ populations. To that end, The Fenway Institute created Transgender Health ECHO, a videoconferencing platform in which health centers can work together to create support systems.
“There’s only so much you can do from a magnet health center,” said Brackett. “The more we can standardize this as an expectation of what primary care and pediatric practice is, the better.”
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