Across Boston, Gender-Affirming Care is Just What the Doctor Ordered

It is past noon, and the sun rays shine through the sixth floor windows of the Lowry Medical Office building in Longwood, where Jamie — whose name has been replaced to protect their identity — is sitting in a sparse exam room. Across from them is Harvard Medical School associate professor Michael S. Irwig, an endocrinologist at Medical School teaching hospital Beth Israel Deaconess Medical Center where he serves as the Director of Transgender Medicine. Jamie is anxious to explain the changes they’ve experienced in the months since their last visit — they’d been having online conversations with other transgender people and experimenting with a more masculine wardrobe, which helped reaffirm their identity as a non-binary person.

Irwig prods deeper: “Going to the support group — has this helped clarify anything for you?”

Jamie traces the history of these feelings.

“Your first period, what was that like?” Irwig asks. “What about breast development?” “What features do you want from the testosterone?”

Like Jamie, most of Irwig’s patients come in for the management of their gender dysphoria. Irwig reviews their bloodwork and medications, conducts a physical exam, and asks questions about their identities to see if starting or changing their dose of testosterone or estrogen would be appropriate.

In all respects, Irwig seems like a pretty ordinary physician. He wears loose khakis and a button-down shirt and tie. His white coat hangs on a hook by his door; there is nothing in the pockets except for a plastic model of a thyroid. His gaze shifts between the patient and his computer as he keys notes into the electronic record matter-of-factly.

Irwig is also one of the leading experts on transgender healthcare and hormone replacement therapy as an experienced clinician and researcher. At BIDMC, he leads a team across multiple specialties — dermatology, gynecology, plastic surgery, primary care, speech and voice therapy, and urology — dedicated to helping transgender and gender non-conforming patients access care before, during, and after their medical transitions.

Gender-affirming care combines a range of social, psychological, and medical specialties to help a patient live in a way that aligns with their gender identity. For now, it is a small world: most of the male transgender patients who came in to see Irwig that day had their “top” surgery performed by the same surgeon in Boston. Throughout his career, Irwig has pushed for hospital-wide and nationwide initiatives to educate more clinicians on gender-affirming care.

Before Irwig joined BIDMC in 2020, the hospital did not have a group dedicated to gender-affirming care, so he had to start “from scratch,” he says.

“There wasn’t a program, but there were these individuals doing this work,” Irwig explains. He pulled them together to form a collaborative team and opened the BIDMC’s Gender-Affirming Services in February 2020, a framework that allowed him to recruit other practitioners. “Once we had this program, that then took us to new heights.”

The BIDMC Gender-Affirming Services department is just one of many gender-affirming healthcare programs that have opened at Harvard’s affiliate hospitals within the past few years. The Transgender Health Program at Massachusetts General Hospital launched in July 2018, while the Gender Multispecialty Service at Boston Children’s Hospital has existed since 2007. They each combine a range of medical specialties and social services to serve gender-diverse individuals while advocating for increased clinical education and research in transgender medicine.

For Robert H. Goldstein, medical director of the MGH Transgender Health Program and a Medical School faculty member, gender-affirming care requires more than just clinical acumen; it represents systemic respect for transgender people.

“What we provide, and what I’m asked to do as the director, is much bigger than just a stand-alone clinic,” he says. “The program really does take the responsibility to make sure that the entire experience for a patient — from the moment they show up at the front door of the hospital to the moment they drive away or get on the subway to leave — is gender-affirming.”

To put these ideas into practice, MGH changed its signage on single-stall bathrooms into gender-neutral restrooms, he says. Many practitioners there started pinning rainbow and trans pride flags to their ID badge to signal awareness and understanding, according to Goldstein.

“We did a lot of things that may seem small when I describe them, but have an outsized impact on the community and their ability to walk in the door,” Goldstein says.

In the fall of 2020, BIDMC changed its electronic health record to include a space for a patient’s pronouns and preferred name. If there’s a mismatch between the sex the patient was assigned at birth and their gender identity, a rainbow flag pops up in the corner of the screen to remind the practitioner.

This kind of institutional support for such initiatives is new, Irwig says. He recalls that during his fellowship at the University of Washington in the early 2000s, the endocrine clinic he worked at had a no-entry rule for transgender patients seeking to medically transition. Only after moving to Baltimore in 2005 could he start seeing transgender individuals, and by the time he was asked to join BIDMC, he had treated around 200 such patients and had garnered a reputation.

“I was lucky in the sense that there weren’t a lot of endocrinologists doing this, so I got to fill a niche,” Irwig says.

There’s still a lack of for gender-affirming care in the clinical canon; Irwig says he hears this from the medical students, residents, and fellows who rotate through his clinic. “They all tell me that they want more of this, and they need more of this, that they don’t feel like they’re getting adequate training,” he says. “I know that they’re yearning for it.”

For now, care of transgender and gender-diverse people is confined to a small circle of physicians in these programs and clinics.

“It is somewhat of a specialty to be able to have these conversations with individuals, to understand how to prescribe hormones and how to adjust hormones, to talk to people about transition, whether it be social, medical, or surgical,” Goldstein says.

Even in Massachusetts, where politics doesn’t impede transgender medical care as much as in other states, “at this point in time, to become trained in this work, you have to seek it out,” says Ariel S. Frey-Vogel ’99, a pediatric primary care doctor at the MGH Transgender Health Program.

Frey-Vogel decided to join the program after hearing a presentation given by a transgender activist at the hospital about the 2018 state referendum on gender-neutral bathrooms in public accommodations. “She talked to us about why we need to advocate for that bill, but also, really, the lack of comprehensive health care for trans folks at Mass General,” Frey-Vogel recalls.

Joining the program without structural guidance meant self-studying and shadowing colleagues like Goldstein.

“I went to conferences, I did a lot of reading, and really immersed myself in the medicine so that I could understand what the guidelines were, what the standards of care were,” she says. “I really felt like this was a patient population that needed to feel affirmed and supported in our environment — and that with my background in primary care and forming relationships and developing trust with patients, I felt like I could play a role.”

Frey-Vogel believes the cultural shift in medicine begins with physicians like herself. “My goal for care for gender-diverse people, eventually, is for everyone to be competent in this and for centers to not need to exist. I truly believe that this work can be done by primary care doctors if they are given the time and support,” she says.

There’s a large gap between that goal and the current reality, according to Irwig’s research. At a 2015 regional endocrinology conference, Irwig administered an anonymous survey to 80 attendees. Only 20 percent of physicians reported they were “very” comfortable discussing gender identity and sexual orientation with their patients. Only 41 percent said they felt “very” or “somewhat” competent to provide transgender care.

“If [patients] sense that you're dancing around a question and that you’re not comfortable saying the word ‘transgender’ or asking them about their sexual orientation, they may not then reveal stuff, they may not want to be open,” Irwig says. “In society, certain things are viewed as private, like your religion and your politics and your sexual orientation, ... whereas for the doctor-patient relationship, you really do need to know them when you’re providing care to gender-diverse people.”

The demand for gender-affirming care in the United States is growing. There are over 1.6 million transgender people in the U.S. in the most recent analysis by UCLA, up from 1.4 million in 2017. As Goldstein puts it, “It is more than the number of natural redheads in this country. So if you’re a provider, and you’ve seen someone with red hair, you’ve probably also seen someone who’s transgender.”

Irwig hopes that more physicians will provide gender-affirming services so that his patients don’t have to drive far “to seek out the expert endocrinologist at an academic medical center,” he says. Instead, they can consult their primary care doctor where they live.

Grassroots movements in Boston have been working toward the same goal for decades. There was a time when one of the only places that Boston’s BGLTQ patients could turn to was a small, community-based clinic off Massachusetts Ave. Established in 1971, Fenway Health became known for diagnosing the first HIV/AIDS patient in New England and for its seminal research and advocacy in HIV/AIDS. In 1995, two providers at the clinic began managing a few transgender patients — 11 in 1997, when they started keeping records. By now, Fenway Health has seen over 5,000.

Steph R. deNormand works at Fenway Health as the manager of the Trans Health Program, which helps patients navigate and access gender-affirming services and implements initiatives to improve quality of care.

“We now take an organizational approach to being an affirming space,” they say. This includes staff-wide training and continued physician education on transgender health issues. Fenway has helped to establish transgender health programs in Boston and internationally.

Together, Fenway and Harvard’s affiliate research hospitals have positioned Boston to be a leader in transgender health.

This work runs contradictory to a national conservative movement to limit gender-affirming care, especially for transgender youth. In February, Texas Governor Greg Abbott restricted access to gender-affirming medical care for minors — including puberty-blocking hormones — and classified such care as child abuse, calling on the state’s Department of Family and Protective Services to investigate reports of physicians and parents seeking out gender-affirming care for children. Missouri proposed a similar law, and it is one of 15 states where gender-affirming care for youth is at risk. A report from UCLA predicts that these measures will jeopordize the care of more than 58,000 transgender and gender-noncomfoming youth in America.

Goldstein sees a responsibility for research in Boston to be artillery in the political battle to preserve transgender care in states where it’s under attack.

“​​We have to do the research to show that outcomes are better — we save lives when we provide gender-affirming care,” he says. “We need to actually prove it with data so that we have a way to push back on these laws and these regulations that are really driven by stigma and discrimination.”

Long-term effects of hormone replacement therapy are one pertinent research area, as it has dominated the political battle around gender-affirming care. But Goldstein points to other questions that are still unresolved: “How frequently should you come into the primary care office as you’re transitioning medically? At what age should you be having surgery to make sure that that surgery has the lowest risk of complications? What should we be doing for folks in terms of cancer screenings? And how do we intervene on some of the mental health concerns that are present in the community?”

Now that BIDMC’s electronic record includes patients gender identity and sex assigned at birth, researchers can differentiate between cisgender and transgender patients to create two groups that can be compared to each other and studied for health trends over time. Irwig says that there’s been a worldwide push to bring more evidence-based practice into the field.

The shift is apparent in the new “Standards of Care” guidelines for transgender medicine that the World Professional Association for Transgender Health is set to release this summer, the eighth version since the organization was founded in 1979. Irwig, who contributed to the rewrite of the hormone and eunuch (self-castration) chapters, says another big change is an emphasis on informed consent for all procedures and therapies. Rather than gatekeeping procedures and therapies by requiring supplementary letters or psychotherapy, the revised guidelines advocate for patients to weigh the risks versus benefits of any option presented during their medical transition with the guidance of their provider.

This is why Irwig takes a holistic approach in his clinic, accounting for a patient’s needs and health to find the best course of treatment. When one patient confessed they had a phobia of needles, Irwig sent their hormone prescription as a gel patch instead of the injectable liquid.

“On the whole, gender-affirming hormones definitely help a lot more people and really improves their quality of life,” he says. “Sometimes, the benefits outweigh the risks, so everything just needs to be individualized.”

It’s still unclear how the revised Standards of Care will change the political landscape in the fight to ensure gender-affirming healthcare for transgender and gender-diverse adults and youth; perhaps the successes will happen slowly, over months and years, as they do every week, patient by patient, in Irwig’s clinic.

Jamie, sitting restless in the exam room chair, is finishing up their second appointment with Irwig and is optimistic about their path forward. The testosterone prescription Irwig has typed up will help them feel confident and reaffirmed in their gender identity, they say, “so I’m me, basically.”

— Magazine writer Dina R. Zeldin can be reached at dina.zeldin@thecrimson.com.

This piece is part of The Crimson’s 2022 Pride Month special issue.