U.S. health officials plan to endorse a common antibiotic as a morning-after pill that gay and bisexual men can use to try to avoid some increasingly common sexually transmitted diseases.
The proposed CDC guideline was released Monday, and officials will move to finalize it after a 45-day public comment period. With STD rates rising to record levels, “more tools are desperately needed,” said Dr. Jonathan Mermin of the Centers for Disease Control and Prevention.
The proposal comes after studies found some people who took the antibiotic doxycycline within three days of unprotected sex were far less likely to get chlamydia, syphilis or gonorrhea compared with people who did not take the pills after sex.
The guideline is specific to the group that has been most studied — gay and bisexual men and transgender women who had a STD in the previous 12 months and were at high risk of contracting one again.
There’s less evidence that the approach works for other people, including heterosexual men and women. That could change as more research is done, said Mermin, who oversees the CDC’s STD efforts.
Even so, the idea ranks as one of only a few major prevention measures in recent decades in “a field that’s lacked innovation for so long,” said Mermin. The others include a vaccine against the HPV virus and pills to ward off HIV, he said.
Doxycycline, a cheap antibiotic that has been available for more than 40 years, is a treatment for health problems including acne, chlamydia and Rocky Mountain spotted fever.
The CDC guidelines were based on four studies of using doxycycline against bacterial STDs.
One of the most influential was a New England Journal of Medicine study earlier this year. It found that gay men, bisexual men and transgender women who previously contracted STDs and who took the pills were about 90% less likely to get chlamydia, about 80% less likely to get syphilis and more than 50% less likely to get gonorrhea compared with people who didn’t take the pills after sex.
A year ago, San Francisco’s health department began promoting doxycycline as a morning-after prevention measure.
With infection rates rising, “we didn’t feel like we could wait,” said Dr. Stephanie Cohen, who oversees the department’s STD prevention work.
Some other city, county and state health departments — mostly on the West Coast — followed suit.
At Fenway Health, a Boston-based health center that serves many gay, lesbian and transexual clients, about 1,000 patients are using doxycycline that way now, said Dr. Taimur Khan, the organization’s associate medical research director.
The guideline should have a big impact, because many doctors have been reluctant to talk to patients about it until they heard from the CDC, Khan said.
The drug’s side effects include stomach problems and rashes after sun exposure. Some research has found it ineffective in heterosexual women. And widespread use of doxycycline as a preventive measure could — theoretically — contribute to mutations that make bacteria impervious to the drug.
Both Tennessee and Kentucky have been given the go-ahead by a federal appeals court to outlaw gender-affirming care for minors.
Earlier in 2023, both states passed legislation to restrict a number of rights for transgender youth, including access to gender-affirming care.
Both were challenged in court by the families of transgender children in each state and the American Civil Liberties Union, who had argued that bans on gender-affirming care discriminated on the basis of sex.
Bans on gender-affirming care have been upheld in both states. (Getty Images)
On Thursday (28 September), the 6th US Circuit Court of Appeals voted 2-1 to honour both states’ appeals, allowing the restrictive bans to go ahead, Reuters reports.
In both states, these bans will prohibit medical providers from treating transgender minors with gender-affirming care, including puberty blockers, hormones and, in rare cases, surgery.
Gender-affirming care for minors has been backed by all major medical associations, including the American Medical Association (AMA) which reaffirmed this summer that they “unequivocally support the health and welfare of people who identify as LGBTQ+, which includes trans and gender diverse people seeking and undergoing gender-affirming care.”
Such treatment can often be life-saving for people suffering from gender dysphoria, and young people will be put at serious risk by having their access blocked.
Despite the overwhelming evidence in favour of gender-affirming care for minors, Chief Judge Jeffrey Sutton wrote in his ruling: “This is a relatively new diagnosis with ever-shifting approaches to care over the last decade or two.
“Under these circumstances, it is difficult for anyone to be sure about predicting the long-term consequences of abandoning age limits of any sort for these treatments.”
A crowd of people, many of whom are young, gather to protest the passing of SB 150 on 29 March 2023 at the Kentucky state capitol. (Getty)
Judge Sutton was joined by Judge Amul Thapar in his vote to allow the bans to go ahead.
In opposition was Judge Helene White, who had argued that neither Tennessee nor Kentucky should pass “constitutional muster” or “intrude on the well-established province of parents to make medical decisions for their minor children.”
Commenting on the ruling, the ACLU of Tennessee said: “This is a devastating result for transgender youth and their families in Tennessee and across the region.”
“Denying transgender youth equality before the law and needlessly withholding the necessary medical care their families and their doctors know is right for them has caused and will continue to cause serious harm. “
Meanwhile, the ACLU of Kentucky said in a separate statement: “Today’s decision is heartbreaking for trans youth across the state. It ignores evidence from medical experts & the trial court who agree that this care is necessary, effective, appropriate, & banning it undermines parents’ right to direct the upbringing of their children.”
“No one should have to decide between their health care and their home.”
Both ACLU chapters pledged to take further action in defence of their clients and the rights of all transgender people in their respective states.
Yellowing teeth. Wrinkling skin. A dry as hell cough. We’ve all seen the ads showing the dangers of smoking cigarettes. In middle school, our teachers would pass out red ribbons and “D.A.R.E.” us to be drug-free. “Just Say NO” still lingers in my brain all of these years later.
We’ve also seen at least one person close to us who has smoked a cigarette, had one too many shots of alcohol, or used some other form of substance to cope with the stresses of daily life. With the FDA declaring youth vaping an “epidemic” in 2018, it is clear that the scare tactics didn’t work. What schools didn’t teach us as kids is truly how stressful and hard being an adult (or even a kid for that matter) is and just how easy it can be to turn to a substance such as tobacco to ease your stress… especially if you are LGBTQ+.
September is National Recovery Month, and anyone on the road toward recovery from a substance addiction should be applauded. What many people get wrong about addiction is the belief that it is a matter of choice. I draw parallels between the experiences of queer people finding ways to cope in our hate-filled world and the experiences of one of my family members who became addicted to alcohol during the 2008 recession.
This family member’s addiction to alcohol was as much of a choice as they had in losing their job. It was as much of a choice as their father who abused them growing up. An addiction to tobacco is as much of a choice as it is to be discriminated against for being queer.
I had the (dis)pleasure of recently attending the Orange Unified School District (USD) Board meeting where they passed a forced outing policy that will undeniably put trans and non-binary students at increased risk for homelessness and depression.
The disgusting display of bigotry from the MAGA supporters and Proud Boys who shouted “groomers” at the top of their lungs made me thankful that I am not a teenager who is just discovering my own identity at an Orange USD school. Needless to say, I believe it’s harder to come out now than it was in 2014 when I graduated high school. It was ironic to see so many people who said to the Board that they wanted to “protect our kids”, all the while supporting a policy that had the potential to increase teen smoking, suicide and depression. A study by the Trevor Project showed that queer youth who had at least one accepting adult were 40% less likely to report a suicide attempt in the past year.
With increased stress, people look for ways to tangibly cope. People look for ways to ease the pain and trauma. One of the tangible ways used by many in our community is reliance on tobacco products. The rush of nicotine can calm a headache… at least in the short term. Nicotine is a powerful drug that can make you feel more at ease and calm when you first start to use it. But as you become more and more reliant on nicotine, your mind and body slowly grow more and more dependent on it to the point where you can’t function without it.
For decades, the Tobacco Industry has targeted the LGBTQ+ community through advertisements featuring drag queens, and for decades, tobacco companies have relied on this path towards nicotine to fill their pockets with cash. They know full well that many of us live with trauma because they relish in it by funding ads and Pride events to grow their queer consumer base. This targeting has led to dire consequences for our community. For instance, many doctors will postpone trans-affirming care for people who smoke because tobacco can make it harder for the body to heal from surgeries. More generally, tobacco is a leading cause of premature death in queer people.
All of this doom and gloom can make it seem like it’s a lost cause to even attempt to fight giant corporations such as Juul or Philip Morris. But just as the LGBTQ+ rights movement has always done no matter what we’ve faced, we are fighting back. We need to go beyond the “Just Say NO” rhetoric; we need systemic change. We need to do the actual work to address why people even start to use tobacco in the first place.
Increased LGBTQ+ rates of tobacco use are a symptom of larger systemic issues. It is a lack of accessible mental health care, livable wages, and stable housing. We Breathe, a program of the LGBTQ+ Health and Human Services Network, aims to create systemic change and reduce tobacco’s place in LGBTQ+ lives.
What good is stopping someone from smoking if they are still depressed, stressed, and anxious? All of which increase other health issues such as heart attack and stroke later in life.
Many of my peers who are also working to eliminate tobacco from all Californian’s lives (Endgame as it’s called) are trying to do so without the slightest idea of how to speak to queer people. We Breathe is working to change that. For more information on how to get involved with We Breathe, contact roda@health-access.org.
Ryan Oda (he/him) is the We Breathe Coordinator for The California LGBTQ HHS Network, working to reduce tobacco’s impact on the LGBTQ+ Community. Ryan earned his BA in Political Science at Cal State Long Beach in 2019.
The CA LGBTQ Health & Human Services Network directs We Breathe, the Statewide Coordinating Center to reduce LGBTQ tobacco-related disparities. We Breathe provides expertise on working with LGBTQ communities, preventing and reducing tobacco use among LGBTQ Californians, and addressing tobacco-related health disparities within LGBTQ communities, to help funded projects reach their goal to eliminate tobacco use by 2035 in California.
If you or someone you know is trying to quit using tobacco, call Kick It CA at 800-300-8086 or visit https://kickitca.org/quit-now to speak to a Quit Coach.
If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat at 988lifeline.org. The Trans Lifeline (1-877-565-8860) is staffed by trans people and will not contact law enforcement. The Trevor Project provides a safe, judgement-free place to talk for youth via chat, text (678-678), or phone (1-866-488-7386). Help is available at all three resources in English and Spanish.
As Republican-led states have rushed to ban gender-affirming care for minors, some families with transgender children found a bit of solace: At least they lived in states that would allow those already receiving puberty blockers or hormone therapy to continue.
But in some places, including Missouri and North Dakota, the care has abruptly been halted because medical providers are wary of harsh liability provisions in those same laws — one of multiple reasons that advocates say care has become harder to access even where it remains legal.
“It was a completely crushing blow,” said Becky Hormuth, whose 16-year-old son was receiving treatment from the Washington University Gender Center at St. Louis Children’s Hospital until it stopped the care for minors this month. Hormuth cried. Her son cried, too.
“There was some anger there, not towards the doctors, not toward Wash U. Our anger is towards the politicians,” she said. “They don’t see our children. They say the health care is harmful. They don’t know how much it helps my child.”
Since last year, conservative lawmakers and governors have prioritized restricting access to transgender care under the name of protecting children. At least 22 states have now enacted laws restricting or banning gender-affirming medical care for transgender minors. Most of the bans face legal challenges and enforcement on some of them has been put on hold by courts.
All the laws ban gender-affirming surgery for minors, although it is rare, with fewer than 3,700 performed in the U.S. on patients ages 12 to 18 from 2016 through 2019, according to a study published last month. It’s not clear how many of those patients were 18 when they received the surgeries.
There’s more variation, though, in how states handle puberty-blockers and hormone treatments under the new bans. Georgia’s law does not ban those for minors. The others do. But some states, including North Carolina and Utah, allow young people taking them already to continue. Others require the treatments to be phased out over time.
These treatments are accepted by major medical groups as evidence-based care that transgender people should be able to access.
James Thurow said the treatment at the Washington University center changed everything for his stepson, a 17-year-old junior at a suburban St. Louis high school who is earning As and Bs instead of his past Cs, has a girlfriend and a close group of friends.
“His depression, his anxiety had pretty much dissipated because he was receiving the gender-affirming care,” Thurow said. “He’s doing the best he’s ever done at school. His teachers were blown away at how quickly his grades shot up.”
For its part, the center said in a statement that it was “disheartened” to have to stop the care. Its decision followed a similar one from University of Missouri Health Care, where the treatment for minors stopped Aug. 28, the same day the law took effect.
Becky Hormuth holds boxes containing testosterone in Wentzville, Mo., on Sept. 20, 2023. Jeff Roberson / AP
Both blamed a section of the law that increased the liability for providers. Under it, patients can sue for injury from the treatment until they turn 36, or even longer if the harm continues past then. The law gives the health care provider the burden of proving that the harm was not the result of hormones or puberty-blocking drugs. And the minimum damages awarded in such cases would be $500,000.
Neither state Sen. Mike Moon, the Republican who was the prime sponsor of the Missouri ban, state Sen. Justin Brown nor state Rep. Dale Wright, whose committees advanced the measure, responded immediately to questions left Thursday by voicemail, email or phone message about the law’s intent.
In North Dakota, the law allows treatment to continue for minors who were receiving care before the law took effect in April. But it does not allow a doctor to switch the patient to a different gender dysphoria-related medication. And it allows patients to sue over injuries from treatment until they turn 48.
Providers there have simply stopped gender-affirming care, said Brittany Stewart, a lawyer at Gender Justice, which is suing over the ban in the state. “To protect themselves from criminal liability, they’ve just decided to not even risk it because that vague law doesn’t give them enough detail to understand exactly what they can and cannot do,” Stewart said.
Jasmine Beach-Ferrara, the executive director of the Campaign for Southern Equality, said it’s not just liability clauses that have caused providers to stop treatment.
Across the South, where most states have adopted bans on gender-affirming care for minors, she said she’s heard of psychologists who wrongly believe the ban applies to them and pharmacists who stop filling orders for hormones for minors, even in places where the laws are on hold because of court orders.
“It’s hard to overstate the level of kind of chaos and stress and confusion it’s causing on the ground,” she said, “particularly … for people who live in more rural communities or places where even before a law went into effect, it still took quite a bit of effort to get this care.”
Her organization is providing grants and navigation services to help children get treatment in states where it’s legal and available. That system is similar to networks that are helping women in states where abortion is not banned get care.
But there’s one key difference: gender-affirming care is ongoing.
For 12-year-old Tate Dolney in Fargo, North Dakota, continuing care means traveling to neighboring Minnesota for medical appointments. “It’s not right and it’s not fair,” his mother, Devon Dolney, said at a news conference this month, “that our own state government is making us feel like we have to choose between the health and well-being of our child and our home.”
Hormuth’s son is on the waiting list for a clinic in Chicago, at least a five-hour drive away, but is looking at other options, too. Hormuth, a teacher, has asked also her principal to write a recommendation in case the family decides to move to another state.
“Should we have to leave?” she asked. “No one should have to have a plan to move out of state just because their kid needs to get the health care they need.”
In the meantime, the family did what many have: saving leftover testosterone from vials. They have enough doses stockpiled to last a year.
A federal appeals court is considering cases out of North Carolina and West Virginia that could have significant implications on whether individual states are required to cover health care for transgender people with government-sponsored insurance.
The Richmond-based 4th U.S. Circuit Court of Appeals heard oral arguments in cases Thursday involving the coverage of gender-affirming care by North Carolina’s state employee health plan and the coverage of gender-affirming surgery by West Virginia Medicaid.
During the proceedings, at least two judges said it’s likely the case will eventually reach the U.S. Supreme Court. Both states appealed separate lower court rulings that found the denial of gender-affirming care to be discriminatory and unconstitutional. Two panels of three Fourth Circuit judges heard arguments in both cases earlier this year before deciding to intertwine the two cases and see them presented before the full court of 15.
Tara Borelli, senior attorney at Lambda Legal — the organization representing transgender people denied services in both states — said excluding the coverage is a clear example of discrimination outlawed by the 14th Amendment.
“The exclusion here is actually quite targeted, it’s quite specific,” Borelli said in court, arguing that a faithful interpretation of the U.S. Constitution and the equal protection clause ensures transgender people coverage.
“One of the most important things that a court can do is to uphold those values to protect minority rights who are not able to protect themselves against majoritarian processes,” she said.
Attorneys for the state of North Carolina said the state-sponsored plan is not required to cover gender-affirming hormone therapy or surgery because being transgender is not an illness. Attorney John Knepper claimed only a subset of transgender people suffer from gender dysphoria, a diagnosis of distress over gender identity that doesn’t match a person’s assigned sex.
Knepper said North Carolina’s insurance plan does not discriminate because it does not allow people to use state health insurance to “detransition,” either.
In updated treatment guidelines issued last year, the World Professional Association for Transgender Health said evidence of later regret is scant, but that patients should be told about the possibility during psychological counseling.
West Virginia attorneys said the U.S. Centers for Medicare & Medicaid Services has declined to issue a national coverage decision on covering gender-affirming surgery.
Caleb David, attorney for the state defendants, said West Virginia’s is not a case of discrimination, either, but of a state trying to best utilize limited resources. West Virginia has a $128 million deficit in Medicaid for the next year, projected to expand to $256 million in 2025.
“West Virginia is entitled to deference where they’re going to take their limited resources,” he said. “They believe that they need to provide more resources towards heart disease, diabetes, drug addiction, cancer, which are all rampant in the West Virginia population.”
Unlike North Carolina, the state has covered hormone therapy and other pharmaceutical treatments for transgender people since 2017. “That came from a place of caring and compassion,” he said.
In June 2022, a North Carolina trial court demanded the state plan pay for “medically necessary services,” including hormone therapy and some surgeries, for transgender employees and their children. The judge had ruled in favor of the employees and their dependents, who said in a 2019 lawsuit that they were denied coverage for gender-affirming care under the plan.
The North Carolina state insurance plan provides medical coverage for more than 750,000 teachers, state employees, retirees, lawmakers and their dependents. While it provides counseling for gender dysphoria and other diagnosed mental health conditions, it does not cover treatment “in connection with sex changes or modifications and related care.”
In August 2022, a federal judge ruled that West Virginia’s Medicaid program must provide coverage for gender-affirming care for transgender residents.
U.S. District Judge Chuck Chambers in Huntington said the Medicaid exclusion discriminated on the basis of sex and transgender status and violated the equal protection clause of the 14th Amendment, the Affordable Care Act and the Medicaid Act.
Chambers certified the lawsuit as a class action, covering all transgender West Virginians who participate in Medicaid.
An original lawsuit filed in 2020 also named state employee health plans. A settlement with The Health Plan of West Virginia Inc. in 2022 led to the removal of the exclusion on gender-affirming care in that company’s Public Employees Insurance Agency plans.
A Missouri clinic will stop prescribing puberty blockers and cross-sex hormones to minors for the purpose of gender transition, citing a new state law that the clinic says “creates unsustainable liability” for health care workers.
A statement released Monday by the Washington University Transgender Center at St. Louis Children’s Hospital said patients currently receiving care will be referred to other providers. The center will continue to provide education and mental health support for minors, as well as medical care for patients over the age of 18.
“We are disheartened to have to take this step,” the statement read. “However, Missouri’s newly enacted law regarding transgender care has created a new legal claim for patients who received these medications as minors. This legal claim creates unsustainable liability for health-care professionals and makes it untenable for us to continue to provide comprehensive transgender care for minor patients without subjecting the university and our providers to an unacceptable level of liability.”
As of Aug. 28, health care providers in the state are prohibited from prescribing gender-affirming treatments for teenagers and children under a bill signed in June by Gov. Mike Parson. Most adults will still have access to transgender health care under the law, but Medicaid won’t cover it. Prisoners must pay for gender-affirming surgeries out-of-pocket under the law.
Parson at the time called hormones, puberty blockers and gender-affirming surgeries “harmful, irreversible treatments and procedures” for minors. He said the state “must protect children from making life-altering decisions that they could come to regret in adulthood once they have physically and emotionally matured.”
Every major medical organization, including the American Medical Association, has opposed the bans on gender-affirming care for minors and supported the medical care for youth when administered appropriately. Lawsuits have been filed in several states where bans have been enacted this year.
Parson also signed legislation in June to ban transgender girls and women from playing on female sports teams from kindergarten through college. Both public and private schools face losing all state funding for violating the law.
Shira Berkowitz, of the state’s LGBTQ+ advocacy group PROMO, said in a statement that Parson, Attorney General Andrew Bailey and the state legislature “blatantly committed a hate crime against transgender Missourians.”
“We are working quickly with coalition partners to explore all possible avenues to combat the harm being inflicted upon transgender Missourians,” Berkowitz said.
The St. Louis clinic fell under scrutiny early this year after former case manager Jamie Reed claimed in an affidavit that the center mainly provides gender-affirming care and does little to address mental health issues that patients also faced. Republican U.S. Sen. Josh Hawley and Bailey announced investigations after Reed’s claims.
Missouri’s bans come amid a national push by conservatives to put restrictions on transgender and nonbinary people, which alongside abortion has become a major theme of state legislative sessions this year. Missouri is among nearly two-dozen states to have enacted laws restricting or banning gender-affirming medical care for transgender minors.
In April, Bailey took the novel step of imposing restrictions on adults as well as children under Missouri’s consumer-protection law. He pulled the rule in May after the GOP-led Legislature sent the bills to Parson.
The vitriol directed at the LGBTQ+ community lately can feel defeating, and studies have shown that anxiety levels for queer folks have skyrocketed. But psychologists have also developed a simple technique you can do anywhere to calm yourself and grow your feelings of self-worth.
You only need your mobile device or a laptop to feel better using “positive affirmation.”
“People wish to view themselves as competent, compassionate, and worthy individuals, but their attitudes, intentions, and behaviors do not always match this ideal,” according to psychological researchers Clayton R. Critcher and David Dunning. “As such, people possess an eclectic toolkit of strategies for defending their positive self-views even when their thoughts, their behavior, or external events call those self-views into question,” they added while discussing their experiments on self-affirmations.
Instead of meditating on all the bad news and negativity being spewed out about LGBTQ+ people, focus on the positives you already know about yourself. Build yourself up instead of letting others tear you down.
The researchers said people may feel an overwhelming sense of “threatened identity” when confronted with challenging situations or confining stereotypes about how one is “supposed to” act. However, “outside intervention” (like affirming thoughts) can help break the cycle of worrying thoughts so that one’s more capable self can arise.
They cite a study that “gave women a task on which they feared they might confirm the cultural stereotype that women are bad at math. In this circumstance, their (threatened) female identity loomed large in their working self-concepts. However, when reminded of their identity as a college student — an identity associated with competence at math — the salience of their gender identity faded. That is, a threatened identity loomed large in the self-concept until another, positive identity was presented.”
We’ve gathered together a few of the best positive affirmation videos available. Check them out below and if they help you, be sure to share them with a friend who is also struggling.
Planned Parenthood of the Heartland and its medical director, Dr. Sarah Traxler, are appealing the dismissal of their lawsuit challenging a Nebraska law that bans most abortions after 12 weeks of pregnancy and restricts gender-affirming care for transgender people under age 19.
They argue that the law violates the Nebraska constitution, which stipulates that any piece of legislation should deal with one subject only. Attorney General Mike Hilgers had countered that the legislation complied with the constitution because the restrictions on abortion and transition procedures both deal with health care. Lancaster County District Court Judge Lori Maret agreed with Hilgers and dismissed the suit August 11. Lancaster County includes Lincoln, the state capital.
The Planned Parenthood group and Traxler filed a notice of appeal Friday with the Nebraska Supreme Court. They are represented by the American Civil Liberties Union, its Nebraska affiliate, and Powers Law.
The trans care restrictions had been subject to a filibuster led by Sen. Machaela Cavanaugh, who vowed to block every bill pending in Nebraska’s one-chamber, officially nonpartisan legislature in order to keep the anti-trans measure from passing. However, her fellow lawmakers eventually overcame that filibuster. The legislature folded the 12-week abortion ban into the anti-trans bill, Legislative Bill 574, and passed the combined measure in May. Republican Gov. Jim Pillen signed it into law within days. The abortion ban took effect immediately, and the trans care regulations go into effect October 1.
The ban on gender-affirming care has taken a different form from the one originally introduced, but opponents say it could still do great harm. The original bill would have banned puberty blockers, hormone treatment, and gender-confirmation surgery for anyone under 19 for the purpose of transition, although genital surgery is almost never performed on minors. The new legislation bans only surgery, both genital and otherwise, but allows Nebraska’s chief medical officer to regulate the use of puberty blockers and hormones.
That officer, Timothy Tesmer, was appointed by Pillen and has said he opposes all gender-affirming procedures for minors, so putting the power in his hands would likely result in a policy as restrictive as the one proposed in the first version of LB 574, possibly more so, according to opponents. Those already receiving nonsurgical care are exempt from new regulations.
“We will never stop fighting for the reproductive freedom, bodily autonomy, and health of our Nebraska communities. We are doubling down on that commitment with this appeal,” Ruth Richardson, president and CEO of Planned Parenthood North Central States, which includes Planned Parenthood of the Heartland, said in a press release. “Planned Parenthood is dedicated to continuing to provide abortion care to the patients we can legally see within the 12-week limit and will continue to connect other patients in Nebraska with the resources they need to get to the essential care they so desperately need, wherever they may be. Every person deserves the freedom to control their body, health, and future — and that right shouldn’t be determined by your zip code.”
“We are hopeful that the Nebraska Supreme Court honors the language in our state’s constitution that ‘no bill shall contain more than one subject,’” added Mindy Rush Chipman, ACLU of Nebraska executive director. “We will continue to advocate for Nebraskans’ rights and do all we can to block both the abortion ban and the restriction on gender-affirming care for trans youth.”
As the country and world become more aware and accepting of LGBTQ identities, an increasing number of people are coming out as nonbinary, which means their gender identity is neither exclusively male nor female.
A Pew Research Center survey published last year found that about 1.6% of U.S. adults identify as transgender or nonbinary. Transgender means someone’s gender identity, or the personal sense of their gender, differs from the sex they were assigned at birth, which is based on their external sex characteristics.
Transgender can be thought of as an umbrella term, and nonbinary exists under that, though not all nonbinary people identify as transgender. Some nonbinary people also identify with other terms that describe identities outside of the male-female binary, such as genderfluid, genderqueer or bigender.
Younger adults are more likely than older adults to be trans or nonbinary. Pew found that 5.1% of adults under 30 are trans or nonbinary, including 2% who are a trans man or trans woman and 3% who are nonbinary.
Two national surveys of LGBTQ people ages 18 to 60 found that 11% of them identified as nonbinary, according to a June 2021 reportfrom the Williams Institute, a think tank at UCLA School of Law.
Though the term nonbinary has gained increasing mainstream recognition over the last decade, nonbinary people are not new or a trend. Out & Equal, a nonprofit that advocates for LGBTQ workplace equality, created a resource that traces nonbinary identities back to 2000 BCE.
Different cultures also have their own terms for nonbinary identities, according to GLAAD, an LGBTQ media advocacy group. Some Native American people, for example, use the term two-spirit to describe people who are neither exclusively men nor women.
Nonbinary people can use any personal pronoun, including “he” and “she.” Many use the gender-neutral pronoun “they,” and some use neopronouns, such as “xe,” “xir” and “xirs.”
According to a 2021 Pew survey, a quarter, or 26%, of Americans say they know someone who uses gender-neutral pronouns, up from 18% in 2018.
Nonbinary people can dress in various ways, and some will pursue social and/or medical transition, while others won’t. Nonbinary is also different from intersex, which refers to people who are born with reproductive or sexual anatomy that falls outside of what people would typically describe as male or female.
International Nonbinary Day is celebrated annually on July 14 and is an opportunity to honor and recognize the nonbinary community.
The day was first celebrated in 2012, after nonbinary writer Katje van Loon wrote a blog post suggesting the nonbinary community be honored on July 14, which falls halfway between International Women’s Day (March 8) and International Men’s Day (Nov. 19).
“We can feel invisible in a world that still hasn’t completely understood what we are. So it’s nice to have a day that recognises our existence,” Loon wrote. “I want people to be happy with themselves. And if having a day helps you be happy with yourself, that’s great. That is the best outcome I could have hoped for from that one-off blog post that I wrote 10 years ago.”
As an increasing proportion of Americans identify as LGBTQ, leaders in sexual and gender minority health care say that the nation’s medical schools are largely failing to adequately prepare the next generation of doctors to properly care for this population.
The need is critical, according to experts in medical education and LGBTQ care. Lesbian, gay, bisexual, transgender and queer people, as stigmatized minorities, often have difficulty accessing health care that properly addresses their health concerns, that is sensitive to their sexual and gender identities and that is not flat-out discriminatory, researchers have found.
“It’s terrible that there’s a whole population of people who aren’t getting the health care they need,” said Ann Zumwalt, an associate professor of anatomy and neurobiology at the Boston University Chobanian & Avedisian School of Medicine and a leader in the effort to improve medical school curricula pertaining to LGBTQ care.
In 2014, the Association of American Medical Colleges, or AAMC, released a call for the 158 U.S. and Canadian medical schools to provide comprehensive training in caring for LGBTQ people and those born with sex-development differences.
Since then, the need for such instruction has only ballooned, given the dramatic increase in LGBTQ identification among young people in particular.
“The current political and social climates are unfortunately leading to many, many health care-professional students and residents feeling uncertain and frightened to engage in LGBTQ+ education and training.”
DR. DUSTIN NOWASKIE, OUTCARE HEALTH
A constellation of medical schools has heeded the AAMC’s call — progress that inspires hope among queer-health advocates. But the schools’ adoption of comprehensive LGBTQ-focused curricula are the exceptions to the rule. The organization’s call, which was buttressed by a 300-page roadmap for reform but lacked the teeth of a mandate, has mostly gone unheeded nearly a decade later.
Progress at medical schools has been stymied by a myriad of factors, including the lack of LGBTQ-related content in medical licensing exams; inadequate or nonexistent knowledge and clinical experience among educators; administrators and the medical old guard’s resistance to change and concerns about competing educational priorities; and outside political pressures as conservatives seize upon transition-related care for minors and diversity policies as wedge issues and as they scrutinize higher education.
Dr. Alex S. Keuroghlian, director of education and training at the LGBTQ-focused Fenway Institute in Boston, and six other medical educators who asked to remain anonymous out of fear of the very reprisals they described told NBC News that recent state-level efforts to restrict diversity programs in education and transition-related health care for transgender minors have instilled fear in some medical schools that their LGBTQ-related medical training could draw increased scrutiny and punitive attacks from legislators.
Keuroghlian, who is also an associate professor of psychiatry at Harvard Medical School, said that the recent state gender-care bans would likely have a chilling effect “on our ability to teach in an evidence-based way that is grounded in human rights and autonomy.”
Where are the needs?
Researchers who have assessed the capacity of the nation’s health care workforce to serve the specific needs of LGBTQ Americans have found them woefully unprepared, especially to care for transgender people. And LGBTQ people remain in dire need of improved physical and mental health care, according to a trove of studies.
Despite the population skewing younger, 23% of LGBTQ people report being in poor health, compared with 14% of the non-LGBTQ population, according to the health-care analysis nonprofit KFF. And research finds that as many as 1 in 5 LGBTQ people have experienced discrimination during health care encounters, including refusals to prescribe medication and even verbal attacks.
Resulting alienation from the health care system, researchers say, is a key driver of the various health disparities that plague LGBTQ Americans. Such apparent consequences include elevated rates of heart disease, cancer, depression and anxiety, substance use disorders and risk of suicide. These disparate outcomes, according to researchers, are likely also fueled by the damage that being a member of a stigmatized minority can apparently inflict upon the mind and body. These are pervasive problems that the health care establishment would ideally mitigate, not exacerbate.
And yet a 2011 survey of 176 U.S. and Canadian medical schools found that their students received a median of just five hours of LGBT-related training. One in 3 schools devoted no such time during clinical rotations.
Dr. Dustin Nowaskie is the founder and president of OutCare Health.Courtesy Dustin Nowaskie
Dr. Dustin Nowaskie is the founder and president of OutCare Health, a nonprofit LGBTQ health-equity organization that is at the forefront of a growing movement to improve medical training on this front and has developed queer-medicine training programs for both medical students and physicians. Nowaskie, who uses gender neutral pronouns, argued in a 2020 paper that medical schools should, in fact, provide at least 35 hours of such training. This instruction, according to Nowaskie, should start with basic terminology and cultural sensitivity and expand to issues such as health conditions that occur at higher rates among LGBTQ people, including sexually transmitted infections and skin cancer.
“These skills should absolutely be required,” Nowaskie said, because of the expanding LGBTQ population and the inevitability that doctors will frequently treat such patients. Nowaskie said they consistently hear from medical students nationwide that LGBTQ-specific instruction is “often minimal,” and that it is “very outdated,” relying on language, terminology and an overall understanding of queer people that has otherwise been retired thanks to recent social progress.
A recent Gallup poll found that over the past decade, the proportion of Americans openly identifying as LGBTQ has doubled, to 7.2%, and that 1 in 5 young adults say they identify as something other than a cisgender heterosexual. The Williams Institute at UCLA Law recently estimated that 0.5% of older adults identify as transgender, compared with 1.4% of adolescents and 1.3% of young adults.
A team directed by Dr. Carl Streed, research lead for the Center for Transgender Medicine and Surgery at Boston Medical Center, is preparing to publish an update of the 2011 medical school survey. Streed was keen to highlight medical schools that have adopted comprehensive LGBTQ-related curricula — including, among many others, the University of Kentucky at Louisville, Stanford University and Boston University, where Streed is an assistant professor. But Streed tempered expectations that his team would identify much of an uptick in overall training.
“Who ends up being remotely comfortable and competent” in caring for sexual and gender minorities, Streed said, “is a matter of wherethey trained rather than whether they’ve been trained.”
Any progress over the past decade has transpired against a split-screen backdrop of sweeping advances for LGBTQ civil rights and, in response, a fierce backlash against transgender rights, in particular. At least 20 states have now passed various restrictions on transition-related care for minors — a legislative effort that even many physicians who express misgivings about the science backing such treatment say they oppose.
“The current political and social climates are unfortunately leading to many, many health care-professional students and residents feeling uncertain and frightened to engage in LGBTQ+ education and training,” Nowaskie said.
“At the same time,” Nowaskie said, “these climates are perpetuating health care stigma among biased, discriminatory providers.”
How medicine can fail LGBTQ people
Delia M. Sosa, a first-year medical student in Ohio, wants to focus on LGBTQ care. Sosa, who uses gender-neutral pronouns, said they are motivated, in part, by their own alienating encounter with the medical old guard.
After growing up in what they described as a conformist Christian community in New England, Sosa came into their trans and nonbinary identity in their early 20s. At 21, they sought to establish a relationship with a primary care physician in their hometown in hopes of eventually having a double mastectomy, or what’s known in trans medical care as top surgery. But after Sosa disclosed to the doctor their queer identity and the fact that they were dating a nonbinary person, they recalled, “she looked at me with a look of confusion” that was also “mixed with frustration.”
“Medicine is playing catch-up in a lot of ways. … I get some really seasoned, experienced physicians who come up to me and say, ‘I never had a chance to learn about this, yet I know this is something I need to learn.’”
DR. SARAH PICKLE
Sosa said they spent the bulk of the appointment providing the doctor a trans-identity 101 tutorial, including breaking down the difference between gender and sex, what it means to be nonbinary, what gender neutral pronouns are and how sexual orientation can be fluid with respect to the gender of partners. They found the experience so off-putting, they let three years pass before seeking surgery again, which they ultimately had last year.
Dr. Sarah Pickle, a family physician and medical educator in Ohio, is a leading proponent of medical schools cultivating a deft hand in up-and-coming physicians in how to care for LGBTQ people. Pickle insists that such training, which focuses, for example, on speaking with sensitivity and inclusivity regarding queer people’s differences, can be crucial in keeping LGBTQ people engaged in care.
“Medicine is playing catch-up in a lot of ways,” Pickle said. “I get some really seasoned, experienced physicians who come up to me and say, ‘I never had a chance to learn about this, yet I know this is something I need to learn.’”
Sosa discovered their own evidence of the potential perils of physicians’ lack of knowledge about treating LGBTQ patients when researching trans people’s experiences with cancer care. Some oncologists, Sosa found, were confounded over how to manage such treatment in a patient taking cross-sex hormones.
“I can’t tell you how many stories I heard of trans folks where they had delayed care because an oncologist didn’t know what to do with them,” Sosa said.
One expert in LGBTQ medicine, who preferred to remain anonymous because of attacks from the far right, described an often cavalier attitude among specialists toward trans patients’ hormone therapy. A cardiologist, they said, might advise a patient to simply go off hormones due to cardiovascular risk, rather than thoroughly reviewing the risks versus benefits of a therapy that is fundamental to many trans people’s sense of self and well-being.
This health care provider and medical educator expressed frustration that such doctors often remain ignorant to studies that provide insight into managing hormonal therapy in the context of certain health problems.
Who is leading the change?
Keuroghlian stands at the vanguard of the movement to train doctors in caring for trans and gay patients.
At Harvard, he and a team of colleagues led a three-year effort to design and implement a new curriculum that provides comprehensive training in such care.
The curriculum, which other schools are free to adopt, permits all professors, regardless of their own identity or experience, to weave LGBTQ themes and practices into their own instruction. So, for example, a course on endocrinology would include instruction on cross-sex hormonal treatment and an embryology course would teach about intersex variations.
Bringing a broad swath of medical educators up to speed is crucial, Keuroghlian said. A major roadblock to progress has been the fact that the professors, who are meant to pass on their own acquired knowledge, have typically never received their own training in sexual and gender minority care. So, in addition to the four-hour training he helped craft for Harvard faculty about how to teach this subject, Keuroghlian is among the educational pioneers, a group that includes Nowaskie, who are designing medical education seminars to train other health care providers nationwide.
Dr. Christopher Terndrup is an associate professor of medicine at Vanderbilt University Medical Center.Courtesy Vanderbilt University Medical Center
Dr. Christopher Terndrup, an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tennessee, noted that most demand for LGBTQ health education “is actually pushed by the medical students themselves.”
But such eagerness from the new generation can hit old bureaucratic walls, according to Dr. Nelson Sanchez, an associate professor of clinical medicine at Weill Cornell Medicine and the chair of the annual LGBT Health Workforce Conference. Sanchez said administrators often resist calls for such curriculum by insisting that a zero-sum game governs all medical-school education hours.
Dr. Lily Rolfe, who recently graduated from Rush Medical College in Chicago and is matriculating to a residency in family medicine, with a focus on caring for LGBTQ patients, at Swedish Hospital in Seattle, conducted an informal survey of students at Chicago area medical schools about the quality of their education in caring for LGBTQ people.
“It’s always, ‘The gay guy has HIV,’” Rolfe quipped regarding the typical way the respondents characterized their limited education on this front.
“HIV is important,” Rolfe said. “We should learn about it. But that shouldn’t be the entirety of LGBT health.”
Otherwise, the Chicago students said that social determinants of health pertaining to sexual and gender minorities were commonly addressed. But the survey respondents, Rolfe said, “noticed a lack of discussion about trans people, including gender dysphoria; gender euphoria; medical, social, legal and surgical transitioning; and a lack of the discussion of the over pathologization of trans people.”
Harvard’s LGBTQ curriculum, meanwhile, goes beyond just infectious disease, including basic concepts and terminology about gender and sexuality; stigma’s impacts on health inequities; major health concerns that are more common in LGBTQ people, such as anal cancer in gay men or breast cancer in lesbians; effective doctor-patient communication methods; navigating power imbalances and implicit bias; addressing microaggressions; and how to generate learning opportunities if an LGBTQ patient responds negatively to a physician’s words or actions.
Other med schools that have also established substantial training efforts on such subjects include Louisiana State University, the University of Mississippi at Jackson, the University of Wisconsin at Madison, Vanderbilt University, the University of Pennsylvania and Cedars-Sinai in Los Angeles.
The current hostile political environment notwithstanding, Keuroghlian said he remains optimistic for how well prepared the next generation of doctors will be.
“People in medical school are increasingly passionate about doing this work, because there’s more understanding for the need for skilled, culturally responsive care,” Keuroghlian said of sexual and gender minority care.
“There’s also a sense of social justice and health equity that drives young people to do this work,” he said. “They see this as one of the major health rights issues of their generation, and that’s very engaging for them.”
