Matching Mind & Body

Individualized care is key in transgender medicine. There are multiple surgeries and multiple hormone treatments. In this podcast, Joshua Safer, MD, Executive Director of the Mount Sinai Center for Transgender Medicine and Surgery, discusses the role of medical care.

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Road to Resilience brings you stories and insights to help you thrive in a challenging world. From fighting burnout and trauma to building resilient families, we explore what’s possible when science meets the human spirit.

Transcript

[00:00:00] Stephen Calabria: For the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria, Mount Sinai's Director of Podcasting. On today's episode, and in honor of Pride Month, we welcome Joshua Safer, MD.

[00:00:17] Dr. Safer is the Executive Director of Mount Sinai's Center for Transgender Medicine and Surgery. In this role, and many others throughout his career, Dr. Safer's work has focused on providing safe and accessible treatment for transgender patients.

[00:00:31] As Dr. Safer makes clear, the medical and social challenges involved in transgender medicine illustrate the overwhelming resilience each of his patients must exhibit. We're honored to have Dr. Joshua Safer on the show.

[00:00:44] Dr. Joshua Safer, welcome to Road to Resilience. 

[00:00:48] Josh Safer: Well, thank you for having me. 

[00:00:50] Stephen Calabria: Could you give us some overview of your background and how long you've been involved in transgender medicine?

[00:00:55] Josh Safer: I'm an endocrinologist myself by training, and I started seeing transgender people in approximately 2004. And then I was involved in developing a program at Boston University when the insurance landscape changed, and allowed us to provide care for transgender people as part of a standard medical operation.

[00:01:20] That was 2015 2016 when Mount Sinai set up its program here. And I joined. The program here in 2018. 

[00:01:29] Stephen Calabria: What does resilience mean to you in your practice? 

[00:01:32] Josh Safer: Resilience means putting up with adversity and succeeding in any case. 

[00:01:41] Stephen Calabria: Well, how is that reflected in what it is that you do? 

[00:01:44] Josh Safer: Well, it's no surprise, I think, to just about anyone who knows anything about transgender people, that there are barriers to care that have been there for years, and there has been a surprising targeting of transgender people by various groups with, I think, various other motives.

[00:02:07] Making for a very uncomfortable reality the past few years. And yet, it's striking to me to observe in my clinic that, it's really quite a festive place. That is to say that my patients, despite all of this, are in surprisingly good places in terms of their mental health when they come to see us.

[00:02:30] Stephen Calabria: It'd be helpful if you could start us off with a clinical definition of what constitutes transgender care. 

[00:02:37] Josh Safer: Transgender people are anyone whose gender identity, that is, the biology of your brain that tells you what sex you are anyone who has their gender identity not completely aligned with the rest of their biology. 

[00:02:53] Specifically, their genitals and such. And transgender care, or gender affirming care, there are several terms, are medical interventions we can do to help people align the rest of their biology with their gender identity. That is, with their brain biology. 

[00:03:12] Stephen Calabria: Now what makes an endocrinologist the, or one of the, best people to undertake this.

[00:03:20] Josh Safer: Well among the things that we can do for transgender people our hormone treatments and surgeries and most transgender people who have medical interventions have hormone treatments of various sorts very much the domain of us endocrinologists. 

[00:03:39] Stephen Calabria: If you would, walk us through a typical life cycle of care for a given patient. Is there a specific age range at which patients first start coming to you and why do they start coming to you? 

[00:03:51] Josh Safer: We see people across the entire lifespan and people are very heterogeneous in terms of their needs. The people look for hormones, people look for surgery, some people look for no interventions at all, actually.

[00:04:05] And we individualize treatment to do what makes most sense for people influenced by where they sit in society. There are other partners and relationships and such. So we see people coming to us, typically younger, meaning not older people. 

[00:04:24] And so that though could include children coming to our pediatric and adolescent programs, where there really wouldn't even be a medical intervention. They're pre puberty and there wouldn't be hormonal differences yet between kids, and so we wouldn't actually be doing anything, but they might come to us, or the parents might come with them to discuss some life strategies, or maybe to get some advice from us, and we see people in high school, or junior high school, or college, various ages where they might be, not in that order, beginning puberty or in puberty where we might take, we might have interventions in that regard.

[00:05:04] And I'd say I personally, I see adult patients and I see a fair number of young adults, maybe starting college or just after college in their first job, who have decided that the timing is right for them to begin, a medical intervention. 

[00:05:22] It's not that they've suddenly figured out that they were transgender as much as they've decided that this is a good time in their lives to begin hormones.

[00:05:31] Stephen Calabria: Is there an age minimum? Do patients have to be above a certain age to receive transgender care?

[00:05:38] Josh Safer: Well, if we think of transgender care as whatever care is appropriate for a transgender person, then there is no age threshold. Anyone who can articulate gender identity might come to talk to us at least.

[00:05:56] And then on throughout the lifespan, including ages where actual medical interventions like hormones would make sense, or among adults when surgeries might make sense for some folks, and literally throughout the life span we have people showing up after retirement looking for interventions, in addition to the younger folks.

[00:06:17] Stephen Calabria: Do your patients typically face significant barriers in accessing transgender specific medical care? 

[00:06:24] Josh Safer: Historically, people had huge barriers to care. Prior to 2015, we did not typically cover care with our healthcare payment systems with insurance and such.

[00:06:35] So there is quite the hurdle, in fact, other than for very resourced people. More recently, the barrier has really been in terms of availability of knowledgeable providers. Endocrinologists, primary care providers, surgeons, who are comfortable delivering the care relevant to their specialty.

[00:06:56] So that actually ends up being an important component of Mount Sinai's program, to train folks as well as to be a major resource for folks who can get to us. 

[00:07:07] Stephen Calabria: As we mentioned, you're the executive director of Mount Sinai's Center for Transgender Medicine and Surgery. How does the Center address those kinds of shortcomings in the medical system at large? 

[00:07:21] Josh Safer: Mount Sinai has really been excellent in working on addressing gaps, and gaps in training specifically. 

[00:07:28] So, our endocrinology fellowship program has a core rotation, so that any endocrinologist trained at Mount Sinai, in addition to having expertise in the things you'd predict like diabetes and thyroid and such, also has a certain expertise in the hormones that transgender people might seek.

[00:07:49] Similarly, the Plastic Surgery Residency Program at Mount Sinai has mandatory rotations, so there are certain minimum skills that the surgeons who come from our program know. 

[00:08:01] In addition to that, we have had four fellowship programs for greater expertise in specific areas. So we have a specific plastic surgery one-year fellowship to train to really be an expert surgeon for those patients seeking surgeries.

[00:08:18] Similarly, we have a urology fellowship training with that same expertise. We have a psychiatry fellowship, also one year, and an LGBTQ fellowship, one year. And now, and I guess we should celebrate it this Pride Month, we have a transgender medicine fellowship training people to be expert in primary care for transgender people with our first academic fellow starting this July 1.

[00:08:46] Stephen Calabria: Congratulations. 

[00:08:47] Josh Safer: Thank you. 

[00:08:48] Stephen Calabria: Now, after patients first start coming to see you, what are the next steps that they take in their care, typically? 

[00:08:54] Josh Safer: Well, it depends what their age is and what they're seeking. And we have several, I guess I would say typical pathways.

[00:09:01] So the youngest, the kids coming in with parents who are coming in before puberty are simply getting some advice from us in terms of some life strategies and how to be respectful and see how things go. 

[00:09:14] Someone coming later, let's say, at the beginning of puberty, already in puberty, might come with parents and look to start initially with GnRH agonists, or what are also called puberty blockers, to pause puberty for maybe up to a year, so that they can consider with their parents what logical next steps might be, and then older teens even, and certainly younger adults, would typically go straight to hormones that match gender identity when they come to us as kind of a typical thing.

[00:09:48] I think that's probably the most common group, the young adults coming for hormones. And then young adults, middle aged folks, some a little bit of a range there come to us from across the country for surgical interventions and those are often after people have been on hormones for some time, but that isn't necessarily so, like you heard me say earlier.

[00:10:10] We do individualized care and some people want some things and not other things.

[00:10:15] Stephen Calabria: How do you address questions around whether a given patient is not old enough to start taking puberty blockers or similar medications?

[00:10:26] Josh Safer: No, I think the question is as it really relates to maturity, especially with, let's say the junior high school slash high school age crowd that might be entering puberty.

[00:10:36] And if we completely trusted that we knew what the right treatment for them would be, we would give them hormones to correspond to the correct puberty, the puberty that matched their gender identity. But, the issue is not so much anti trans, it's anti kid, is what I sometimes say to these kids.

[00:10:56] Which is, we want to be conservative, and we're not always completely trusting that they know what it is that they really want in the long term. It's not that they don't know their gender identity. Most of these kids who are showing up to us at this time, who are saying they are trans, are quite clear what gender identity is.

[00:11:16] And they are quite clear that they are trans, and we don't see that there's a significant shift as they age. Still, we're conservative in that approach.

[00:11:24] So that's kind of the situation is, we're dealing with navigating kids who know their gender identity for whom we want to do the right thing, but we're worried that they're a little impulsive and we want to keep those guardrails up a bit.

[00:11:37] Stephen Calabria: A common question people also ask is, well, it's such a huge decision and what about people who change their mind after receiving the surgery? They'd say, isn't that a reason to hold off or to not do it entirely? 

[00:11:49] Josh Safer: Well, there, there are several things there. First of all, there is no "the surgery." There's no the anything. It's all individualized and there are multiple surgeries and there are multiple hormone treatment options. 

[00:12:00] And, in terms of worry about people who will have different thoughts in the future, it's a fair concern and it's a reason to be systematic in our approach. The rule per the major guidelines and what we follow at Mount Sinai is that anyone under age 18, has an assessment with one of our mental health providers. 

[00:12:22] We actually don't even defer to outside mental health providers. We use our own folks, so that we can be quite conservative, actually. And then we work through what makes sense from a pacing perspective. 

[00:12:36] That's true for anyone under the age of 18 for any medical intervention. Like I just said, we follow a similar protocol for someone seeking genital surgeries. 

[00:12:49] Those would be adults, but the same thing. We would have a meeting with our mental health people, making sure that everything makes sense, which, by the way, it almost always does. 

[00:13:02] But we do have people who have mental health concerns that sometimes interfere with our ability to be certain or confident that they're clear on what they want to be doing. And so we might work on that with them a little bit in parallel with the actual gender affirming interventions. 

[00:13:22] Back to the kids, because I think that's where the anxiety sits. I think people need to be really reassured. Actual children, prepubescent children, don't get treatment. That is not a thing, and so people need not worry about that. 

[00:13:36] And if they wear their hair differently, it's not a thing. Or have different clothes, those are very reversible. You can cut your hair. You can give the clothes to the cousin if it really were a phase, which it mostly is not. 

[00:13:49] But for those who want to be super conservative, we are indeed super conservative. Like I said, we sometimes want to take more time. with young people, and that's why we don't rush to hormones. So even puberty blockers are a very conservative maneuver. 

[00:14:04] The reason being, really, for somebody who just did puberty blockers, for whom further treatment was not the right thing, puberty blockers are reversible, with no harm that we can detect. Not long term bone harm, not long term fertility harm. None of the things that people put out there. 

[00:14:22] We still do need to be conservative because the overwhelming majority of our kids who get on puberty blockers are trans kids who want further treatment and so they aren't going to stop those puberty blockers in a year or so.

[00:14:36] They really are going to go on to other hormones and so we do need to be thoughtful about, let's say, fertility preservation because the opportunities before beginning all those treatments. 

[00:14:46] And then, one other thing, we're not obligated to move quickly necessarily. So in someone who's very certain and very mature for their age, we can move right along. But for people who need time to think, we can do any of these things in a slower and more deliberate way. 

[00:15:06] Stephen Calabria: You've touched in multiple ways on there being a fair amount of misinformation or outright falsehoods out there in the media, perhaps certain political actors. 

[00:15:18] What would you say are the most pervasive and yet incorrect things that you would like to make people aware of when it comes to transgender medicine?

[00:15:29] Josh Safer: I'd say there are three or four common misconceptions. One is that the majority of kids are wrong in terms of their desires for treatment or even knowing that they're transgender. 

[00:15:46] There is an old Dutch study from some years ago, where the questions were sex stereotypical questions and the investigators at the time assumed that they would associate with gender identity.

[00:15:59] Things along the lines of, if you like to play with trucks, then maybe you think you're a boy. But, it could be that some girls like to play with trucks and, things like that. The author of that study, who I have worked with many times, and been on committees with many times, is very clear about the weaknesses of study.

[00:16:19] Now when we ask kids in a more straightforward way, are you a boy? Are you a girl? Things like that and then, overwhelmingly, their answers are consistent and continue as they age. 

[00:16:31] Stephen Calabria: Among your patients, what are some resilience stories that stick out most for you? 

[00:16:36] Josh Safer: Well, I'm very struck by the fact that my patients are a pretty satisfied, happy crowd. It's striking to me, I'm an endocrinologist, and I sometimes feel that my patients who see me for other reasons, reasons, let's say for thyroid hormone and such, are more fragile and sometimes show up with more need of mental health support than my transgender folks.

[00:17:06] And I wonder if it's because the transgender folks have been exposed to so much adversity already that they've developed a few more coping mechanisms. 

[00:17:14] We have a study in the works here at Sinai, actually, connecting a condition called neurofibromatosis, where people get these neuromas on their skin, and it can be a little disfiguring, and then there are other elements to it that can be uncomfortable.

[00:17:30] And of the people on our team took an interest in that, specifically in transgender people. And one of the things she observed, is that, in terms of ability to deal with the stresses of that condition, that transgender people were doing as well as, maybe better, but certainly as well as the people who are not transgender, the cisgender people.

[00:17:55] This surprised her initially because she was thinking that when you superimpose one adversity on another, that it just gets to be too much for some folks. But I actually was not surprised and I told her, well, frankly, that's kind of how I see things in clinic. 

[00:18:11] I feel like I'm dealing with these people who've got all these coping mechanisms and they're in a way doing better than the people who haven't suffered as much. 

[00:18:18] Stephen Calabria: Well, in coping with adversity, are there certain strategies that you employ to assist patients in their journey, in dealing with both medical and perhaps social adversity? 

[00:18:31] Josh Safer: It's an interesting question and I come at this not as a mental health person. So I actually don't do as much of that kind of strategic support, as it were. I think the biggest thing that we offer, at least for us folks doing endocrinology and such, is that we're very respectful in our clinic. 

[00:18:51] And we take the situation very seriously. And well, like you heard me say, this is just part of biology.

[00:19:00] We are even developing some animal models of this because we see this kind of heterogeneity and diversity in animals. So we must have it too. And then simply logically trying to figure out ways that we can do things for folks, with this specific biology is what we do.

[00:19:20] It's not a source of anxiety, it's just simply what we do, and I think it just creates a very safe, comfortable environment. 

[00:19:29] Stephen Calabria: How does the Center participate in Pride Month, and what significant, and what significance does it hold for your patients and staff? 

[00:19:37] Josh Safer: We join with the rest of Mount Sinai in being very, very public participants in Pride. We will be joining in marching in the parade. We will be joining in having our materials available at various events. I almost flip it around. 

[00:19:55] It's not so much that the transgender program participates as much as Mount Sinai participates, and the transgender program is evidence of Mount Sinai's energy in this space that it invests to this degree for trans folks. 

[00:20:13] Stephen Calabria: And for those looking to participate in New York City's Pride Parade, it's on Sunday, June 30th. So, be sure to check that out. And speaking of staff, what are some of the unique challenges faced by doctors and medical staff in the field of transgender medicine?

[00:20:30] Josh Safer: That's an interesting question. I think of us actually, I don't think of us as challenged so much. I think that we are really lucky to be able to be in a position where we can do so much good for folks. You know, we go into medicine for purposes of helping people. 

[00:20:46] And sometimes the help you provide is more visible than other times. And this happens to be one of those areas where the help we can provide is visible. So I don't think of us as having a stress. I think of us as being in a lucky place.

[00:21:02] Stephen Calabria: And would you say that folks like your staff in the medical community at large play a role in fostering greater social acceptance and understanding of transgender people?

[00:21:13] Josh Safer: I'm certain that the staff plays a role, not so much the staff who already were probably playing that role before they got to us and have some special interest in the field. We have staff who are simply working for us because they're working for Mount Sinai, and we happen to be the area within Mount Sinai where they work.

[00:21:33] And they might not have ever really thought about this area and suddenly become expert and share with their connections, who are people who might have been exposed last too. And so I think that's a great opportunity, in fact, for us. for people across Mount Sinai. 

[00:21:47] Stephen Calabria: Well, there's the social acceptance, and there's the policy and health rights acceptance. What role, if any, would you say the Center at Mount Sinai plays in advocating for transgender health rights and policies? 

[00:22:01] Josh Safer: On the subject of policy, we are the experts. We are among the experts, although we're a large number of the experts. Certainly here in the state of New York, in New York City, even on a federal or an international level.

[00:22:16] And so people from our program are called upon to provide expertise. And we've played a big role, beginning with the formal opening of the program in 2016, for example, in having one of the managed Medicaid programs for New York City, specifically Amedicare, focus on providing care for transgender people and making sure that all the relevant areas of care are covered in what they provide for the people under their care.

[00:22:47] And they looked very much to us to inform them. Similarly, the fellowship program, the Transgender Medicine Fellowship Program starting this summer. Is something that's sponsored by New York State, which looked to us to be able to provide training for folks and we could advise them what that looked like and they could support us.

[00:23:13] And then there are individual things. I mean, I personally had the good fortune to be called upon to help the Pentagon when it was first integrating transgender people into the U. S. armed services. 

[00:23:24] Both under the Obama administration and under the Trump administration, and that, again, relates to the fact that we are the experts and I, similar kinds of things for our surgeons serving on expert panels, for our nurses, and for others of our medicine providers.

[00:23:41] Stephen Calabria: So there isn't necessarily a focus on activism and advocacy as much as, here are the facts, and what you choose to do with those, we hope you do what's right, but here are the facts, do with that as you will. 

[00:23:57] Josh Safer: I think, you said it partly right. It's not here are the facts, do what you will. It's here are the facts, and this is what you should do. But it's not activism, that's right. 

[00:24:08] We are not political. We're very much in line with, I think, Mount Sinai's role on any subject, whether it be diabetes or heart disease or cancer. 

[00:24:17] Stephen Calabria: Are initiatives or programs in place to continuously educate medical professionals about transgender health issues? 

[00:24:25] Josh Safer: Yeah, we definitely have programs for continuing education. Sinai has an online group of videos that are connected to the Coursera system. That's a company that hosts these sorts of things, which has been available for several years.

[00:24:42] I think we've had about 5, 000 people look at those videos, interestingly, from all over the world, especially places where they might not otherwise have access. 

[00:24:52] I always enjoy the testimonials from places that seem more remote to me where I don't think they have much transgender learning going on.

[00:25:00] And then, closer to home, we hold every few years, the only live surgery conference for transgender care with surgeons. mostly from around the United States and North America in general, but maybe a little bit internationally as well to compare best practices. 

[00:25:20] And, of course, we, like any other center, institute, division, department in Mount Sinai, participate in the programming of our field. 

[00:25:30] Elsewhere, we are perhaps one of the largest participants, because we are a large program, in the annual national and international meetings for providers of transgender care. 

[00:25:43] Stephen Calabria: Looking ahead, what are your hopes and goals for the future of transgender medicine and the services provided by the Center at Mount Sinai?

[00:25:51] Josh Safer: For the care of transgender people in general, my goals are to simply have this get boring. That's my goal. My goal is to speak in a low voice and have everyone fall asleep and have three people attend the meeting. 

[00:26:08] Stephen Calabria: Well, hopefully not on a podcast. 

[00:26:11] Josh Safer: Sorry. But that is, right, make it a little bit like NPR. But that is genuinely a goal where this is not so fraught and not necessarily considered an exciting issue. It's just part of healthcare. 

[00:26:25] And for Mount Sinai specifically, I want us to be big enough and comprehensive enough that we can care for everyone who needs care. And I, you know, that's the same as is true for any element of medicine.

[00:26:37] But in transgender medicine, where there's still so little out there, that's very much an area where I think we need to continue to grow to be able to take care of the community. 

[00:26:48] Stephen Calabria: How can the broader medical community help contribute to creating a more resilient and supportive environment for transgender patients and health care providers?

[00:26:56] Josh Safer: Well, the good news is that the medical community is reasonably good already in terms of its attitude. And so some of this is just a matter of time of people getting educated and for there being time to expand services.

[00:27:12] Things that are less specialized, like primary care and even endocrine hormones and such, you would hope that people would simply be comfortable delivering care already. And I think that's the case.

[00:27:27] If you look at young people, young providers, that is, anyone graduating from anywhere seems reasonably open. I'm looking at people who are, let's say new recruits to Mount Sinai.

[00:27:37] If I look at some of the older people here, they think of providing care for transgender people as more of a niche service or something that requires some expertise.

[00:27:45] But the young people who are coming up into their ranks consider it just what anybody in that specialty ought to know. On the other hand, some more specialized things like some of the surgical procedures require some more sophisticated expertise. 

[00:27:59] It's going to take people who already have certain training, let's say in plastic surgery or urology, who to even begin to come to a program, and then we can only train so many people each year, and there I think there's going to be a little bit more of a lag. 

[00:28:14] But the bottom lines to me are that the medical community is actually already quite good and serious. I find this everywhere I go in this country and even across the world. 

[00:28:27] And so some of this is just a matter of time getting everyone educated and then, depending on our non medical neighbors to stop raising barriers like has been the case in a handful of states and countries.

[00:28:42] Stephen Calabria: What is it about transgender medicine that made you want to devote your time and expertise to this particular field? 

[00:28:49] Josh Safer: Well, truth is I'm in this field by accident. I actually started out in thyroid. And even that was an accident because I went into endocrinology to take care of people with diabetes because that's actually the larger concern in terms of need.

[00:29:04] But, like I said already, I accidentally ended up in the field, and when I entered the field, it was considered a niche thing, and I was then asked whether this it was even the right thing to do, to provide hormone care to transgender people.

[00:29:19] And right then, I thought there were enough data already for me to be able to convince medical audiences that not only was it right for me to be doing this but really all of us should be doing it It should be generalized across all of medicine. 

[00:29:35] And so, I'm like the convert who becomes the zealot or something like that and in the end, I just feel really lucky to have been in a position then and to be in a position now where I can make a difference.

[00:29:48] It's just a gratifying situation for somebody who went into medicine for purposes of helping people to actually be able to help people. 

[00:29:57] Stephen Calabria: Finally, during Pride Month, what messages of hope and resilience would you like to share with transgender people and their allies? 

[00:30:05] Josh Safer: Well, the one thing that strikes me is how already resilient so many transgender people are. And we luck out, I think, that people actually put up with quite a bit of adversity and turn out okay anyway. 

[00:30:21] So that's, I don't know if that's hopeful for transgender people, but that is the good news is despite everything, there's quite a bit of good and I am an optimist.

[00:30:30] And so this is logical that we should deliver care in a not fraught way. And it is, I think, a matter of time and clearly the future that this is what will be the standard. And I'm sorry for the hard times now, but they make no sense.

[00:30:49] And so I'm quite certain they will end. 

[00:30:52] Stephen Calabria: That was it for my questions. Was there anything else you wanted to say? 

[00:30:55] Josh Safer: Thank you much for having me. It's been a pleasure. 

[00:30:58] Stephen Calabria: Thanks to Dr. Safer for his time and expertise. That's all for this episode of Road to Resilience. If you enjoyed it, please rate, review, and subscribe to our podcast on your favorite podcast platform. 

[00:31:09] Want to give us feedback or offer suggestions for a future episode? Email us at podcasts at mountsinai. org. Road to Resilience is a production of the Mount Sinai Health System. 

[00:31:19] It's produced by me, Stephen Calabria, and our executive producer, Lucia Lee. From all of us here at Mount Sinai, thanks for listening, and we'll catch you next time.