We’re excited to bring you a conversation between two of the leading experts in health care for transgender adolescents. Dr. Levine is the Physician General of Pennsylvania, an expert on transgender health care, adolescent medicine, and eating disorders, and one of the highest-ranking openly transgender government officials. Dr. Steever is a physician at the Mount Sinai Adolescent Health Center. He oversees the Transgender Health Program at the Center and runs Project Impact, a support group and medical care program for HIV positive young people in New York City. Together, the two doctors have decades of experience and insight into the health care needs of transgender teens.
Dr. Steever got the chance to ask Dr. Levine about ways to talk to parents of transgender youth, the way the mind and body work together, eating disorders in the trans community, and more. Read on.
Q: Transgender minors can’t medically transition unless they have parental consent. Do you have any thoughts on how to work with families to obtain support?
A: When I see transgender teens, often they’ve only just come out, even though they tend to have felt this way for a long time. The parents are still catching up. It can take a couple of visits to educate them to the point where they’re comfortable.
I talk to parents about neurological brain development theories that show being transgender is not a choice. I also talk about the established nature of the WPATH guidelines–we’re not making up your child’s treatment as we go. I stress that the treatment is very safe. And, a lot of parents are scared their child will suffer because of their identity. I’m openly transgender, and I tell my own life story to make them comfortable.
Q: Transgender youth face significant mental health challenges—depression, anxiety, substance abuse, even suicidal thoughts and attempts. How can the medical care we provide help to alleviate those mental health issues?
A: What it all comes down to is this: there’s no association merely between being transgender and having poor mental health—it’s because of our society’s lack of acceptance of transgender people. Having support is really helpful. Often as a doctor I would speak to school staff about how to help a young person who’s transitioning in high school. A Gay-Straight Alliance makes a big difference, as do other organizations that create a safe space.
Most people will question many things in their lives—their school, their profession, their boss—but their gender is a fixed star in their universe. If you’re transgender, this is always like a splinter in your brain. This is hard for cisgender people to understand.
As a cis person, listen. Approach transgender issues with a healthy (but not lurid) curiosity. Don’t make assumptions. Understand that there are lots of people who have non-binary genders. Ask people what names and pronouns they want you to use, and respect that. People feel strangely empowered to ask about genitals, but it’s very personal. It’s like “don’t ask, don’t tell.”
Q: In your career, you’ve emphasized the importance of integrating primary and mental health care, which is something we also care quite a bit about here at the Mount Sinai Adolescent Health Center. How does this integration help keep adolescents healthy?
A: My whole career, and all of my medical interests, including eating disorders and transgender health care, focuses on this mind-body connection.
Integrating behavioral and medical care works well for adolescent medicine, but it feels radical to a lot of other specialties. For example, an adolescent patient of mine was transferred to the hospital. Her nurse called up, and said, “What do I do? She’s so upset!” And my coworker responded, “Uh, talk to her.” A lot of people in the medical field get used to dealing with just physical problems, not the way they’re related to behavioral health.
Q: There’s a stereotype that eating disorders are primarily the purview of straight white women. Who is actually impacted by eating disorders? Does this misconception make it so men, queer people, and people of color are less likely to seek treatment?
A: It’s true that eating disorders are more common in young, Caucasian women than in other groups, but they can be found across all ethnic, cultural, and socio-economic lines, throughout time. Eating disorders are caused by a combination of neurotransmitter dysregulation, biology, life stresses, and culture. They’re like Hurricane Sandy—the perfect storm.
It’s also true that eating disorders are a problem in the LGBT community. Lots of gay men and gay women experience eating disorders. Transgender women might develop an eating disorder to develop a traditionally slight “female body.” Teens with anorexia often don’t get periods or develop breasts and hips, so that’s a way for trans men to avoid female secondary sex characteristics.
Q: The world typically isn’t very welcoming to transgender people, and yet as the Physician General of Pennsylvania, you’re clearly thriving. There are a lot of young people whose identities also put them outside of the mainstream, and to them, the success you’ve had can seem unreachable. What would you say to these young people?
A: Here’s what I would say: Success means different things to different people, but having a productive career and a rewarding personal life isn’t unattainable. Be hopeful, optimistic, and empowered. That doesn’t mean there aren’t challenges – personal challenges, family challenges, school challenges, career challenges. There have been more than 22 murders of transgender women, and more than 20 suicides this year. Trans women of color are especially vulnerable.
But we shouldn’t despair, there absolutely is a future. We need to develop resilience in the face of adversity. I’m pleased to be a mentor to show young people that it can be done.
Q: Can you say a little more about resilience?
A: A metaphor I use is that the world is like a hurricane, but you can find a place of balance in the midst of the storm. For some people, that place is meditation. For others, it might be music. It might be your faith, or sports. There are a million different ways to find your still point.
The Grant Study—I took a class about it in my freshman year of college, believe it or not—has a lot of biases, but it concludes that it’s not the events of your life that determine happiness, it’s how you cope. Everyone experiences trauma, stress, and loss. Find the place where you feel comfortable with yourself.