Dr. Jennifer Siegel shares what gender identity means, the difference between sexual orientation and gender identity, and the different levels of care offered for patients at the Center for Transgender Medicine and Surgery.

Featured Speaker:

Dr. Jennifer Siegel

Dr. Jennifer Siegel

Jennifer R. Seigel, MD is a Medical Director at the Center for Transgender Medicine and Surgery and an Assistant Professor of Medicine at Boston University School of Medicine. She received her degree from Harvard Medical School and completed her residency at the University of California, San Francisco on the SFGH Primary Care Track and was a Chief Resident at San Francisco General Hospital. She has special interest in Women's Health, LGBT Health, Hepatitis C Treatment, Addiction Medicine, and Medical Education. She is board certified in Internal Medicine.

Learn more about the Center for Transgender Medicine and Surgery


Melanie Cole, MS (Host): Many people have questions about what it means to be transgender and what do the different terms mean. Here to help us today is my guest Dr. Jennifer Siegel. She’s the medical director of the Center for Transgender Medicine and Surgery at Boston Medical Center. Dr. Siegel, I'm so glad to have you with us today. This is such an important topic. Tell us what the term transgender means and explain a little bit about how many kids struggle with their identities.

Jennifer Siegel MD (Guest): Sure. So I think maybe even stepping back before we define the term transgender, it’s good to remember what the term gender identity means. We often talk about sex of babies in the delivery room. What do your genitals look like? That’s your sort of outside body sex, but gender identity has much more to do with how you feel inside, what your gender identity is. All of us have one. Most people in society identify as cisgender, and that is a situation where your anatomical or your biological sex lines up with your internal gender identity. For folks who are transgender, it’s the opposite. Their external sex, the sex that they're assigned at birth, is not aligned with their internal perception of gender. So that’s where the term transgender comes from.

It’s important to recognize though that’s there’s also a group of people who identify as something called gender non-binary where they maybe don’t seem themselves as all on one end or the other of gender spectrum. They may not see themselves as all male cisgender or transgender or female. That’s a group of people who sometimes is put together in the transgender community as well.

In terms of how many transgender people are out there, it’s a question that we’ve only started asking recently as a society. So the numbers do keep changing. But there’s some good data from 2016 that about 0.6% of the population, at least in the U.S. identifies at transgender. That’s going to be about 1.4 million people.

Host: As someone who has a sister who is gender binary, I hear questions from people all the time, Dr. Siegel. Tell us how someone knows. I know what I went through with my sister while she’s trying to figure a lot of herself out, but how does someone know they are transgender? How does that differ from being gay? I’ve heard that question a hundred times.

Dr. Siegel:  Sure, sure, sure. Well maybe I'm gonna take your questions in reverse, if that’s okay. So the first question which is sort of getting at the difference between your sexuality or sexual orientation, that’s terms like lesbian, gay, bisexual that you might see. Sometimes you’ll even hear the term queer, which is increasingly being reclaimed by the community. Those are all terms that have to do with your sexual orientation, which is much more about who you're attracted to romantically or sexually, and who you choose to engage in relationships with. That’s sexual orientation and that is quite distinct from these issues around gender identity that we’ve just been talking about. So talking about being cisgender or transgender, which has much more to do with who you are as an individual inside and less to do with who you're connecting with in relationships and your sexuality. So two separate terms.

So we often do though as a community the LGBTQ, you’ll even see a plus after that at times, which refers to all of the different ways in which you might be outside the dominant heterosexual cisgender norm.  Another term that you'll hear used is sexual or gender minority. So the whole community shares that, but I'm glad you brought it up because it’s a very big different between being a sexual minority—so having a sexual orientation that is lesbian, gay, bisexual, something like that—versus having transgender or gender non-binary gender identity.

In terms of how you know for all of these things, I think that’s one of these areas where individuals know for themselves. That we as their physicians and clinical providers are not the ones who get to say what your sexuality is or what your gender identity is. Rather, these are really innate, intrinsic things that we really think most of us are born with. So it’s more about us as providers and as families creating an open and accepting environment of people so they have come to terms with who they are on their own.

Host: That certainly is true. Tell us a little bit as the medical director of the Center for Transgender Medicine and Surgery. What are some of the medical challenges that you see most often with transgender patients? What are some of the common ills that they face and some of the barriers to treatment?

Dr. Siegel: Sure, sure, sure. So I think a lot of the health issues that come up in the transgender population are often times related to the way transgender individuals have been treated in society over the years. It’s the community that’s experienced a lot of discrimination and a lot of marginalization. That, we know, can lead to poor health outcomes in any communities whether you're looking at racial minorities, gender minorities, sexual minorities. So what you see are common resulting conditions. So higher rates of psychologic distress. Higher rates of things like depression, and actually a really remarkably higher rate of suicidality in the transgender community. Nearly 10 times that of the general population.

Depending on which subsets of the community you're talking about, you might also see things like higher rates of HIV and other sexually transmitted infections. So these are all very real health concerns that we have to deal with. We believe that a lot of this stems from something call gender dysphoria where you really feel that your body doesn’t match your identity and often that you're not treated as well as you should be in the world because of that reality. That’s probably the underlying issue for much of the health conditions that we see in this population.

I think the last thing I’d say on this topic is also there’s a lot of issues with how the transgender community has been treated by the healthcare world itself. Many transgender individuals talk about having to educate their doctors because their doctors didn’t know what they needed to to properly take care of them. Many transgender individuals talk about experiencing pretty significant adverse experiences in the healthcare system, discrimination. Sometimes verbal harassment and even worse. So I think we have so much to do in our health system to improve that. That’s something we’re really proud to be working on through the center to make sure the Boston Medical Center is a truly welcoming place for all of our patients, including our transgender and gender non-binary patients really throughout their experience here.

Host: I’m so glad you brought that up. What a perfect segue. Tell us about the center. What is your aim and goal? I mean you kind of just stated it but expand a little bit for us on some of the treatment options and services that you can offer.

Dr. Siegel: Sure. So at Boston Medical Center we have our Center for Transgender Medicine and Surgery, which has been around since 2016, but it’s brought together a whole bunch of clinical services. Some of which existed prior to that and some of which are newer. Our goal is really to provide truly comprehensive care for our transgender individuals to meet all of their health needs within a single academic health center. So that’s doing everything from front line primary care, both for youth and adults. That’s for folks who are seeking gender affirming treatments meaning that they might like to medically transition their bodies. We offer services such as hormone therapy, both in primary care and in our endocrinology clinic. We also offer a full, well nearly full I should say, range of gender affirming surgeries through our urologists, our gynecologists, and our plastic surgeons.

We also offer really comprehensive mental health services and a bunch of extra services that can be helpful in this population, such as voice therapy, pelvic floor PT, and a host of other services. We’re not one physical space. We’re spanned across the campus here. That’s in some ways aligned with our goal that we hope to be infused across the clinical campus so people receive and have a positive experience in the healthcare system, wherever they may be.

Host: How do you work with the families as well because I think one of the big issues when somebody is—whether they're transitioning or whether they are just seeking, as you say, mental health. How are the families involved, Dr. Siegel? Do they get to be involved in support and education so that they can help their loved one as well?

Dr. Siegel: Yeah, no. This is a really great question that you're asking. I think some of it is just, I think, what we hope to do as a medical center as a whole. Make sure that we have assessed all of our patients to make sure that they're receiving great psychosocial support, whether that’s from their family or whether that’s from friends or other people in the community. I think that this is no different. I think particularly when you look at the high rates of mental distress that we already talked about in this population, and the fact that transitioning—even when highly desired—still represents a pretty big change in your life. It’s so important to have a community of supporters on board. Whether that’s your family or others, again, is going to vary by different people. But I know that that’s something that we really try to actively try to engage with with all of our patients, and certainly as we go about providing gender affirming care for the transgender and non-binary patient population.

Then, I think, I just would say lastly that there’s a few places where we do that particularly well. Particularly in our pediatric and adolescent center, or CATCH, where family is obviously critical as you're going through those phases of life. We have a very nice model where our adolescent specialist and members of our mental health team meet with patients and families in concert to make sure that we’re, as you're saying, providing a positive experience for all and providing needed education for a patient and their support people as they move through these processes.

Host: Well, it’s true. As someone who has been there, I can tell you that we have a lot of questions, the families. We want to know what pronouns to use and what is respectful and what is considered not respectful. So I think that that’s such a great service that you're offering. Looking forward to the next 10 years, Dr. Siegel, what do you see changing in care for the transgender community at large? What do you want to see happen?

Dr. Siegel: Sure. Well, I think already we’ve seen so much change in the last three or four years. That relates to changes that came in line with the Affordable Care Act, or what we often call Obamacare, which was part of the structure that allowed gender affirming services to be covered by most, although not all, insurance. That’s a huge change from the past where transgender individuals typically had a very hard time accessing the healthcare system because so much care was not covered by insurance. So that’s certainly a trend I would like to see continue to expand and to make sure that when we talk about coverage for gender affirming care that we’re being really comprehensive in what we mean. We’re fortunate that at Boston Medical Center and at some of the other regional centers here we’ve been invited to meet with some of the local insurance companies to make sure that we really are able to offer a comprehensive range of services that are needed. So that’s definitely one direction I'd like to see things move in.

I think I am proud of the work we do here at Boston Medical Center as an academic health center. It’s allowed us to bring transgender health beyond just the community setting, which is incredibly important. To loop in a greater range of medical providers, subspecialty providers, emergency providers who are also going to be caring for this patient population and who need to have the resources and skills to work with them successfully. So that’s, I think, something I'd really like to see in the future.

Then I'd like to see us to keep working as a society to decrease stigmatization and marginalization of the transgender community. We have some recent successes as a society and some recent very real challenges, thinking about things like the ban on serving in the armed forces. I think as we address some of these societal challenges, health will improve along with that. I think as we improve the health of this community, we’ll improve the health of everybody.

Host: Wow. So beautifully put. Thank you so much for all of the great work that you're doing. I certainly really appreciate it and it’s been so educational and informative. Thank you, again. This is Boston Medtalks with Boston Medical Center. For more information on the Center for Transgender Medicine and Surgery at Boston Medical Center, you can go to bmc.org/ctms. This is Melanie Cole.