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"Uncleaving sex and gender is going to change the entire world..."



"Starting as a teenager, I came to think of queer health through of lens of social justice in many different ways. I started thinking about the world through a feminist lens in the 80s and I became involved in reproductive justice and abortion-rights. I grew up in a small town in Ohio where rich girls had birth control and poor girls had babies. No one wanted to have an abortion. I definitely was influenced from the very beginning by seeing issues of bodily autonomy, lack of access to healthcare information, and lack of access to something as simple as birth control and abortion rigged by class. All of this existed in a highly charged, political society with deep roots in sexism and race. And of course, we know now that sexuality and gender identity play large roles in that struggle. I understood the world of social justice and problems through the lens of how our physical bodies are impacted by the world’s conflicts.


Then in the late 80s and early 90s I became involved in HIV and AIDS activism. I moved to New York City where I attended Sarah Lawrence College. I worked at abortion clinics in Westchester County that were sites of bombing. Again, this idea of healthcare being under siege was very real to me. There was actual violence that was attached to accessing healthcare. I was not an active member of ACT UP, but I was involved in The Women's Health Action Mobilization that grew out of the ACT UP movement. I think back on these experiences now and recognize how much of an influence these experiences had on my involvement in LGBTQ healthcare advocacy today.

While I’m not a clinician and never pursued a science program, I've always been an advocate around issues of access and what can be thought of as cultural competency. I have always lived in this gray area of translating between what some people knew and what others needed which allows us to bring those groups together so those who needed something could actually obtain what they need. Whether it's social justice issues, technology, city building, urban planning, racial justice, I’ve always played this role of a bridge-builder and community organizer.

In the early 2000s, I became an executive director of a small nonprofit in Chicago called the Lesbian Community Cancer Project. When lesbians, bisexuals, and queer women who had been deeply engaged in HIV/AIDS started to get cancer, they were once again confronted by the unjust systems that they had experienced with their gay brothers and sisters. That's where I really learned to build coalitions and partnerships between people with different health concerns. Between HIV/AIDS and cancer related advocacy we built the foundation of what today is considered to be the LGBTQ+ health movement.


I then worked at a place called Howard Brown - one of the largest FQHCs (Federally Qualified Health Centers) in the United States - that serves mostly LGBTQ folks and people with HIV. That is where we started to address and think about transgender healthcare in a deeper way. It was always about unpacking our understanding of these categories of women and men, of bodies, and how physical body parts don’t equal identity. This is where we got really real about who people are, how they were identifying now, what they needed access to, and how some of the language and the way we conceptualize healthcare was actually part of the problem. I am proud to have been somebody who helped push what we thought of as lesbian care, LGBTQ health into much deeper understandings of gender identity and the idea of screening parts not people. There was finally a real growth of people feeling free and demanding better health care. I was really proud to be a part of that and I have been deeply involved in in transgender healthcare since then. Those of us who love trans people but are not trans ourselves play a special role in fighting on behalf of our families.


Today, I think most young people are more familiar with the federal recognition and advocacy regarding insurance coverage, insurance companies, medical education, and medical training. Prior to 2010, I think of LGBTQ+ health care as islands in the stream. We have our FQHCs, sliding-scale healthcare, we were taking over mammogram vans, and we even trained each other to do pap smears. We were creating our own safety net. What we see by 2010 is a demand for a larger, federal response to LGBTQ people’s lived experiences and realities. Then we start to see this coalesce around the Affordable Care Act. For the first time there is money to be made in LGBTQ health. There's no polite way to say it. This is where my most recent role in medical education comes from.


We see that data collection started to matter at this time; there was an expansion of technology and insurance coverage in healthcare. This growth changes everything. With the ACA, for the first time, these amazing folks who were a part of the LGBTQ health struggle from the beginning now have a seat of power in DC, and we were having real, productive conversations. For the first time, LGBTQ+ and more specifically trans health care is covered. So logically the next question arises. Where is the medical training in all of this?


For the 25 years prior to ACA, I was in some form of participation in cultural competency training. Experts and outside people would come in and do some 101s. Amazing people developed curriculum and cultural competency trainings about LGBTQ healthcare starting in the early 2000s. Keep in mind this was the early 2000s. We used overhead projections! We were doing piecemeal training at clinic sites, public health departments, hospitals with the goal of getting professionals to integrate a holistic understanding of our community into their education before they go out in the world. I spent years trying to talk to nurses and doctors and healthcare administrators after they've already been in practice for decades. Unlearning harmful assumptions and practices is a lot harder than getting it right the first time.


So here we have an opportunity inside one of the most prestigious institutions - a pace-setter institution if you will - that is Harvard Medical School. In 2011 to 2014 they formed an internal group of actual gay and lesbian doctors, students, and staff. They come together to demand that their medical school do more. There we have an example of internal activism that leads to a big difference for future folks coming into the school. This coalition really felt the zeitgeist of the federal change around them and a renewed sense of energy. From that energy Harvard Medical School became the first medical school in the United States and the world to dedicate real resources to a staff position that would coalesce all of this LGBTQ medical work. Until you put a real paid person in charge with concrete strategies to make sure things get done, then the work doesn't get done. With that, I became the first person in the US paid to make sure medical schools were changing for the better for LGBTQ people.

So here we are in 2021. There is not a medical school in the United States that is not in some way thinking about LGBTQ inclusion and LGBTQ students, physicians, and patients. They might be struggling with where inclusion fits in, who should lead it, and how to make it happen, but there is not a medical school in the United States that does not know these issues are important and that change needs to be made.


The goal today is to focus on three spheres of influence that academic medicine plays in:

  1. It is first and foremost a place that needs to think about the best patient care they can provide. Academics need to think about the best evidence-based practices and lead the way in creating more opportunities and access for patients who have been left out.

  2. How do we train the next generation - including continuing education - of healthcare providers at every level? How do we train them to understand and treat every single LGBTQ patient -- and those born with intersex conditions -- with the right care and real respect? How do we ensure that we’re doing the best for our patients?

  3. The third sphere - and this is the sphere that I am deeply passionate about and I think deserves more attention - is uplifting, supporting, and strengthening the LGBTQ folks themselves who are inside healthcare. I believe this is the fastest way to make change in these other two spheres. I want more openly proud, successful, confident LGBTQIA+ healthcare professionals at every single level. I want them living their best lives in medicine, and whether they are a part of these other spheres or not is actually not as important as just being in the healthcare professions. It’s about mentoring and supporting LGBTQIA folks, whether they be young people, junior faculty, old faculty, or others who are struggling with or are curious about how to be open, loud, and proud.

If we’re talking things I want to see happen in healthcare, first and foremost I want to see Medicare-for-all. This was always at the core of the LGBTQ health movement; living a healthy life should not be tied to coverage or your job. It's the most important answer to us living long, happy, healthy lives.


I have this passionate part of myself that believes in changing medicine from the inside, but if I could clone myself I would like to complete work that allows us to reach a place where my people need hospitals and doctors less. As a working diversity professional, I'm trying to put myself out of a job! How do I get my people to need doctors less? How do I get us to take care of each other? If we had great access to care, if we ate nutritious food, if we could move our bodies safely in different spaces, if we could heal our original traumas, and if children weren’t being abused or bullied, we would put doctors out of business. My dream is that the estrogen or testosterone therapy that a trans person uses becomes a blip in their daily lives. I want advances in the medicine so that doctor’s visits become conversations about everything else right, and then treatments/therapies aren’t a big deal.


I do all of this work for one big reason, and that is the sexual and gender liberation of all people. It's a good thing for everyone, right? We’re not the only ones who have a gender, who like to have good sex or not have sex, or who talk about sex. Everyone has a relationship to sex, sexuality, gender, gender identity, and gender expression. I want everyone to be freed from those imposed restraints from current societal norms. My original politics was feminism, and these gendered categories are messed up. These 'roles' are hurting all of us, so we need to destroy these limiters. Gender liberation! Gender freedom! Sexual freedom! I don’t want queer people to be seen as those with problem genders or problem sexuality. Instead, I want everybody to be free to do their thing and be happy.

 

I'm not going to sugarcoat it. It is not easy to be a trans person in medicine right now. You always have a diverse gender - either through expression or internal concept that you may not be able to push to the side as you walk through the world. That’s not to say some of us can’t move a little more freely. Plenty of gay, lesbian, and bisexual people can do that with some ease. For example, I was coaching a bisexual woman in her interviews, and it was very important to her for people to know she's bisexual. She wanted to find a way to bring it up in a residency interview, and we found a way to bring it up in a joking manner.


'I need you to know I'm part of the LGBTQ community. I identify as the ‘B’ which stands for bisexual. You might think this is so strange to bring up in a residency interview since no one has sex in residency.'

 

My piece of advice is this: when you can understand the difference between sex & gender and live that truth, then you become a revolutionary in your own right. This difference is the hardest thing for any human being to understand. Those who have internalized these ideas can’t unsee these differences. The rose-tinted glasses come off. You can’t not see it.

Yet, there is a world of people who are blind to the difference between sex and gender, and that is very foundational to what we know in and how we conduct science. It's not their fault they were taught this from a very young age. However, what you need to remember is that when you move through the world, that simple act of existing causes friction. That is a radical revolutionary principle. The inability to separate sex and gender is currently the cement, the trees, and the air we breathe. Uncleaving those, sex and gender, is going to change the entire world. We're not yet close to achieving that in medicine, but we're working on it.


Holding that truth of understanding of the innate difference between sex and gender is your challenge, but it is the truth. We will win this because we are right. They just don't know yet.


We’re the magic wizards who move amongst the 'muggles' at all times, and they are blind to our magic. But it's not their fault that they're not born with this magic. So we have to hold our magic close to us and protect it. We have to honor it. We have to cultivate. We have to get support for it. Just because we have to move amongst those without this magic, doesn't diminish or take away our magic. We just feel sad for them. This revolution we’re fighting is not going to happen tomorrow. I'm not going to pretend that it is. LGBTQ+ folks are going to be misgendered and non-LGBTQ+ folk will ask us hurtful, stupid questions. For those of us who have chosen this work, we do it for very big and real reasons. Those reasons are often not in the room with us. They are those patients that will never make it in the room. They are those friends that are suffering needlessly. They are those who we have lost. We have to just dig in and do this work everyday. Some days we will be able to correct pronouns and others we will decide we can’t. As the students used to hear me say all the time, 'We cannot be at a 10 everyday. Every fight cannot take us to a 10.' Some days are going to suck and some days are going to be great. But you have to protect your magic in the meantime because great things are happening. We are winning.

 

My favorite conversation to have with people who have chosen this path is how to make the time to practice your advocacy. So my challenge to you is to find people and practice those moments of friction. I am a theater person at heart, and I love practicing these moments. For anyone who uses they/them pronouns, I want you to practice how you're going to advocate for yourself and correct people in a way that works for you but also keeps the ball moving forward. Medicine is a team sport. So, how do you get to a place spiritually and mentally where you can be brave enough to advocate for yourself, a patient, or somebody else in a way that brings everyone along and in a way that doesn’t create more barriers or push people away? That’s the chef’s kiss moment.

Medicine is a deeply hierarchical world where power dynamics define space. If you go into medicine looking for every gotcha moment, you will be exhausted by day three because every attending or faculty member will say something harmful. It's going to happen over and over again. Use your spidey sense and understanding of these power structures to harness power and help people advocate in a way that brings everyone along. Let’s be real, it's basically like the 1970s in most of medicine. So go in eyes wide open while protecting your heart and spirit. Move within this atmosphere as someone who can make change in tiny little ways every day through these opportunities to have challenging conversations. You have this knowledge about how the world works and you get to share it with others and bring them along with you.


I believe that change happens institutionally and systemically when people in power do important things. I believe change happens when coalitions and thousands of people rise up and demand change. I also know that change happens with small one-on-one interactions. Think about it, a one-on-one conversation with a patient in a way that’s loving, open, and responsive to their body language could save that patient's life. I believe that all of our interactions in medicine can be like that. Really leaning into those moments between you and a classmate, medical assistant, transporter, scribe, attending, etc. could be revolutionary.


If you didn't know it, let me be the person to remind you that you come from a world of queer ancestors. We are all right here with you every step of the way whether you ever get to know us or not. All we’ve ever wanted was to see all of you be brave and strong and to take this big step. This is what we wanted and needed. You are fulfilling your ancestors’ wildest dreams. And we are so proud of you." -Jessica Halem, Wellfleet, MA (she/her/hers)


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