"Letting fear get in the way of coming out is not the answer..."


My name is Rebecca (she/her). I’m cisgender, queer, white, and Jewish! I work as a gender specialist, so I partner with queer and trans youth throughout their journey of becoming and am a guide to their parents in affirming their journey.


I only came out, as being publicly queer both on the internet and professionally, a year and a half ago. I finally found the chutzpah to put it on my website! Prior to that, it had really been kind of a slow drip situation of where I would tell people here and there, wherever and whenever. But, I came out in a big way, in part because I am in a heterosexual appearing marriage. So even though my friends in college, and even some people from high school, knew I am queer, my life moved forward in this way where many people assumed I was straight based on my relationship. So, being queer was never a thing that I was very open about because it just didn't feel relevant most of the time. Until I said ‘wait, actually it's super relevant all of the time’.


I realized that simply being myself is an opportunity for visibility, especially because I work with young people. I want them to feel like they know a queer adult who is fairly well adjusted. I've had clients reflect back on how they had this one gay English teacher and bless them — we all need that English teacher! But other than that they're living in these suburban areas, not necessarily having good exposure to queer individuals. I work in Massachusetts, which is pretty liberal, with a lot of acceptance. Considering the kids that I work with say they don’t see a lot of great representation in Massachusetts, I only wonder and have deep concern for the kids who are living in places where it's not really safe to be out.


In terms of my own experiences with queer health, I noticed disparities as early as high school, especially when going to early OBGYN and even primary care appointments. No one ever asked me all of the questions — they would always ask if I had a boyfriend and I answered their questions, honestly, but I didn't answer all of the more inclusive questions that were never posed. So that's where I see this major problem still existing in medicine. There are all these blind spots that don't get asked about-- not even blind spots, but spots people are well aware, of and are actively choosing not to focus on or not to honor and acknowledge, which I don't believe is good health care.


I feel like things have stayed stagnant in the primary care realm of my life. I know my doctors are working off of the assumption that I am married, but first there’s the assumption that I’m married to a cis-man, then there’s also further assumptions around relationship structure and monogamy. This year, I actually had an experience at my OBGYN where they asked if I have any other partners, which was the first time anyone had asked me anything that was both gender neutral and acknowledging the fact that non-monogomy exists which was refreshing! Because of that, I would say that the OBGYN office is probably the only place where I've seen some shift towards inclusivity. In general, though, I think the providers I see are consciously trying to do a good job around me, because I always adjust their forms and make comments in the margins or directly on how to make it more affirming and inclusive. So sometimes, I feel like they put in a little extra work, because they know that it's something that I'm paying close attention to and I will call things out whenever I see them. I have no problem doing that. Everywhere I go I am constantly surveying through this lens, and my work allows me to have some of these difficult conversations with a certain amount of comfort that not everyone has.


The bulk of what I do in relationship to medicine is writing letters for people's surgeries and consulting with care teams. The GALAP (https://thegalap.org/) is a directory of therapists, that I am a part of, who have all signed a pledge to commit to free or reduced letter writing for folks who need letters for surgery. The GALAP was created as an attempt to disrupt the gatekeeping practices in trans health and start to work towards a decolonized version of what trans health should look like.


 

When younger children come in, I always err on the side of just listening — we don't need to make any major medical decisions right now. That time is more about psychoeducation for the parents, for them to recognize how gender develops, and for them to process their own fears. With parents, I validate their concerns, because it usually comes from a place of wanting what's best for their kid. But, I also make sure to mention that, ultimately, resisting what we're being clearly told by the child will cause far more harm, in the long run, than if they just listen to their child, follow what they say, and support their child regardless. The research supports this as well. So, with little ones, it's a little bit more straightforward and that's because it's less of the medical piece and more of the social transition of thinking about a possible name or pronoun change, if dressing differently in the home would feel good, and what would that look like at school, potentially and so on.


For that reason, I designed a course called ‘How to Talk to Kids About Gender’ (https://www.genderspecialist.com/learn) — because people don't know how to talk to kids about gender! I really want it to be for a general audience, not just for parents who think their kid might be trans. Ultimately, we all need to learn and unpack where we got our ideas around gender from and be able to problematize it as well as communicate about it with kids.


With adolescence, it's a little more complicated, and that's where the bulk of my work is. With young adults, it is easier since they can make some of their own decisions, though they are often dependent on parents for insurance so they are still involved in decision making. But, it's really those teen years where most of the questions come up around medical transition, and some parents have varying degrees of fear that preclude them from being able to show up in a way that they could. A lot of my work is around helping parents understand what some of these things mean, specifically what the actual information and true data is, because so often they're Googling and getting information that's not accurate or well supported by literature and research. Some of it is psychoeducation and then the rest is walking people through the process and setting them up with a medical team. There are a couple of great programs here in Boston, so we're very lucky — everyone gets really well rounded, holistic care from a full team. Starting with hormones, there are various different clinics that people can go to. One of the clinics here is much more dependent on conversations with the therapist, so I sometimes have those meetings, discussing how long I’ve been seeing the child and what I’ve observed.

 

Emotionally, the process of transitioning is difficult. The pandemic only made things harder. I had a lot of clients whose top surgery got canceled or moved, and there was so much justified disappointment around that. Not coming to be was really challenging for some of them, in addition to having their whole world turned upside down by a global pandemic. But, I think how the process goes really depends on the kid, the family, and the care providers. It doesn't have to be messy and miserable, especially if you've got a good team and a family who's on board. When it gets much more challenging is when you have one or many parents who are not in support of the medical transition, and so they drag their feet or they have twelve different opinions or they want to visit an M.D., instead of a therapist. So, for some kids, it's an incredibly emotional process that is really challenging. It comes with a lot of small movements and small wins. For example, kids will get on the blocker and that feels like, all of a sudden, they can take a deep breath. But then, the next step becomes ‘how are we going to convince mom, dad, or my caregiver, that I can go on T?’. There’s always one hurdle after the next after the next. My role is anticipating those hurdles and those challenges so we can prepare for them and go through them as smoothly as possible.

 

In terms of finding a care program, I’ve seen that it’s incredibly beneficial to get all of your care at one facility. All of the providers are in the same loop and so, it becomes a more shared and collaborative approach to care. Sometimes, that's not possible for folks depending on where they live and insurance, so they have to piece a team together. No matter what type of provider they decide to see first, a gender competent provider has to be the first step. Having a psychiatrist who has no idea what you're talking about when it comes to your gender is not going to work. Sometimes, primary care doctors feel out of their depth when it comes to supporting people through some of these things. Having an endocrinologist that actually knows what they're doing is essential. Similarly, having a good surgeon, if surgery is part of someone's transition, is absolutely necessary. A good place to find community sourced reviews for surgeons is Trans Bucket (https://www.transbucket.com/surgeons). It is not for the faint of heart as there are pictures before and after surgery. Ideally, a gender competent psychiatrist, primary care physician, and a therapist, like me, would round out that team. Lastly, those people should all be willing to be in communication with one another.


The quickest and easiest way to gauge how gender competent a provider is, is to look at their materials online. If they're using outdated language around gender, that would be a red flag to me. Ideally, having a gender informed therapist is a good place to start, and usually, that therapist knows all of the local teams. For example, I know who I tend to send my clients to, for each of those different things depending on their needs, but it's going to be different in every situation. If there are many options, people can also meet with more than one team and get a sense of whether or not they feel like a good fit. That's certainly the case for therapy, as well. I never want people to feel like they have to be working with someone that's not a good fit.


My conversations with providers usually occur when I feel like the other providers aren't doing something that the client needs, or when the client wants more information and the provider is being more of a stickler around certain criteria like diagnoses and the standards of care. Sometimes, I talk with the team of people that I'm working with when there's certain questions. For example, when someone's non-binary and they want to stay on a low dose of T for a variety of reasons, but then maybe that changes and the team has to figure out how to support them best. Unfortunately, sometimes these conversations feel like I need to convince the other provider that this person is who they say they are and wants the things that they say they want, even though this client or patient has said that to them. Even though the client is an expert on their own experience, they clearly prefer to hear it from me.


One of my happiest stories is about a client of mine who came out in middle school, and because he came out relatively early, we were able to stop puberty and those secondary sex characteristics before they really set set in. To clarify, this was a client who was assigned female at birth and is a trans man. We were able to start him on blockers before puberty and then start T. He never even had to have the experience of menstruating, nor did he end up having to undergo surgery, because all of the secondary sex characteristics were put on pause from the beginning. It's undeniable that he has had better psychological outcomes because of that — now he won't have surgery scars, and he can go to the beach or a birthday party, take his shirt off, and never have to be publicly outed because of what his body looks like. I think there's a lot of power in that. This is not to say that having scars is bad, they can be an empowering marker of peoples gender journey, but this is more, to me, a story about how hormone blockers are lifesaving health care.

 

In terms of the future, I think that perfect, idealized trans healthcare starts with these things not being in the DSM, because they're not disorders. Secondly, people should have access to care that is informed and actually meets them where they are, without them having to seek out a specialist or live in a accepting area — I just want it to be that all providers are conscious of a variety of identities, and are providing competent care that's beyond the binary and our heteronormative assumptions. Ideally, I want people to be able to elect for surgeries if they want to, without two letters, from two different therapists. It’s really about having as few touch points as possible and honoring peoples bodily autonomy.

 

For future advice, I would suggest thinking really carefully about the questions that we ask clients and the ways in which we indicate assumptions without even considering it. I had a client who saw a therapist before me, for a year and a half, and never told her that she was in a relationship with another woman. This was solely because during the intake session, that therapist asked if she had a boyfriend, and then never asked anything else about relationships or attraction. Then, the client was afraid to tell her and felt like she shouldn't bring it up, and they kept seeing each other for so long after that! She was receiving care that was not adequately informed. I think that this clearly highlights why we need to be thoughtful about the way that we phrase our questions.


To my past self, I would say that it's okay to come out sooner, especially in professionally. It has, in fact, created a lot more trust and safety for some of my clients. I was worried that parents wouldn't trust me and that parents would think that I was trying to turn their kids into someone they weren’t, but that has never happened. So, basically, letting fear get in the way of coming out is not the answer.


My last piece of advice is that people deserve to advocate for good care, especially if they're not getting good care — don’t be afraid to go somewhere else that affirms your needs. If you're working in an environment that's similarly not healthy or supportive of your queer identity, you can and should go work somewhere else. It’s okay to do this! There's a lot of power in choosing to quit something! No one should have to just push through so much. My goal is to be able to do this work in a sustainable way, so that I'm able to do it for my lifetime. And, pushing through is not going to be how that happens." -Rebecca Minor, Boston, MA (she/her)



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