"Queer health starts with education"


"My name is Jackson Knappen and I use he/him pronouns. I’m from the suburbs of Kansas City and I grew up in Johnson County, which is a pretty homogenous community. I was raised in a conservative Christian family, which has definitely made my coming out process more complex.


I grew up in a very privileged environment. I went down to the University of Alabama for my undergraduate studies, where I studied biology and Spanish, and I've always had plans of going into medicine. My mom is a neonatal nurse practitioner and she always found so much joy and passion in her career, so medicine is something that has always been on my mind. I graduated in 2017 and during my senior year, I applied to medical school and a Fulbright scholarship at the same time. I was fortunate enough to receive both. I went to Madrid, Spain for a year and this was the first place that I was comfortable with my queer identity and my identity as a gay man. It was a really great area to just flourish and explore myself while gaining an international perspective. I, then, came back to Kansas City for medical school, but I wasn't super excited about coming back since KC isn't necessarily a queer hub. But, it's been really wonderful since I've been back. I took on the mentality that I want to gear my time in medicine toward LGBTQ+ activism and make it a part of my practice.


I think that the process of coming out kind of binds the queer community together – we've all had to make this decision of looking at ourselves in the mirror and saying ‘okay, this is how I am and I've come to terms with that and these are all the things in my life that I could lose because of it’. Eventually making the decision to continue forward with it and living in your authentic self, even at the risk of everything that you can lose, is really what brings us together.


My parents are really wonderful people. They both grew up in smaller towns around the Midwest and they’re both very religious. I think that the religious community, in general, has some authentically good people with really great and compassionate mentalities. But organized religion, especially, just teaches people how to think. Because of that, the coming out process was really difficult for me and it was difficult to escape the mentality of organized religion. I even made a list of all the things that I would be responsible for if my parents weren’t accepting.


I ended up coming out to my friends, first, during my junior year of college. That was when I first started to accept myself and, frankly, not hate myself like I did for so many years during early college due to my religious upbringing.


The night of my college graduation, I came out to my parents.They left the next day to go back to Kansas and I was also leaving for a month to go to Nicaragua as part of a health initiative program. We did not talk the entire month that I was down there and there was a lot of walking on eggshells. I came back to Kansas for ten days before I left for Spain for the year, and it was a really difficult time for our relationship and communication. I think it's taken a long time and a lot of compromise to repair our relationship. I was never cut off, I was never kicked out - people have definitely had it worse. But, I think it is a unifying factor with queer people that we all make this decision of ‘do I really want to go through with this and how important is this to me?’, and have all had to deal with some of the fallout from that decision to be our authentic selves.


And even after going through difficult situations like this, I will say that it is very liberating on the other side of it.

 

The first time I experienced an intersection of my queer identity with medicine was during the summer after I graduated, before I left for Spain. I told my mom, regardless of your thoughts on this, I need to get on PrEP. She didn't really know anything about it, but I basically said. ‘I'm going to do this and I need to schedule an appointment with our family doctor’.


Since then, many times when I interact with healthcare providers, they often will look at the Truvada in my chart and they'll say, ‘Well, why are you on this?’


I often have to explain that I’m not HIV positive and that I’ve never been exposed to it, but it's a preventative measure. I even had to explain this to my small group of fellow students in medical school as well, since I was the only person that was queer. I think I'm only one of five in my whole class. And because of that, you have to educate people because people, quite frankly, just don't know.


It can be tiring to be the person that feels like you have to educate people, but at the same time, you're the only other person that can. I felt a lot of that at the beginning of medical school being one of the only and, frankly, the one of the loudest queer voices in our class-- I would always be the person that would speak up from the queer perspective.

 

In terms of my involvement with queer health, we have a free clinic that's associated with the medical school- it's called JayDoc Free Clinic. I was one of the three executive directors my first year, and we oversaw all the management of it. We have two thousand patients a year and we operate three nights a week. It was a really wonderful experience and taught me a lot about community health, since the majority of the people that go there do not have insurance and are not fully covered by insurance-- in general, we see mostly disadvantaged people in the Kansas City Metro community.


Previously, the idea of providing transgender care at JayDoc had been floated by another student, and while I didn't conceptualize this idea, I was in a really unique position where I understood how the clinic was set up and how, with my position, I could create this opportunity. And so, me and two other medical students went for it. It was a lot of planning that culminated with us presenting to the Board of Medical Students and showing why, from a data perspective and from what little research there was about trans health, this is beneficial. We mostly referenced the rates of suicide and depression in trans people and the positive results of hormone replacement therapy, and what a difference that can make for people. Since I'm cisgender I’ve never experienced these feelings of dysphoria, but I have seen it reflected in our trans patient population.


There were only two other places in Kansas City that did hormone replacement therapy, at the time, and they both required insurance coverage. Trans people, because they are trans, can be kept out of good jobs that provide this insurance, and it just turns into this cycle. So, we saw that there was an issue and we realized we actually had the ability to create change.


We planned for six months, we defended it to the board, and ultimately, it passed. It was difficult…But, it did pass and we've been functioning since February of 2019. 70 patients have gone through our program so far. I’m still dumbfounded that it even happened, and that it was something I got to be a part of.

 

I’ve been asked about if we have trans care in Kansas. My response is always that the public and medical providers in Kansas are neither straight up against it nor are they full advocates for it. So, to appease both sides healthcare administrations have been permissive of gender affirming surgery where they aren’t trying to shut it down, but at the same time, they aren’t urging it on.


I’ve seen this same *permissive* mentality when it comes to our curriculum throughout medical school. When I got to medical school, conversations about greater minority representation in medical education had started to become more present.. And by that, I mean that there was one lecture specifically devoted to trans health, which is honestly good! So, starting the conversation had already been in the works. The medical student community was also so supportive. I know a lot of medical student classes don't necessarily jive but my class gets along so well, and because of that I felt really supported in my endeavor with JayDoc Trans Night. For example, it's difficult to get a volunteer spot at Trans Night just because many people are so interested and they want the experience of interacting with trans patients, since that's not something that we ever really do in the hospital. It feels really nice that the student community really supports it. And honestly, it's been a little microcosm for queer medical students, where anytime that you go to a Trans Night, the majority of the medical student volunteers are the queer people in the class, so it just feels familial.


Queer health, in my opinion, starts with education-- it starts with ingraining it into our normal medical student education that this is something that is expected of you and that this is something that you need to learn that you will come into contact with throughout your career. The more that you sweep queer health under a rug or confine it to one lecture, the more it becomes just queer health, a foreign topic that you may or may not interact with.


During my third year, on one clerkship, a trans male patient came in with a urologic complaint. I asked him about his symptoms, and at one point, I asked ‘has there been any trauma to your genital region?’ He responded with, ‘yes-- I recently had an episode of sexual assault and have been sexually assaulted eight other times.’


Truthfully, as queer people in medicine, those are the moments that we need to be there for other queer people, people that you actually understand and can talk to without them feeling weird. It's so important for queer medical students to be that representation for queer patients who are afraid, who have no idea what's going on and who don't know the medical facts behind certain things. You being able to explain to them and say, ‘hey, this is the reason I'm asking these questions-- I'm sorry and I know this is hard. I don't want to make you rehash these things but this is a safe environment and let's talk about it,’ truly makes all the difference.


A majority of my friends are cisgender, heterosexual and are going to make fantastic physicians, but like…I don't think they would have handled that situation the same. They wouldn't have known how to talk about these things, why these things are important or why they are traumatic to talk about, and I think it's really important as queer medical students for us to be comfortable with that and be bold with that-- let us not hide our sexuality, but use it to connect with our LGBT patients.

 

In terms of the future of queer health, I really think that trans surgery is going to change. Especially right now, female to male surgeries like phalloplasties and metoidioplasties are really going to change. I think, at this point, we're trying to replicate heterosexual intercourse. The mechanics of actually creating a functional penis for a trans man is, unfortunately, very difficult just from a tissue perspective, so I think that that could change.


In general, I hope that just queer health is more of a widespread, understood, and taught thing. Integrating more into medical curricula and, for example, having everybody knowing what PrEP is, even on a community basis, could really help.


The biggest frustration that I had throughout my time in medical school was just the lack of representation of queer patients and queer identities. I was actually really impressed the first and second week of medical school, because one of our first standardized patients was actually gay…if you asked the right questions. But after that I didn't see a queer standardized patient until my second year of medical school.


During second year, in our STI lecture, four out of five of the patient cases patients who identified as queer. During one of the patient cases it explicitly stated a patient 'identified as a heterosexual male', which I found odd because usually they only specify their sexuality if it isn’t heterosexual. He later started showing symptoms of HIV. I leaned over to one of my best friends, and I said, ‘if it comes out that he's bisexual and had sex with a man and got HIV, I'm going to scream’. And that's exactly what happened. Granted, I won't argue that that is based on a real case and that is a patient's story…but to use that example, and to reduce it to ‘HIV can only be contracted from men who have sex with men' was disappointing. I spoke up and I explained that this is a really important moment to realize that people are more than just the vignettes that we see, more than the questions that we ask, and more than the epidemiological risk factors that they have. It was really frustrating in that it reduced queer health down to just sexual health, rather than looking at the whole person.


I voiced complaints to the administration afterward, but this is what I was mentioning earlier, that a lot of the conversation and change has been forced by medical students. We need some more normal representation of queer identities, for example, someone that has diabetes that is also gay. I hope that changes in the future too and that medical education becomes more inclusive and representative of the whole gambit of patients that we will actually see. Putting stories out there and elevating voices is something that is vital-- important perspectives need to be heard.

 

What I would urge to queer people in medicine and to queer medical students is to just be proud. Be polite, but confident, and strong in your explanation of your sexuality in a clinical setting. People often don’t know things in queer health. You will have to educate-- for example, you will have to explain to people what PrEP is or what the correct language is for your pronouns, your parts, or your partner. It's annoying and it's frustrating, but don't shrink yourself during this, either. Be respectful and professional. Make yourself heard. Take up space and be seen. Do this with grace and your head held high. Make people give you the respect that you deserve.


Be direct and clear that who you are is not wrong. Be respectful and be polite, never come into an interaction expecting that someone's going to discriminate against you but be strong if they do. Make it the expectation that they respect you because that should be the expectation. Have strength in your own queer identity, and don't let our heteronormative society ever make you feel guilty for doing so." -Jackson Knappen, Kansas City, Kansas (he/him)


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