Chronic Disease, LGBTQ, Mental Health, Provider Communication Skills, Suicide Prevention 07.14.2021

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LGBTQ+ Health and Gender-Affirming Care: A Q&A

Richard E. Greene, MD, MHPE, is Director of Health Equity Education at NYU Grossman School of Medicine. Dr. Greene spoke with us about health equity in the LGBTQ+ community and his experience serving as a subject matter expert on Kognito’s upcoming gender-affirming care simulation.

LGBTQ+ Health and Gender-Affirming Care - Demo

Dr. Greene, tell us about yourself and your involvement with LGBTQ+ health.

I currently work at NYU Grossman School of Medicine as Director of Health Equity Education, focusing on how we include health equity topics about race, gender, sexuality, and gender identity into our curriculum. I’m also a residency program director, but my clinical training is in general internal medicine and primary care.

I’m the person that folks see every few months to take care of their health. I run the Pride Health Center, which is the LGBTQ+ health services at Bellevue Hospital, the largest public city hospital in New York. I’ve been involved in LGBTQ+ health care as a doctor for many years, but I started the first Pride Health Center in the system back in 2011.

What is gender-affirming care?

Gender-affirming care is life-saving treatment. When your body doesn’t match what you feel inside, that can be really traumatizing for people. Your ability to live your life authentically is potentially lifesaving. We know it is life-saving because we know that the rates of suicide among trans and non-binary people are disproportionately high, whether that is from societal stigma, inability to access care, or internal stigma.  We also know the risk goes down when we can provide affirming care. In our culture, stigma against trans and non-binary people is extraordinarily high. The risk of violence to someone who is trans or non-binary just walking down the street is incredibly high.

If you’re an adult and you want to begin hormone therapy, and you understand the impact of taking these medications, and you give consent, then I can give you hormones. My contract with you as the healthcare provider is that I need to know enough about the hormones to talk with you about how to take them safely because that’s my job. And there are lots of resources out there to help me learn and figure that out that don’t rely on you teaching me.

How did you become interested in LGBTQ+ health and gender-affirming care?

Personally, I came out of the closet when I was 12. I was most interested in my own identity at first and then started learning more about gender and gender identity. I learned that gender-affirming care is not something that a lot of people know about. And trans and non-binary people have a really difficult time accessing care from providers who know how to take care of them.

One of the things that I started doing pretty early on with standardized patient simulations was using actors or community members who identify as trans or non-binary. By the end of their training, my trainees have met and engaged with folks who are trans and nonbinary. It seems like a simple intervention, but at the time that was something that not a lot of places had done. There are places in the country where it’s hard to find community members to participate in simulations, but I’m proud to say that for the last almost 10 years, we’ve had simulations involving members of the trans community.

How common is a role like yours in schools of medicine or other health professions? How is this evolving?

My first title was Director of Gender and Health Education. The idea was that I was adding LGBTQ+ topics to the curriculum and focusing on some research. My title evolved into Director of Health Equity Education because my role expanded from identities of sexuality and gender to include race, ethnicity, and other health equity topics. Health equity for me is patient-facing. Thinking about how we make sure systems and structures are inviting, affirming, and trustworthy for people who hold these different identities, and how we can bring them in and really care for them as individuals.

I suspect my title is probably either rare or unique across the country, but there are other people who are doing the same work I do, and doing it well. My work is to think about how we can develop longitudinal curriculum on topics of health equity including LGBTQ+ Health. How do we assess learners and patient outcomes? I’m the person who ensures that these topics make it into the curriculum and that they are discussed in an affirming way so that we understand what we’re talking about when we discuss the health of different communities.

In the last year, there’s been an explosion of people who are thinking about and focusing on these topics. I get to work closely with the Office of Medical Education and the Office of Diversity Affairs and Student Affairs and say, “how are we thinking about integration of this material into the curriculum?”

You are a subject matter expert working with Kognito on a new solution for clinical training in gender-affirming care. What has your role been?

LGBTQ+ Health and Gender-Affirming Care - Demo
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My experience so far has been great. I always have concerns when I start working on projects that trans people won’t be involved or that trans voices will be overlooked; and consequently, that assumptions will be made that aren’t authentic. All along this process, there have been folks who are trans and non-binary identified who have been participating. I think the results that we’re coming up with feel really authentic to clinic visits that I have, and to the kinds of coaching that I’ve done with providers who may not be as expert.

As we learn from our patients and we learn communication techniques, I expect this module will be really helpful for folks who are trying to learn to be more affirming of trans and non-binary people, but who may have less experience with folks in their professional lives and their personal lives. And I think it will help increase people’s self-efficacy.

What impact will the availability of a simulation like this have?

I think these modules will occupy a really essential middle ground. In my career, I go around and give talks on transgender health and how to do good gender-affirming care. How do you talk to people about starting hormones and how do you get hormones? You can sit in the lecture all you want, and that stuff will wash over you. Too often, that doesn’t move people along the continuum of actually providing good gender-affirming care.

With an in-person simulation, actually meeting a human in person changes you from the inside, but not everyone has that opportunity and those opportunities are expensive. Particularly people in practice or who have finished their training don’t have access to experiences like that. These modules really provide the psychological safety to practice, to gain information, and to watch a patient response. The patient response to the module is really authentic, and it paints a picture of a three-dimensional person who has concerns that are not just about their gender.

It provides practice. You can make a mistake and it’s okay as long as you learn from it. And you haven’t harmed a person and you haven’t hurt their feelings. And those are the things that healthcare providers worry about. To be reminded that I could have said this a different way or that I want to try that a different way. What an opportunity! We don’t get to do that in practice and I think it’s a great opportunity for people.

Some states are passing legislation to ban gender-affirming care for youth. How can providers in these states continue to support LGBTQ+ health for these young trans and gender diverse patients?

What’s happening right now is so tragic because it is preventing people from having access to care and preventing healthcare providers from delivering care that we know can be lifesaving. I think about the 11- or 12-year-old trans boys out there who get their periods and have a monthly reminder that their body just does not match their insides. That’s an intensely high risk of suicide moment for them.

Within our clinical practice, we can continue to be affirming for the people that start hormones, but a lot of people come to me knowing what they’re looking for and knowing what they want. There’s so much to unpack in our culture. Being a part of creating a module like this, people can access information in a new and safe way so that they can be advocates in their local communities of practice and say, “actually, I now know a little something about this.” It’s really about identifying who this person is and figuring out the best strategies for communicating with them, which I cannot emphasize enough, can be lifesaving for people.


Want to learn more about clinical training in gender-affirming care? A new simulation from Kognito is coming soon! Read more here, or try a demo here.

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