Half of All NIH Grant Cuts have been to LGBTQ+ Research

 

Research looking at LGBTQ+ health has collapsed in just a few months, as the NIH has canceled grant funding. Some of those studies actually focused on trans health, like projects examining what sort of mental health support best reduced the risks of depression and anxiety in trans youth. But the bulk of the canceled research examined other topics--HIV prevention, the wellbeing of intersex people, the effectiveness of various antibiotics in treating common STIs, LGBTQ+ elder health, diagnosing autism in LGBTQ+ populations. Even studies looking at topics beloved by the Trump administration--increasing the birthrate and opposing gender-affirming care--were defunded. The canceled pregnancy research sought to determine the causes of the high stillbirth rate among lesbian and bisexual women; several studies examining the risks of gender-affirming hormone therapy were also defunded. (I have no idea if these hormone therapy risk studies were canceled because the Trump administration has been incredibly hasty and sloppy in its work, defunding things based on keywords with little human oversight, or if there was actually some weird rationale, like, "Well, what if the study doesn't find the higher risks of breast cancer or heart disease it is looking for? We must stop all studies looking at gender-affirming care so we can say there is no good data!")

It's important to see what is happening right now. In the mirror universe of the Trump administration, where virtues are called evil and evils good things, research attempting to decrease health disparities is now "DEI", said to harm the majority that enjoys the longer lifespan. Good, rigorous, objective studies aimed at improving health are canceled as "anti-science" and "political ideology" because they acknowledge the fact that trans people are a patient group among many that exists, rather than erasing their existence as now commanded by executive order. Increasing the birthrate is to be encouraged--but studies focused on impaired fertility and stillbirths among minority groups including sexual minorities are defunded, because that would "discriminate" against the straight white group the government is solicitous of. . . We're not at active genocide levels of activity--but we're at passive ones. "Don't study how to save these people; if they die, they die," says the administration.

Some researchers are trying to block the grant cuts in court. That's good, but it's slow, and also, this administration is all-in on ignoring what the courts say and seeing if they can get away with that. So it's important that we, the people, are aware of what is going on, and express our opposition.

Why must I list the sex marker on my original birth certificate to get vaccinated?

 

A personal anecdote about going to the drugstore while trans. . .

I was born right after a vaccine for measles was introduced. In those early years of the vaccine, killed virus was used instead of live, and only a single shot was given instead of a series of two. So, the pre-Kennedy CDC urged people in my age bracket to get a modern MMR vaccine if there was a possibility of encountering measles (initially considered in terms of foreign travel or healthcare work). Now, medical news reports recommend that my age cohort get vaccinated.

So, I decided to get an MMR vaccine at my local Walgreens. I've been getting my vaccines at Walgreens rather than a nearby CVS because the Walgreens registration form to schedule a vaccine just asked me to indicate my "gender," while starting in the first Drumpf administration the CVS form began requiring that I check the "sex originally listed on your birth certificate." But recently, Walgreens started making the same registration demand.

I waffled over whether to ignore the new requirement and just list my lived gender. People of any gender get the same vaccines--they don't come in pink and blue sex-variants. There is zero medical reason for Walgreens to have to know my original-birth-certificate sex in order to vaccinate me. In any case, I was born intersex, and so my original binary birth certificate sex-marker was never accurate. And trans people living outside of large "blue" coastal cities receive medical care that is on average substantially worse in quality than that cis people receive in the US. When I am dressed, I currently have the privilege of being gendered correctly by strangers more often than not. Being balding and bearded thanks to testosterone access has a lot to do with that. Sometimes they recognize that I am transmasculine--but here in Wisconsin, sometimes they just presume I am a cis man. (Transmasculine people face a lot less scrutiny than do transfemmes, so my being 5'2" and pear-shaped can go overlooked fairly often.) Should I not try to conserve that privilege in interactions that could negatively impact my health? After all, I have dependents. . .

In the end, I entered the sex originally listed on my birth certificate, for the same reason that my backpack features trans pins and I wear t-shirts with trans-celebrating graphics and I post about trans topics on social media. As someone who has the privilege of often being properly gendered by strangers, it's important for me to be out, and not leave the hard work of trying to navigate and lessen transphobia to those who don’t have that privilege.

Well. I went to get my shot. I filled out my paperwork at the counter (with "Sex: F" printed at the top right corner next to my name) and took a seat in the waiting area. Twenty minutes later, my name was called. I got up and started walking to the pharmacy tech—young, with feminine makeup and long hair. “No no,” she said, “I’m not calling you.” I looked at her for a moment, then went and sat down while she watched. “Next is Cary,” she articulated loudly. I got up again, and walked over. “Your name is Cary?” she asked dubiously. “Yes, that’s me,” I said. She looked down at the form on her clipboard, where my name sat next to the “F” marker. She looked at me. “OK. . .” she said, and led me into the little vaccination cubicle.

Once we were in and the door was closed and I sat down, she had to go over the checklist of prevaccination questions—all of which I had to answer already on the form—but first she said, with a stony look, “Sorry, Cary is a female name so I was confused.”  I have a standard routine in circumstances like this, bringing up actor Cary Grant, but she never heard of him. So with a smile I said I am old, and many names change in how they are gendered over time, almost always going from traditional men’s names to gender-neutral ones to names seen as quite feminine. Lesley. Beverly. Meredith. Lauren. Taylor. “Really? Beverly was a boy’s name?!” “Yep,” replied I.

She didn’t mention the gender marker, though she did glance several times at my chest. (I wear a binder.) She just went ahead and gave me my shot. But she looked uncomfortable the whole time. Who knows what she was thinking. I didn’t ask, because it was a socially awkward situation, and there were a batch of people awaiting their shots. Getting a simple injection is a short medical interaction, and hard to get wrong, so it’s not like this tech’s discomfort posed a substantial risk to me.

But many other medical interactions do put a person’s health or life at risk.

Folks who are trans, nonbinary, intersex, and gender-nonconforming had been seeing improvement in the quality of our interactions with medical practitioners, but now that’s reversing, because institutions all over the US are caving and pre-complying with executive orders demanding disrespect for trans people that are all being legally challenged. And you see it even in the simplest of interactions, like going to get a shot at the local drug store, and having that experience become more uncomfortable.

It's important that we push back at things like this. There’s no reason to force people to misgender themselves to get a vaccination. Or to get a passport. The cruelty is the point, and we need a nation that is less cruel, not more! I know there are many worse things happening right now, from deportations to the attempt to destroy universities. But so much of our lives exist in little moments and short interactions. . .

This administration has turned a cold cultural civil war into a hot one, but we can mitigate that at least to some degree by being civil to one another. For example, if we’re unsure what’s going on with someone else’s gender when we’re dealing with their paperwork, we can just carry on being friendly and kind.

Do that!
 

On Anti-Androgens and Covid-19

 

Perhaps you learned this past week that among the self-"treatments" Americans opposed to vaccination have been using for cases of Covid are anti-androgens.

Anti-androgens are medications that block the body's production of testosterone. They have lots of uses recognized by the medical profession: as part of a medical transition for trans women; to suppress testosterone production in cis women whose bodies are making a lot of it and who don't like how that manifests; to slow the process of balding; to treat hormonal acne.

Taking them to try to treat Covid is not among these medically-recognized uses.

Some observers--especially in the trans community--have been chuckling or groaning or tearing their hair to see that a subgroup of people who are often highly transphobic have been ganking spirnolactone dosage and scheduling information off of transition information websites. Some suspect that a person who takes anti-androgens according to information they got from a transfeminine education site, all the while claiming to despise trans women and to be the most "alpha male" person ever, might as well be holding up a sign saying "Hi! I am selfhating, trans, closeted, and in denial!" That is an excellent point.

But what I wanted to focus on here is the underlying belief that has led those pushing "alternative" medical treatments for Covid to put anti-androgens on that list. That belief is a truism you hear all the time in discussions of Covid lethality. And that truism is that "males are more likely to die of Covid than are females."

It isn't actually true.

Or, ok: it is true in some places at some times, but false in others. In Texas, it has been true during the entire pandemic. In Connecticut, it was true during some months of the pandemic and false in others. In Massachusetts, it is women who have died at higher rates from Covid. There are more states in the US in which Covid has proven more fatal to men than women than the reverse, but it's highly variable by region and point in the pandemic.

Do you know what doesn't vary by region and month? Biological sex characteristics. If testosterone was making people more vulnerable to Covid, that would be as true in Massachusetts as it is in Texas.

What does vary regionally are social factors. What does the gendered division of labor and occupations look like in a given area of the country? And which of those gendered jobs involve heightened risk? (We often think of "dangerous jobs" being those that involve heavy machinery or violence, but caregiving jobs that are framed as feminine, like working in an elder care facility, or daycare center, or as a nurse's aide, are both highly stressful and associated with high exposure to disease.) Also varying by region is gender expression. How do men perform masculinity? Does it involve considering actions like handwashing "sissified," or not seeing a doctor until symptoms have become dire? Or are washing your hands and seeing a doctor deemed nongendered, commonsensical activities?

Suppressing testosterone production does have real effects--ask any trans woman on HRT, or cis woman with PCOS, who is taking spiro. Over time, it thins body hair production, for example. But those effects do not include making you wash your hands and wear a mask more diligently! They do not magically change the gendered division of labor in your region of the nation.

The presumption that if a gendered difference is noticed in some kind of health outcome, it must be biological and universal is, to be blunt, stupid. The ideology of biological essentialism blinds people to the empirical reality that what it means to be a man or a woman or any other gender is largely social. This is not to deny that biological sex characteristics are real! Estrogen really makes breast tissue grow. Testosterone really makes facial hair grow. But hormones do not cause employers to pay people in jobs coded as masculine more than they pay people in jobs coded as feminine. They do not make girls like pink and boys like blue. And they don't make you wear face masks more or less often.

Taking anti-androgens will not magically cure Covid. I can't say I'm surprised it has been proposed to do that by conspiracists on social media--having watched people fervidly believe in and seek out such "alternative treatments" as bleach solutions and horse de-wormer over the course of the pandemic.

What does sadden and annoy me is how there have been a bunch of medical studies looking at the idea of taking anti-androgens to prevent or treat Covid. Early in the pandemic, when we knew little about the coronavirus, its understandable that medical researchers would be grasping at straws. But it is now clear that the higher mortality rate for men that was observed in some studies is not at all universal, and doesn't appear in 11 US states. Medical researchers should know that if some phenomenon is gendered one way in state X, and the opposite way in state Y next door, and this shifts over the course of a year, then it is strongly social in causation, not due to chromosomal variance. 

But the demand for "alternative treatments" of Covid has been high, and the public's beliefs about testosterone inflate its importance and paint it in magical terms, for reasons rooted in patriarchy and the framing of testosterone as the "essence of maleness." And so, while most medical researchers consider the proposal that anti-androgens can prevent or cure Covid to have been disproven, a subgroup persists in asserting this claim--and they get lots of attention from conspiracists and tabloid-style journalism.

And that is how, recently, advice from "alternative medicine" influencers--a few of them doctors--to treat Covid with androgen blockers went viral. 

Anti-androgens will not save you from Covid. They'll slow your balding, if that's your thing. (It's not mine. I'm very happy with the balding hairline testosterone HRT granted me!) But a person who avoids vaccination, masking, and social distancing, thinking they can just take that bottle of spironolactone they acquired to cure Covid if they catch it. . . well, that person can die. 

And among the factors we can blame for their death--along with MAGA intransigence and the rage for conspiracies and quack doctors profiteering--are magical beliefs people have, about testosterone in particular, and physical sex characteristics in general. 

Best Practices Checklist for Providing Medical Care to Trans Patients

I have been asked by some organizations to provide them with a pamphlet or list of best practices that they could share with medical practitioners regarding the care of trans patients.

I suggest as a substantial resource for outlining trans medical care standards  the materials provided by the Center of Excellence for Transgender Health, which can be accessed here.  

What I've done is write up a checklist that others can share with medical practitioners that is succinct and that includes practical suggestions highlighting key concerns raised by many trans people.  This checklist is founded on the presumption that transphobia is unacceptable in health care practice, and that care providers wish to provide high quality care to all patients, including sex and gender minorities.

Best Practices Checklist for Providing Medical Care to Trans Gender and Gender-variant Patients

Compiled by Dr. Cary Gabriel Costello

1. Members of your practice group have received cultural competence training in interacting with trans gender and gender-variant individuals, and medical training in the needs of trans gender and gender-variant patients. ( An outline of standards of care is available from the Center of Excellence for Transgender Health.)

2. Your medical records are kept in such a manner that the name the patient uses appears at the top of files. (If that name differs from the patient's legal name or the name on the patient's insurance card, it is the name that the patient uses which is first seen by any staff interacting with patients, so that the patient is always called by the name the patient uses.)

3. Patient records prominently display the pronoun that the patient uses, and staff are careful always to use that pronoun.

4. Sex/gender characteristics are recorded in the following manner based upon patient self-identification:

        a.  Patient's gender identity: male____ female____ self-designation_________

        b.  Patient's gender identity matches the sex patient was assigned at birth: yes____ no____

        c.  Patient is intersex/has a DSD/is physically sex-variant: yes___ no____

5. At least one member of your practice is able to supervise hormone replacement therapy for individuals who gender transition medically.

6. Members of your practice can present interested patients with a list of practitioners in the area who perform transition-related surgeries, including orchiectomy, chest reconstruction, and genital surgeries. Staff are aware that patients may wish to access all, some, or none of these services.

7. When a trans gender/gender-variant patient visits, the patient is treated with discretion, and attention is not drawn to the patient's status as a gender minority. For example, a patient's trans gender status is not discussed where other patients can overhear; other medical staff are never invited into the examination room to educate those other staff about trans bodies unless the patient volunteers to serve as an educator; pelvic examinations are never performed with the bed facing the door so that the patient's genitalia might be exposed if the door were unexpectedly to open.

8. When a trans gender/gender-variant patient is examined, practitioners use language to describe body parts that does not undermine the patient's gender identity; e.g. for a trans man, say “chest” not “breasts,” “pelvic exam” not “vaginal exam;” for a trans woman, say “genitals” not “penis.” If robes are provided to patients, they should not be gender-marked in a way that undermines the patient's gender identity.

9. Trans gender and gender-variant patients and the general patient pool are protected from uncomfortable situations in waiting rooms, testing facilities, etc. For example, the presence of a visibly trans gender person in a mammography waiting room can cause stress for the trans person and for the other patients. The solution to such situations should always center the patient's gender identity—for example, allowing the patient to wait in a private room. Trans women are never asked to wait in a room that says “men” and trans men are never made to wait in a room that says “women.”

10. Medical staff are prepared for patients to “come out” about being trans gender or gender-variant. Staff respond with composure and empathy, and focus on the patient, not on how member's of the patient's family or community will react. Staff are able to inform the patient about what medical transition entails if the patient is interested, and can provide the patient with a list of therapists in the area who work with clients who are considering medical transition.

11. Members of your practice are aware that children can have trans gender or gender-variant identities, and are able to refer these children and their families to appropriate pediatric and family therapists for support.

12. Treating trans gender and gender-variant patients respectfully and well is one of the criteria of medical staff review. Those who do so are credited; any staff who treat trans gender/gender-variant patients disrespectfully are disciplined.

Trans and Intersex Children: Forced Sex Changes, Chemical Castration, and Self-Determination

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