100: A Pediatric Endocrinologist Talks Transgender Medicine

Specialty Stories

Session 100

Dr. Kara Connelly, a transgender medicine specialist. A pediatric endocrinologist by training in an academic setting, she has been out of training now for six years. Today, we talk about Transgender Medicine, why we have it, and why it's important for transgender patients.

[04:13] Interest in Transgender Medicine

Kara drew inspiration from patients and their families going through hoops they had to go through to access care. Knowing how challenging and difficult it was, she felt passionate about trying to make healthcare easier and more accessible.

Additionally, this was in the realm of pediatric endocrinology that it naturally felt like they could build what they did to help more patients access the care they needed.

[05:00] Traits That Lead to Being a Great Transgender Medicine Specialist

Communication is the most important piece of being a great transgender medicine specialist. This goes for pediatric endocrinology as well. This being said, you also have to be a good listener and open to hearing people's stories and their needs.

You also need to have an open mind in helping them access what they need. With pediatric endocrinology, you have to be able to tailor conversations based on who's listening. Be able to get the same points across to patients across different age ranges.

[06:26] Types of Patients

Kara mentions that one of the things that has been continuing to shift is where patients are accessing care. In this regard, pediatric patients are different from adult patients.

Currently, they see patients as specialty care providers. They're often referred to by their primary care providers who are likely to have not had any training in the area since this wasn't included in their medical training.

Not long ago, Kara didn't have any access to transgender medicine when she was a medical student. So it's still relatively new for many pediatricians.

A lot of family medicine providers are gaining more experience because of their work with adult transgender patients. But many pediatricians are still wanting to refer to specialty care.

As part of pediatric endocrinology, one of the treatments they offer is pubertal suppression or sometimes referred to as puberty blockers. These are medications that pause puberty and used for patients who are not transgender and go through puberty too early. This can also be accessed by transgender youth who don't want to go through the physical puberty changes that are not aligned with their gender identity.

They also prescribe prosperity hormones to many patients who are not transgender. The patients come to see them pretty often after 3-4 months. They're prescribing hormones in starting puberty so they build relationships with these patients.

For young adult and adult transgender patients, they usually access hormones through their primary care providers.

So there are not a lot of adult patients that access these medications from adult endocrinologists. However, there also adult endocrinologists that are active in transgender health.

[09:44] Focus on Transgender Health

There aren't enough trained providers to be able to provide the care that is needed for this patient population. Kara explains that transgender health will be part of medical training and by that time, there will be more primary care providers with the knowledge and expertise to do the care.

Pediatric care is a little bit more complicated than adults. But in adults, it usually involves prescribing hormones and monitoring for side effects which are low and rare.

It's easy to get the training that's needed to become an expert in transgender health. So it's just a matter of training people.

Taking care of this population is critical because transgender people in the U.S. and in the world, are not able to access a lot of the rights and healthcare that other populations are able to.

It's important that as a society, we're able to gain awareness of what this means and how important it is to be able to provide basic healthcare needs to all patients. We have to recognize the significant disparities that transgender patients face by not being able to have their basic healthcare needs met.

There are studies demonstrating high rates of transgender patients not accessing basic healthcare. This includes primary care and preventative care – because of the fear that they will be rejected by their healthcare provider or their healthcare clinic setting.

[13:43] Typical Day

Kara doesn't think she has a typical day. Working in an academic setting, she does clinical care, medical education, and a bit of research.

Clinical care is in the outpatient setting done at the clinic in their hospital. She also travels to three different cities for outreach clinics. She provides pediatric endocrinology care to patients outside of the major city she lives in who don't have access to a specialist.

She provides telehealth care where she sees patients from her office while the patients are sitting in a clinic in another city. She also sees patients whenever she's on call providing inpatient service. They mostly see patients children with Type 1 diabetes as well as consults with other services in the hospital.

That said, each day is a little bit different in terms of where she's seeing patients or whether she has an admin or nonclinical day. Nonclinical time is spent on scheduled roles with undergraduate medical education.

She works with medical students in their preclinical years. She also works the rotation for pediatric endocrinology for students and residents rotating with them. She does didactic teaching, focused primarily on transgender health throughout their hospital and throughout their state.

Her research is also primarily focused on transgender health, mentoring students and residents. She also helps oversee projects pediatric endocrinology fellows are doing in their field.

[16:15] Academic vs Community

Kara chose the academic setting primarily because of her passion for teaching and education. She loves seeing patients. Her primary interest is clinical work but it's not all that she wants to do.

Kara wanted to be able to incorporate the education piece and research into her career. And the academic setting is the best place to do this.

[16:55] Taking Calls

Kara takes calls as a pediatric endocrinologist. She hasn't experienced getting any calls for transgender medicine.

As a pediatric endocrinologist, their group takes calls evenly, where they do a week of call at a time. They're the main person somebody will call if they have questions about any of their patients.

On the weekends, they see patients in the hospital for a couple of hours. Then she gets to come home and live her life through the rest of the day and the weekend. She doesn't get very many calls so she doesn't really feel it's interrupting her home life.

During the week, it can get pretty busy as they could get inpatient consulting and they still do clinics. So while the weekday calls can be busy, the nights are not too bad. Kara thinks this is partly because they're in an academic setting.

They have pediatric endocrinology fellows who take the calls from the patients during the day and night. The attending doesn't get a lot of those calls. Basically, she gets 9 or 10 weeks of calls per year.

[19:10] Transgender Medicine as a Full-Time Career

Kara does transgender medicine as a pediatric endrocrinologist and sees pediatric patients. A lot of the transgender specialists in the country are trained as adolescent medicine providers.

If you want to do this as a full-time career, you can do more of general adolescent pediatric care but also have a special interest in transgender care. Basically, it's up to the individual to decide what percentage of their practice they want to focus on.

Moreover, there are different ways to provide care for transgender patients.

As they continue to build more capacity for training providers and acceptance and understanding of the needs of this patient population, it will no longer feel as a specialized field. It will feel like being able to prescribe medications for high cholesterol patients.

[21:06] Work-Life Balance

Kara thinks that one of the best things about pediatric endocrinology is the lifestyle. They have low acuity and high complexity patients. But generally, their patients do well and it's their role to help them stay healthy.

She feels their field is very conducive to being able to have a family. She has two young children but still gets to spend time with them even if she works full-time. She may miss out on school activities during the day if she had not been able to plan ahead for them.

But she has a lot of vacation time she can use if she knows about activities in advance. Also, when she's on call at night, she never had to go back into the hospital. Even if the patients are sick in the hospital, they have residents seeing them as well as the ICU team.

[22:40] Training Path to Becoming a Transgender Medicine Specialist

Basically, the training path depends on what specialty somebody wants to go into.

If you're interested in transgender medicine, the first question to ask is what patient population, specifically, age, are you interested in working with. What other skills do you hope to attain and have and work on?

Kara went into pediatric endocrinology even before she knew about transgender medicine. But she always knew she wanted to work with pediatric patients. She did 3 years of pediatric residency and another 3 years of pediatric endocrinology fellowship.

In pediatric endocrinology fellowship, you will likely get training in providing care to transgender youth. In fact, this is one of the things that the Pediatric Endocrine Society is actively working on. They're building a curriculum for pediatric endocrinology fellows where they would have standardized training for transgender care.

In the primary care setting, you may do a family medicine residency and then become a family medicine doctor who can see youth and adults and provide transgender care.

This may also look the same for somebody who wants to be a general pediatrician and be able to provide transgender care. So they go through three years of pediatric residency and then practice.

Surgical care is more specialized and requires additional training. This has not been incorporated into the residency training yet. But there are special training fellowships for gender-affirming surgical care. This can be done after finishing the surgical residency training.

At this point, there is no board certification for transgender medicine. There are groups or organizations dedicated to transgender healthcare such as the World Professional Association for Transgender Health (WPATH). It's an organization of professionals dedicated to providing transgender care.

To match into pediatric endocrinology from general pediatrics is not very competitive. There are more training physicians than there are applicants. Kara believes that this is a great field to enter if you want your pick as far as training program and where you want to live."

The pediatrics side can be competitive depending on which programs you want to apply for.

[27:00] Subspecialty Opportunities

From a primary care standpoint, you can specialize in transgender care. In pediatric endocrinology, when they're providing care for transgender patients, they do prescription of pubertal suppression medications for different conditions regularly. But it's not really specialized training.

[28:34] Bias Against DOs and Working with Primary Care and Other Specialties

Kara is not seeing any problems with DOs having access to training.

When working with primary care providers, Kara wants them to understand how to create an affirming care environment. People who identify themselves as transgenders want to go into the clinical setting not knowing if they're going to be respected.

They have to understand the basic things like using the right names and pronouns and how to ask the questions. They need to make sure all the people the patient is going to encounter are being consistent in being affirming and using the right names and pronouns.

Secondly, primary care should be sensitive about physical exams. People who identify as transgender or gender-diverse are often really anxious or uncomfortable about the chest exam or the genital exam. So help them understand the purpose of the exam and why it's necessary. Then make sure they give permission and consensus first before the exam is done.

Lastly, when a patient comes in for any reason, focus on the reason why they're there. If they want to start hormones, that's specific to transgender care. This is important for emergency room providers to recognize and just ask the questions pertinent to the reason why they're presenting.

Other specialties pediatric endocrinologists work with include general pediatrics, adolescent medicine, psychology, and psychiatry.

In transgender health, they have an integrated team of many clinical providers that provide care for all ages. They work closely with primary care providers in family medicine, internal medicine, OB/GYN, urology, and plastic surgery.

[32:50] How to Start a Dialogue with Transgender Patients

Several clinics use written forms, which is an easy venue for the youth to write things down.

It's important to leave the forms as open as possible so they don't feel like they have to check boxes. For example, it's important not to have a male or female box for gender identity. And specify gender identities separate from sex assigned at birth.

Verbally, pediatricians can just ask the youth about their gender identity and whether they feel comfortable with it. And it would feel more natural if this is something you ask all patients.

Just opening the space to have that dialogue and making that just a routine part of every well adolescent visit will start to feel more natural.

Sometimes, pediatricians could ask very young children (as young as 3 or 4) whether they're a boy or a girl. This is a simple way to open the conversation to very young children. Sometimes, this could be the first place where young children are able to say who they are.

[36:35] Special Opportunities Outside of Clinical Medicine

There are tons of opportunities for advocacy and getting closely involved with community partners. You can work on having resources outside of the clinic setting for gender-diverse youth. For example, you can get involved with support groups for parents and youth.

[37:34] What She Knows Now that She Wished She Knew

Kara finds transgender medicine to be a very rewarding career as you get to build relationships with parents and patients. This is something that she loves about her specialty. And it's really unique for this specific population.

Another thing she had no idea about getting into this specialty is how hard and complex the care is. They face so many barriers in terms of getting insurance coverage for some of the basic needs of these patients.

In fact, 30-40% of the care she provides to patients is battling insurance companies just to get approval for basic things. But it's gotten better though. Their state Medicaid plan will cover all transgender-related medications and surgeries. But a lot of commercial insurance plans won't. And if ever they do cover treatments, it can be very costly.

Hence, they have a specialized team of people who can work on this aspect. They have a full-time medication authorization specialist who focuses on getting authorizations for the medications prescribed for patients.

[40:30] Most and Least Liked Things

What she loves most about transgender medicine is being able to develop meaningful relationships with patients. It's great to have a place where they can come and know that every conversation is safe. They can ask any questions.

Kara also loves working with families and help them overcome resistance and fears they experience around supporting their child's identity.

From the pediatric endocrinology standpoint, Kara loves working with patients of all ages. She loves working with kids that have chronic health conditions and getting to know them over the years.

On the flip side, dealing with insurance companies is one of her least liked things. Another thing is the Electronic Health Record. She appreciates it in terms of the way it has improved communication among providers and between patients and providers.

But it can be pretty cumbersome and can take up a lot of time. That being said, you have to be really strategic around the ways you use it. In their case, they're building teams consisting of more medical assistants and nurses that can help triage those questions and issues.

Nevertheless, if she had to do this all over again, Kara would do it without doubt.

[47:00] Final Words of Wisdom

Find a mentor or somebody in the field that you respect who's doing something you think you might be interested in.

It's so valuable to have a mentor in the field that can help you really understand what that field is like. This could be in the form of shadowing or doing a scholarly project with them. Understand what their life is like and if it's something you want to pursue.

Your mentor could also help you make connections with other people, whether it's the same field or a different field.

There's so much value in face-to-face contact with people. It's so hard to get swallowed up in the paper of applications without the ability to show who you are as a person and the skills you bring.

Links:

Meded Media

World Professional Association for Transgender Health (WPATH)