Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine.

Melanie Cole, MS: I'm Melanie Cole. And joining me today is Dr. Julia Cron. She's the Site Chief of Obstetrics and Gynecology at Lower Manhattan Hospital, New York Presbyterian Hospital and Vice Chair and Assistant Professor in the Department of Obstetrics and Gynecology at Weill Cornell Medical College. She's here to tell us today about care for trans youth.

Dr. Cron, I'm so glad to have you with us. And what a topic we're about to discuss here today, because everything going on in the country today is really scaring some parents and some trans youth themselves. So, I'd like you to start by speaking about some of the unique healthcare needs of patients in the transgender community. What are some of the challenges you see most often?

Dr Julia Cron: Hi, Melanie. Great to talk with you today and I just want to thank you for inviting me to talk about this really important topic. I think your question of challenges speaks to this issue of you inviting me. I think just talking about it and having the discussion out there is one of the huge barriers to make sure that there's evidence-based information out there for people. So, I think that's one thing.

When I talk about care of transgender youth and gender-diverse youth in kind of a broader sense, I usually say that my requirements or my qualifications are twofold. One, as an OB-GYN and an adolescent gynecologist, I'm pretty used to talking about sensitive, somewhat maybe embarrassing topics. So, that to me is a requirement. And then secondly, I think just being open-minded. The field of care for transgender youth and transgender patients in general is changing every day. And it is not something that we, who like myself trained many years ago, we didn't really learn about this in training. So, I think being open-minded to learning is really, really important and being open-minded with your patients. I always learn from my patients, particularly this population. And I think that I've learned a lot over the past several years caring for these patients and guiding with being open-minded and being willing to talk about things that are a little bit sensitive.

Melanie Cole, MS: Other than being open-minded, speak to other providers for just a minute. Because there are so many healthcare providers that are being pulled between politics and their desire and their passion for being really caring healthcare providers with their, you know, philosophy of care. If you were to say something important about creating a transgender family-friendly practice, and that's for parents and for the community and for the youths themselves, what would you want them to know?

Dr Julia Cron: interestingly, I was just reading a study showing that about a quarter of transgender patients have been denied care in the past. And then, another interesting statistic to me is more than half of providers are interested in caring for patients or have a specific desire to care for the gender-diverse population. But over 80% feel like they are not equipped. So, I think educating providers and educating all medical professionals is really important.

So, I think, again, going with the guidance of being open-minded, and I think that goes to everybody that interacts with the patient. From the person that makes the appointment, to the person that checks the patient in, to the person that puts the patient in the room, talks to the patient on the phone, I think being open-minded and accepting and also recognizing again that we are all learning. And it is okay to correct yourself. It is okay to ask the patient, for example, what name do they prefer? What pronouns do they prefer? What are their preferences? We are not expected to know everything and we can learn a lot from patients. In my experience, that has been really, really important to me. And I've had some of our staff come and ask me and are very worried, and maybe feel like they made a mistake in calling the patient by the wrong name. And I always say, you know, just be humble. Go and correct yourself. Ask the patient what they prefer. And I think patients really appreciate that. Patients really appreciate their medical providers having some humility.

Melanie Cole, MS: Rock on. I completely agree with you. That is such an important aspect that you brought up. Asking questions is not a wrong thing to do. And as someone with friends and family in this community, I did it at the beginning, feel weird asking them to explain "they" because I didn't understand it. And I understand that that is a source of confusion. And, you know, they're really happy to explain it because it makes them feel seen and heard. And I think when you're talking about a family-friendly practice, that is one of the most important aspects, being listened to. Now as you're talking about care, what kind of assessments and treatments do you offer to patients and how is this individualized care established?

Dr Julia Cron: So for me as an adolescent gynecologist, my practice is focused on the gynecologic care for the gender-diverse patients. So, that is very broad. And I think that's the important thing. So, there are many levels of care for the gender-diverse patient. And I like to kind of simplify things. And when you think about this care, you think about, number one, the fully reversible care, the partially reversible and the irreversible.

So as someone who cares for young patients, I usually am working in the realm of fully reversible gender-affirming care. And one of the most common things that I do is what is called menstrual suppression. So for gender-diverse individuals who have dysphoria from their menstrual cycle, suppressing the menstrual cycle can actually be life-changing. And I learned this several years ago when I started caring for these patients. And it's really been amazing to me to see the, again, life-changing results from just suppressing somebody's menstrual cycle. And I like to tell my colleagues that we suppress patient's menses for so many reasons. For pelvic pain, for heavy bleeding, even for elite or non-elite athletes who don't want to get their period or patients that are going away for the summer, like we do menstrual suppression for so many things. So adding that to the toolbox of things that we can offer, particularly to the gender-diverse population, it's amazing. And so, we can do that super easily. We know how to suppress the menses with hormonal modification, and it's really easy. Most gynecologists feel really comfortable with it.

I think also, I add to the category of care is "routine GYN care," right? So, that includes, number one, assessing the need for contraception. I think it's really important for us to realize that things are not binary, right? So, we can't make assumptions about people. How they identify does not necessarily imply one thing in terms of who those patients are attracted to. Therefore, the need for contraception needs to be assessed with every single patient. So if there are patients who have a uterus and ovaries and they are having sexual activity with a person that has sperm, and there's the ability for pregnancy, we need to talk about contraceptive options. And I think one thing that's really important is that gender-affirming hormonal therapy does not equal contraception. So, I'll give an example of trans male patients who are on testosterone therapy. Even if they are not having their periods, they can still become pregnant if they have sex with somebody that has sperm. So, having that conversation is really important and talking about, contraceptive options and desires.

Secondly, fitting under the "routine GYN care" is preventative care. So, STD screening, Pap smears when indicated. All of those things are really important to maintain preventative health. And then, there are several things that can result from gender-affirming care. For example, irregular bleeding from hormone therapy. Sometimes patients experience vaginitis or like itching and discomfort in the vaginal area, so assessing those things. And remember that in an unsupportive environment, patients might not seek care for these important things. So going back to having the supportive environment, the supportive office, makes it more likely for patients to come in and seek care, and we are able to provide that care in a very sensitive way. And then, hopefully, that will prompt patients to come in when they need assessment. So, I personally do not do hormone gender-affirming care. I partner with endocrinologists and other physicians that do that. But I personally don't do that. I kind of like to think of myself as providing gynecologic care for the gender-diverse population.

Melanie Cole, MS: You make so many great points, that it's really a bit of a vicious cycle. If they don't feel comfortable and cared for, then they're not going to come back and they're not going to get the care that they need. And that, in turn, will just roll over on itself. Now, speaking along those lines, Dr. Cron, how is that social, emotional and psychosocial aspect addressed as a physician? Do you feel that there is even more of a stigma for the transgender community to seek help for mental health issues? Which I mean, we know among our kids across all genders, there is a mental health epidemic right now. But among the ones that are feeling the most vulnerable and the most attacked, this has got to be something that is top of mind.

Dr Julia Cron: I totally agree. And I do feel fortunate that I practice in an environment in New York City that is very supportive of trans rights and trans care. So, I think that's an important caveat to say that I feel very fortunate that I have the resources to provide evidence-based care for these patients. But I think your point of addressing mental health is really what is at the crux of this. And if anybody needs to be educated about this, the education around the importance of mental health and how the data supports gender-affirming care, patients that receive gender-affirming care have less depression, less anxiety, less suicidality. I mean, if nothing else, that should be something that cannot be ignored. and that's where I get at the point of this is lifesaving care, because gender-affirming care decreases the rate of suicide among transgender patients. I kind of can't say that enough or more loudly. And if you need any other reason, I don't know why you would, anything that prevents suicide seems to me to be an appropriate treatment.

But I think, yes, we are having a mental health crisis among our youth. I think in order to provide comprehensive care, it has to be multidisciplinary and having mental health providers on the team is really paramount. And I think that's the important thing for people to understand, right? That nobody is going about this lightly. And those of us that care for the gender-diverse population recognize the importance of comprehensive multidisciplinary care. And that is the way we're going to provide evidence-based care.

Melanie Cole, MS: So, that was one of my next questions, is discuss that multidisciplinary aspect of the clinic. What other services are incorporated? And when you say multidisciplinary, not everybody knows what that means. Speak about some of your team members and how they are working with this community, and even how you're offering support for parents and family members that are also feeling a bit lost as well and not sure how to support their loved one.

Dr Julia Cron: So, I am fortunate to be one of the team members that actually serves as a consultant to something called the Compass Clinic, which is run through Adolescent Medicine at Weill Cornell Medicine. And that is a multidisciplinary clinic that provides care for gender-diverse patients. So by multidisciplinary, I mean that there are experts in many different aspects. So, it is kind of housed under the Adolescent Medicine Division of Pediatrics. So, you have adolescent medicine providers, you have pediatric endocrinologists. So, those are doctors that are specialized in hormonal care. So, those are doctors that provide puberty blockers and gender-affirming hormonal therapy. You have a team of mental health professionals to address the really complicated mental health issues that go along with this population. And then, again, I am the gynecologic consultant, so offering contraceptive care, menstrual suppression and, as I said before, what I like to talk about is routine gynecologic care.

One other important thing is I'm speaking about the adolescent population, but there's a whole other aspect of the care for transgender patients as they get older and are considering potentially fertility preservation, surgical gender-affirming care. But again, that's not really what we're talking about today, but just to know that there's a whole other aspect of this care that is available once patients are adults.

Melanie Cole, MS: What a great episode. This was so informative. And really, we hit the heart of so much of this gender-diverse community, their needs and the challenges, and really the care, the philosophy of care that goes into what you do, Dr. Cron. As we wrap up, I just want you to summarize how you feel that this improved and specialized care is so important for the gender-diverse community and their families, and what you want listeners to know.

Dr Julia Cron: What I want listeners to know is that the care of the gender-diverse population is multi-leveled and requires many providers who are open-minded and willing to learn and willing to ask questions and willing to talk about sensitive things. So, it's a spectrum to me. There are patients that ultimately want surgical gender-affirming care. There are other patients that all they want is menstrual suppression and that relieves their gender dysphoria. So, taking it out of the "black and whiteness" and recognizing that this needs to be individualized care. And we, as the people caring for these patients, need to determine what it is that these patients want and need and recognize that changes over time. But again, going back to the menstrual suppression, like for some patients, that's all they need and want. And as a medical provider, as a gynecologist, it's pretty easy to provide that care. So, we need to be asking the questions.

Melanie Cole, MS: Well, we certainly do, and that is what we were doing here today. And thank you so much, Dr. Cron, for joining us. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcasts and Spotify and Google Podcasts. And for more health tips, go to weillcornell.org and search podcasts. And definitely, don't forget to check out Back to Health. I'm Melanie Cole. Thanks so much for joining us today.

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