In Support of Gender-Affirming Care
This week was sort of a “coming out” for me.
I was interviewed on the Life (Un)Closeted podcast with Rick Clemons to discuss my interests in expanding the reaches of Functional Medicine and Functional Nutrition to meet the unique needs of transgender patients. Rick is a coming out, sexuality, and authenticity expert. He inspires gay and bisexual men to live their lives without apologies.
So, as you can imagine, he was the perfect host for me to speak with about my passions for serving trans folx more fully, (and in aspects of their lives that may not currently be receiving what’s considered gender-affirming care).
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The World Health Organization defines gender-affirming care as encompassing a range of social, psychological, behavioral, and medical interventions “designed to support and affirm an individual’s gender identity.” And while it is not my job as a Functional Medicine Nutritionist to directly address the social, psychological, behavioral or medical interventions a person may receive, it is my job to ensure that those factors are taken into consideration when that same person is receiving care for a chronic or underlying condition. It’s also my role to support anyone going through a therapeutic treatment, whether that be antibiotic therapies or chemotherapy, as well as surgery and hormone therapies.
It is in this arena of physiological care and reinforcement that I see some major GAPs in gender-affirming care that Functional practitioners can fill.
As a Functional Medicine Nutritionist I support gender-affirming care.
I’ll link to the podcast in its entirety below, but wanted to share an excerpt with you on these pages. Whether this topic is of interest to you or not (and I hope it is), the principles I share are ones that help us see the powers of Functional Nutrition in action – embracing the realities that everything is connected, we are all unique, and all things matter. Once you’ve given this a read (or the podcast a listen), please share your feedback and comments below. How we get to the changes we need in healthcare is not a prescription, but a dialogue. My dialogue with you is a part of the necessary evolution.
Excerpt from Life (Un)Closeted podcast with Rick Clemons:
Andrea Nakayama:
…That really leads me to what my interest was in working with transgender practitioners and seeing how there can be more Functional Medicine and Functional Nutrition practitioners helping LGBTQIA+ folx because I don't think there is enough. I do not think this is a conversation that's happening enough in the Functional Medicine and Functional Nutrition spaces. I do feel like I need to say, I am a cis-gendered, straight, white, middle-aged able-bodied woman. I'm also a widow of 20 years. I'm a single mom, and I founded a successful women-owned business.
I like to think of myself as a disciple of the human condition: What are all the factors that bring you to where you are seeking help today?
In gender-affirming care, we tend to think about that term in relation to the psychological and the surgical interventions related to transition. The studies and the research (regarding gender-affirming care) are primarily around those two areas – the psychological and the surgical interventions.
And yet there are so many other health conditions that transgender folks are struggling with as well… heart disease, diabetes, there's autoimmune conditions like Hashimoto's and rheumatoid arthritis, and lupus… None of us are exempt from these health struggles and the research into gender-affirming care in primary care is very minimal. And in Functional Medicine and Functional Nutrition, like I said, I just don't hear it spoken about enough…
We have to recognize that the people coming to us have likely experienced discrimination in their healthcare and may or may not have had access to healthcare throughout their life, depending on their family of origin, their experience, other marginalization that they experienced in their life. That really piqued my curiosity and led me to consider four different factors that make me feel like we're doing care for this population all wrong…
Something you and I share, Rick, is that passion for the story. For me, that whole story is loaded with triggers, big-T triggers, little-T triggers, as with traumas, big-T traumas, little-T traumas. And that's what helps us to really help somebody untie the knots that got them to that particular place in their health, in their behavior, in their thinking, and all of it…
The four areas that got me thinking about gender-affirming care in Functional Medicine
For me, the things that really got me interested in working with trans communities and trans folx was less about where we get in the “self-care”, and more about how we manage the medical interventions. My passion is working with people with chronic illness. That's my passion – really diving into where things just aren't working as we would like them to work. So the four areas that really started to get me to think more about diving in (to this work) were:
the biology
the surgery
the hormones
the trauma
Biology
…When we look at the biology of how we are formed in utero, there's a change. We start the same for seven or eight weeks. Then there are shifts in hormones and hormone suppressants that actually turn the fetus into what we then term a “girl” or a “boy”. There’s a lot that could happen in utero in relation to hormonal exposure from mom and from our environment that can shift the expression of what we think of as gender norms. Gender is a continuum. It is not polar and so that understanding for me, once I understood the physiology was like, wait a minute, this is why transgender folx have existed throughout history. It's something that happens throughout the lifespan of an embryo and a fetus.
Surgery
When I think about surgery – and I'm going to use a term here, and I'm all for gender-affirming surgery, so I want to say that – but surgery is an “insult”. I say that in (air) quotes, not because I think getting surgery is an insult. Getting surgery (may be) necessary. However, it's a mechanical trauma. When we have surgery, there is tissue injury, there's tissue inflammation. Surgery induces a cascade of physiological stresses in different phases. There's oxidative stress, enzymatic stress, energy stress…
Surgery is #2 in the four that got me thinking about this. (And) it's my desire to help people through it. YES, you are having surgery:
What's being measured before you have surgery?
How are you healing from that surgery?
How do we help your body to transition post-surgery?
And get ready pre-surgery?
So (we’re) recognizing surgery is a physiological “insult” and I'm putting that in (air) quotes, that it is a mechanical trauma. I mean, if I'm going to the dentist and having anything done… I'm helping my body prepare for and recover from surgery. So YES, to gender-affirming surgery AND I believe people deserve help to prepare and recover from that surgery because it will induce other underlying or silent inflammation. We have to remember what we are doing to the body to support it through the transitions.
And I know I told you before we went live, Rick, I feel like this is my ‘coming out’ show because these are hard things to talk about because we want to just be the YES for gender-affirming care in its psychological and surgical and hormonal forms. And I am a YES for that, but I'm a YES, AND in an ideal setting, and I do feel like we have to get this kind of care, this adjunct care to more folx who may be going through it. Not all transgender people decide to have surgery or hormones. So there's different decisions and opportunities based on a number of factors. I just want to say, how can we help? How can we help you?
From a Functional Nutrition perspective, we are embracing trauma-informed care, which is another piece of the puzzle… As I was coming to my own desires to do this work, when I got to the point of “how can I help?,” it looked very different (than I thought it would). Getting to these areas that I was concerned about, which I'm sharing now – the biology, the surgery, the hormones, and the trauma – was not even the conversation I was able to have at the beginning. Sometimes actually helping is a whole different thing than what we think it is (or is going to be).
Hormones
What we know about hormone replacement therapy (HRT) and its history is that it started in the 1960s. It was popularized in the 1990s. The first clinical trials were in the 90’S and the World Health Institute released its findings in 2002, showing that hormone replacement was more detrimental than beneficial in its effects. Now a lot has changed and we are able to deliver (safe) bioidentical hormone replacement therapy (BHRT) for menopausal women. But I don't see that we're applying what we’ve learned about hormone replacement to trans folx choosing hormone therapy through gender-affirming care. So again, it's the YES, AND. YES, we need those hormones, AND…
Who's measuring your hormones?
Are those hormones working for you?
Are you detoxing the hormones you don't need so you don't have the ill effects of estrogen dominance, which (can be) estrogen dominant cancers?
Who's looking at it more holistically, more functionally so that we can say YES to the hormones and YES to your health and your long-term life? I know it's a big ask. I think we're far from being able to deliver this kind of care, but it's part of what really drove my passions (to dive into gender-affirming care in Functional Nutrition)...
I'm concerned that we've created a box for gender-affirming care that focuses on the gender-affirmation surgery alone. I know people who are doing great work in gender-affirming care and psychology but it doesn't look at the rest of the human body, and the history of that human body, and what other conditions might be at play in that body… We've created another box. And it's an important box. It's a critical box. But how do we widen the walls of that box?
Trauma
That brings me right to the fourth point that really concerns me…I always say, there's no protocol. There's a framework. There's a framework for how we think into the case, but there's no protocol… Two people with the same diagnosis got there for different reasons. So the reversal or management is going to look different and the fourth point that I was going to talk about… The fourth point is trauma.
We talked about biology, surgery, hormones, and (now) trauma. There's a lot of research around trauma-informed care now and it tends to take place in the psychological realm as opposed to the physiological realm. It’s moving there, but we know the research shows us that people who have experienced adverse childhood experiences (ACEs) of any sort are also then more prone, more at risk, to experiencing chronic conditions, usually related to autoimmunity and pain-related conditions. So how do we embrace that for the trans folx that are looking for care? How do we recognize that they may or may not (to different extents), have a history that is informed by some kind of trauma, and how do we hold that?... I know that when people are receiving the surgical and therapeutic parts or psychological parts of gender-affirming care, they are receiving trauma-informed care.
But if we widen the box or open the closet, how do we bring that into all of our (healthcare) practices, whether our practices are geared towards (current standards of) gender-affirming care or not? How does it all become gender-affirming care so that trans folx feel safe and welcome in our practices – exploring their diabetes, their BMI that might be keeping them from surgery, their autoimmune condition? How do we all become more trauma-informed and gender-affirming? That's really the final point that kind of led me to raise my hand and have a scholarship group where I could put it to the test.
Trans teens are at a far greater risk of experiencing disordered eating
I do have to mention that trans teens are at a far greater risk of experiencing disordered eating, probably four times greater. There's certainly gender dysphoria that can lead to body dissatisfaction and there's social oppression and oppression-based trauma that lead to the need to really carefully address “self-care”. So self-care is less about the ‘shoulds’ and what we ‘could’ be doing, and more about creating that space of safety for looking at the connections between how we talk about food, or when it's (even) appropriate to talk about food. Maybe we have to talk about sleep for six months before we can even touch the food, right? Because there's a lot there in terms of disordered eating patterns because of that body dissatisfaction, which is tough.
I’d like to shift the conversation from self-care to self-health care.
To listen to the interview that these excerpts came from in its entirety, please be sure to head over to the Life (Un)Closted website, or you can find the podcast on iTunes, Google Podcasts, Spotify, Radio Public, Podchaser, or TuneIn.
