[00:09:38] Host: For another series, I was able to interview Linda Villarosa about her book Under the Skin, which was all about health disparities for Black Americans. One of the things that came up in this book and in this conversation was that the level of stress of living with systemic racism, and we talked about, you were talking about stress of traffic, but this daily stress of microaggressions on a daily basis prematurely ages Black Americans. Now, looking at the LGBTQ+ community, I would imagine that the stress might have the same effect and maybe even more so when we're looking more specifically at the transgender community.

[00:10:25] Rivera: Absolutely. I think that this is, the term that we use sometimes in medicine is called minority stress, which is anyone who is minoritized or at the fringes or in a minority, they experience stress in ways that other people don't or increase stress. The idea that if you are worried about how people are perceiving you based on the color of your skin, you're not thinking about your job fully because you're constantly thinking about other things. Or if your fear is that you may be perceived differently for being a woman or for being transgender, that that constantly occupies your mind. It creates neurochemical responses of stress in your body and mind, but also affects your ability to perform well in your work environments, in your home life, even to walk down the street. If you're a transgender individual, and you're afraid that somebody is going to assault you when you walk outside your house every day, how are you supposed to take your doctor's advice to go exercise and walk 30 to 40 minutes every day after work or go to a gym if there's all these discussions in your community about who's using what bathrooms and genital checks and things like that?

Or even as I think this is very timely, last night we saw they revoked some protections for not surveilling people based on gender or sexual identity, those kinds of things. Now, people in the LGBT community, queer individuals, are like, "Great, now I can be tapped into by national security groups, and I can be monitored and watched. I have to watch all of my behavior at every moment of every single day, otherwise, I could potentially be considered a threat."

[00:11:54] Host: Wow.

[00:11:55] Rivera: Those are things that not everyone thinks about. Most people just get up every day and put on their clothes. Sometimes there's this what-about-ism that happens about this, where people are like, "What about me? I have struggled to pay bills. What about me?" It's true, you have that is a minority stress. Being economically disadvantaged is a minority stress. Although you might argue, in the United States, more people feel economic stress than don't, it's still a stress. You have to remember that even if that is your stress, the color of your skin, your gender identity, your sexual orientation, your religion, those things, they are not maybe factors for you also. You have to think about how these compound into what we call stigma stacking, where certain stigmatized identities in your place of living, in your country, in your city, they become stacked higher and higher and higher to have a greater effect, like an exponential effect on you.

[00:12:48] Host: I want to focus the rest of this conversation on the social determinants of health for the transgender community, specifically, because they are this large target of our current administration. I think that this is a powerful moment to be able to have these conversations. At the very basic, I would love for you to explain the difference between gender identity, gender expression, biological sex, and sexual orientation.

[00:13:23] Rivera: Absolutely. I think there are ways that we have to think about these as all different elements that have a spectrum between them. What we start with is the sex assigned at birth. This is what some people understand as the biological sex. I try not to use the word biological sex because biology is really messy. When you really get down into different types of animals and things, it's not as clean-cut as we would like it to believe. We talk about the sex assigned at birth, and that's the first place that we start. That is where a doctor, or when you gave birth, whoever looked at your external genitals when you came out, said, this is either male appearing or female appearing, or somewhere in the middle, intersex.

Or they may have done a genetic test and said you have certain type of chromosomes that would identify you as XY as a male, or XX as a female, or some combinations in between. There's XXY, and things like that, that are certain medical conditions that have varying genetic compositions. That's why it gets messy. For most people, a doctor looked at their external genitals and said, "This is a male," or, "This is a female." That's what gets put on the birth certificate. We call that the sex assigned at birth. Then you have your gender identity, which is in your brain and in your mind, and in your hormones, who does your body tell you you are?

Does your body tell you that you are more female or more male, or somewhere in between on the spectrum? That's your personal feeling about who you are on the inside. Then, knowing who you are on the inside, you may change what we call your gender expression, which is this culturally defined way that we style our hair, position our bodies, make our voices sound different ways, or dress in our clothing, that are socially built categories of what is traditionally more male or traditionally what is more female. You get these ideas of you can appear more physically masculine, or in your mannerisms, more masculine, or feminine or somewhere in the middle. This idea of being androgynous, that you don't really fit into any one category or the other.

I like to point out that this is a culturally based thing because the example I like to use is, if I wear a skirt in the United States, that may be considered a feminine act of a gender expression. If I'm in Scotland and I wear a skirt, that may be considered a very masculine expression of gender identity. It is culturally defined, which is why I love things that are culturally defined because we use these hard categories as if they're natural, when this is just something that we make up in society, and you can follow or not follow these things. That's your sex assigned at birth, your gender identity, and then your gender expression.

Then what comes to this is your sexual orientation. Your sexual orientation is who do you love having romantic, spiritual, emotional relationships with? You might be someone who wants to have a relationship with the opposite sex. Nobody. You are perfectly happy with your relationships with friends, but you don't want to have sex with those people. That's all where we separate out your sexual orientation from your sexual activity. That's another separate category that we bring out. Then you might say, "Okay, I'm bisexual or I'm pansexual. I look at the person, not the genitalia or not the body, or not the gender expression."

This is how you tell the world who you are interested in creating relationships with, who you are romantically or sexually, or physically attracted to. That's your sexual orientation. I think that it's important to point out that we lump LGB and T, lesbian, gay, bisexual, and transgender, queer, asexual altogether in this umbrella term that covers sexual and gender minorities. Remember that being transgender is not the same as a sexual orientation. Right?

[00:17:18] Host: Right. Yes.

[00:17:19] Rivera: Being transgender is a physical thing, is like your sex assigned at birth does not match your gender identity. Even though they're lumped in together, there's a slight nuance between those things. I don't know that it's necessarily bad to lump them all together, but what I think is that people will have different needs and different advocacy, and they will focus on different parts of their identity. When you try to combine it all together, sometimes it takes away that identity of the transgender community as a choice because it is lumped in with things like sexual orientation, which people might consider a choice.

[00:17:58] Host: There's another aspect, too, of this concept of sexual orientation. You're dealing with a little more adult decisions, or this concept of arousal, physical attraction aren't things that you experience as a child necessarily. There's something that are more post-pubescent when you are becoming sexually aroused and have these desires for this connection. Gender expression and gender identity are things that start revealing themselves at a young age, sometimes a very young age.

[00:18:37] Rivera: Absolutely. I'm so glad that you bring that up. Go ahead.

[00:18:40] Host: No, I just think that it's the children who are at this greater risk right now to suffer as our administration and places like Children's Hospital Los Angeles put a pause on gender-affirming care.

[00:18:58] Rivera: This is really interesting because you are correct. All of the research shows that your gender identity and expressions start very early on in your life. Actually, there was a really great movie called Everybody that came out recently that looked at the lives of intersex individuals and where we understand these things. Some of the research done was basically looking at, can we shift people's genders early on. One was the case of a gentleman who had an injury during his circumcision. A young boy was being circumcised, and they damaged the penis.

They said to the parents, "At this point, it's not going to be a functional penis. You should just remove it and raise this child as a female." They were twin children, actually. What ended up happening was the child raised as female was constantly battling that identity of being female because they, to themselves, were male. The parents tried very hard to suppress that. It ultimately had a very unfortunate outcome for this individual who grew up, became an adult, got married, ended up going back and affirming their gender as male when they were an adult, and learned what happened to them.

All of this research was published saying, "Oh, it was great. We did great things for this young person. We changed their gender, and we fixed it, and now they can be raised socially as a female." What was being published, unfortunately, was the opposite of what was actually happening. A lot of the way that we treat patients and think about transgender patients and think about gender comes from studies like that, which are not true. Then we get this whole movement of we have to protect children. We have to protect children. This idea of protecting children, if you want to follow the evidence, the evidence says that protecting children from the harm of gender dysphoria, the idea that a gender assigned at birth doesn't match your gender identity, protecting them, prevents suicide, prevents bullying, prevents all kinds of negative outcomes, but making children live in a gender identity that's not theirs is actually super harmful.

You're not protecting children, but rather causing higher rates of suicide. In some ways, it feels like that's the point because if you can get trans kids to harm themselves, then they don't exist anymore. It's almost like there's this purposeful attempt to try to erase trans people from childhood and make it difficult for them to exist in society so that they either choose to hide their identities or choose not to exist at all.

[00:21:28] Host: I wanted to point out this 2021 Gallup poll that you used in your lecture at Chapman, stating that 20.8% of generation Z identify as LGBTQ compared to the 10.5% of millennials, and the 4.2% of my generation, generation X. 2.1% of generation Z identify as transgender compared to the 1% of millennials and the 0.6% of generation X.

This is an incredible increase. We're not even looking at Gen Alpha right now, but my daughter, who is 16, is surrounded by this concept of gender fluidity and exploring gender identity. I see it all over Southern California. Yes, we're in this liberal state that has more acceptance, but these are the kids who will benefit the most from gender-affirming care.

[00:22:30] Rivera: Separating out sexual fluidity and gender identity, I think the point to make with this is that trans people have existed from the beginning of time. Trans people have always been here. There are different cultural understandings of being transgender across every culture. You have the Moches of South America in Mexico. In India, they have a population, the name is escaping me now off the top of my head.

You have this understanding that there's two-spirit in First Nations cultures, Native American cultures, the idea that people have always been born transgender and always have existed. Right now, we're giving people visibility. We're giving people understanding. We're giving people a way to say, "That is me. That is who I am, and that is who I feel." People are becoming more comfortable. People aren't just becoming transgender, they're becoming more comfortable with being transgender publicly because that's what happened is people would hide their identity.

They would get married, they would have kids, and then, later on in life, they might come out. Things like that. The narrative is that we are turning kids trans. I think that was exactly what came out yesterday in one of the executive orders about education is, if kids don't understand the amazingness that it is to be an American, they become trans was basically the wording of the executive order. It causes problems that makes them trans. It's like, no, they've just always existed, and we're just giving people an opportunity to be who they are. Yes, kids are surrounded by more of this because there's more discussion happening around it. You can turn on any social media, and most of the media influencers will talk about being bisexual. When you think about it, it's almost a commodity. You can have more followers if you appeal to both audiences. There can be some commoditization of it, but I think that takes away from the truth, that is, people are who they are, and letting people feel comfortable with who they are, it just means that we're seeing more people. This is the exact argument with autism and vaccines. Because we are better at understanding autism, we are better at detecting and diagnosing autism, doesn't mean that more people are autistic. It means that we're getting better at recognizing these things, or that we're realizing there is a spectrum of how we understand the world and interact with the world cognitively. I think it's really funny because you can create correlations to anything. Like, I could say that there is an increase in organic food sales in the world, and therefore, there's also an increase in autism or transgender kids. I can say that, okay, so the rise of organic food sales is causing more trans kids or more autistic kids. You can make associations to anything, but that's not what the data shows.

It just shows that people are more comfortable in expressing themselves, and that's why we're seeing these numbers change because nobody has used-- Well, maybe some groups, but previously, religion had been used to say that this is what you have to be and this is who you're going to be. Our culture does things like this. It really is about the growing acceptance and culture that is where we're seeing these numbers.

[00:25:30] Host: Let's talk about what gender-affirming care is and why preventing it for those under 19 or younger could be detrimental to the health and wellbeing of a patient.

[00:25:44] Rivera: Gender-affirming care is actually, again, one of these things that is very misunderstood because of the public narrative. I'll start at the very beginning in my broadest idea of what gender-affirming care is. Gender-affirming care is your ability to do Botox, to do lip injections, to have a breast augmentation. For people like, I'll call it Joe Rogan, or some of these high testosterone exercise guys, when they get gynecomastia from the testosterone that they use, gender-affirming care is taking away the extra breast tissue you get from using exogenous steroids to become a big muscular masculine man. Gender-affirming care is using Viagra to be able to have sex with people that you want to have sex with. Gender-affirming care is dyeing the color of your hair to make it more in line with the color you want to be for that particular moment. There are so many things that we do. Gender-affirming care is allowing you to wear a bra that is comfortable, that supports your breasts so that you can exercise or feel comfortable in your body. There are so many things that would fit into this category of gender-affirming care. At its broadest definition, it is what allows you to feel more comfortable in your gender expression of who you are, whether that's masculine, feminine, somewhere in between.

What the narrative has become is that gender-affirming care is mutilating genitals, that gender-affirming care is modifying hormones. Then, that it's these terrible things that we should be afraid of, but how many people allow their children to get nose jobs or breast augmentations or Brazilian butt lifts and things like that, that are against gender-affirming care for transgender or gender non-conforming individuals? We somehow have chosen to villainize the idea that people shouldn't have surgeries to adjust their gender expression or to adjust their bodies, but we allow people to modify their bodies in so many ways outside of this.

Why did we pick this way? People let children dye their hair. People let children pierce their ears. People let children do all kinds of gender modifying, gender-affirming things so that they can be in line with who they visually want to express themselves to be. For me, when we look at this idea, gender-affirming care for transgender people is so important because there's this idea of gender dysphoria. The idea that when your sex assigned at birth and your body don't match your gender identity or your gender expression, you want to do things to make those things congruent because if I feel masculine and every time I get my period, I have to go through this idea of, what does it mean for me to be a person who sees myself as masculine male, but has to go through something that is culturally ascribed as feminine and maybe even biologically ascribed as feminine, is a reminder that I have a uterus, is a reminder that I have ovaries.

Every month, I have to go through this dysphoria. I would want that to end, and I would want my body to match more what I feel and make me feel more comfortable in my own body. What happens is when people can't access gender-affirming care, they end up having higher rates of dysphoria and suicide. They have difficulty with social relationships because you can't be comfortable in your social relationships to people if you can't even be comfortable in your own body that you exist in. There is research that shows it has all kinds of negative outcomes to force people to live in these bodies.

I think there's this other argument that exists in the narrative right now that this is, people will do it, and they change their minds, and they want to go back, but there are more people-- I love that statistics are great because they can really make fun of ideas sometimes. There are more people who regret buying Harry Potter books than there are transgender people who regret their gender-affirming surgeries or care and things like that. I understand, for adults, we want adults to do what they could do with their bodies, but how do we work with this for children?

I think that's another category that is deeply misunderstood because what is happening for children is we are not changing children's genitals. We are not doing things to harm children. What people are doing is they are delaying puberty. There is research that shows that having a child go through the puberty of the physical gender that is not their gender identity is torture to children. High rates of suicide, high rates of social dissatisfaction, poor relationships, poor friendship making, and things like that. Lots of bullying. To force a child to go through that traumatic experience of puberty, puberty is traumatic enough for a person whose gender identity and sex assigned at birth are the same.

We get acne, our bodies change, our voice changes, everything is awkward and terrible, and so this adds an extra layer of terribleness to it for people. The idea is that we can delay puberty using depo hormones or using hormone pills and things like that, to allow people a chance to make decisions, to get older and feel more comfortable to do the things, like do their therapy, figure out who they are. Make sure what their gender identity is, and make sure that they are comfortable with making those changes and making those decisions. For a parent whose idea is that I want my child to be healthy and well and happy, if you want your child to be healthy, well, and happy, why would you not want them to be the most comfortable, the most confident, the most who they are that they can be?

This argument that we are mutilating children and changing their genitals, it doesn't happen. Parents don't get to decide these things aren't things that are happening. Where we are mutilating genitals is, the previous advice for intersex individuals, was that we are supposed to give them surgeries to make them appear one specific pole of the gender, male or female and that being intersex is somehow going to ruin their ability to have social relationships and things like that. What we're finding now is that, that's where we were mutilating children’s genitals to try to make somebody a gender that they weren't or stop someone from being intersexed.

[00:31:43] Host: This is all fairly new. While you said that transgender people have always been here, our understanding, our collective understanding, we've only been having these public discourses about gender-neutral bathrooms for a little over a decade. Up until recently, the term gender dysphoria, it was considered a mental or behavioral disorder. The World Health Organization just changed the way they categorized it in 2019, so this is all new. It was thought of similar to having schizophrenia. One of the statistics that you mentioned, another statistic in your lecture, is that one in four transgender people report having avoided medical care out of fear of being disrespected or mistreated. This isn't even for gender-affirming care. This is going to the doctor for the flu, or appendicitis, or a sprained ankle. We're all working to understand, and I would love for us to be at a better place, but this is a growth process.

[00:32:52] Rivera: I think you point out some really important things like, yes, trans people have always been there, but support, and understanding, and kindness has not always been there in our culture, in American culture, because, arguably, we are a nation of the Puritans that came here to establish a strict religious kind of colony outside of the Church of England. That has been the background to our experience and framing of the world, but we as a society have grown and changed so much. We have a diverse group of people who live here with diverse religions and diverse cultural experiences. What ends up happening is we have to, as a society, assess whether we want to be this melting pot that we have previously bragged about being, or whether we want to be exclusionary as a society and only accept certain people who come from certain backgrounds or have certain life experiences.

I think another part that you touched on was this idea that transgender people may not seek care unless it's an absolute emergency. There's actually a name for this. It's called transgender broken arm syndrome, is this idea that a trans person could come to the emergency room for a broken arm. Oftentimes, the discussion with the clinician centers around, "Oh, have you had surgeries? Oh, do you take hormones?" While we're ignoring this broken arm sitting in front of us, that has no need for that discussion. The idea is that people who identify as trans or gender non-binary, the focus always often becomes this identity piece rather than the actual healthcare, or that people think that all of the patient's healthcare has to be filtered through this lens of their transgenderness. It's hard. We try to train people not to do that, and not to get focused on that, but that's what happens, is that's why people avoid care because it becomes either they are insulted, they are looked at.

One of the other studies that I showed in my presentation looked at transgender and gender non-conforming patients in emergency rooms. Some of the quotes were things like, "They brought other people over to look in my room like I was an animal in a zoo, and they kept misgendering me and wouldn't call me by the right name," or, "When somebody found out that I was trans, they wouldn't let me use the bathroom, and they basically followed me out with security." These are the experiences that people are having. Why would somebody seek out care in this environment unless it was an absolute emergency?

Which is what happens is you get people presenting in later stages of disease processes more sick and more likely to have a bad outcome because there's this social pressure to avoid seeing. This comes from many things. We look at these health and social impacts of different parts of our personality. There's the environment we grow up in, the community we grow up in, the narratives we're hearing in social media or in media or in our families or in our communities, in our churches. These all coming together into help make us decide whether we can or cannot do the thing that we're going to do.

That's one of the things that trans people are constantly navigating is, this like social cognitive theory, do I have the ability myself? Will my society accept me? Are there other environmental factors? What are my reserves emotionally? These kinds of things that people are constantly trying to navigate to decide whether or not just to go to the doctor's office.

[00:36:22] Host: What do we do? The big question, what do we need to do to be better, to make healthcare better for my daughter and her friends and the generations to come, as these numbers, as the understanding and the acceptance of this identity grows and increases exponentially?

[00:36:44] Rivera: I think the first thing is, from a societal perspective, we have to follow real, true information. One of the things I think about is this narrative around transgender individuals playing in sports. When you look at the actual numbers, it's like less than 1% of elite athletes or athletes identify as transgender. The idea that we have this political narrative about this is insane. I think we need that. When we talk about the numbers of children who are seeking gender-affirming care or puberty-blocking therapies, things like that, we have to look at the real numbers. What percentage of this is this really? Is this the problem that it's taking up in our political discourse and in our social discourse? Because it's not. Having an accurate understanding of what this actually means is one of the first things that we have to do as individuals, but that's hard because we're not all fact-minded people. We're not all scientists who dig into research and look at the value of research. I think the second part of it is what humans do really well is listen to the narratives and listen to people. Follow trans people or gender non-conforming individuals or queer people on social media, listen to their stories, learn how they experience life, and then really have a reflection of how this reflects your experiences as a woman.

Someone who was assigned female at birth and whose gender identity matches being female, do you have experiences like this of being followed and harassed and mistreated or assaulted because of who you are or the way that people want to establish power over you? The experiences of these individuals are not so far off from other people's experiences. When we can find that empathy, when we can understand their experiences, it changes them and makes people more human to us. I think that's what we're good at. We're good at listening to stories of people.

We are much more interested in the stories of people. For example, I always bring up vaccines, but when people talk about there was a vaccine reaction, "My cousin, sisters, brothers, uncles, aunt had a reaction to the vaccine, and I'm very scared to get this vaccine now," why is that story about your brothers, cousins, sisters, aunt, that may not even be a true story, more powerful to us as humans and more likely to affect our decision-making process than all of the doctors or research studies that showed that vaccines are perfectly safe and these are very rare exceptions to things?

Why do we choose to believe those narratives first? I think that's a really big step an individual can take, is to try to open your social bubble to include more people who are different than you and realize that there are ways that you are very similar. We have to work on the legislative pieces of it. We have to stop trying to legislate people's bodies and choices and things like that, understanding that there are real implications to these rules. I bring up an example, you talked about bathrooms. People forget every bathroom in their home is a-

[00:39:41] Host: Gender-neutral.

[00:39:41] Rivera: -gender-inclusive bathroom. Every bathroom that has a door and a toilet is a gender inclusive bathroom.

[00:39:49] Host: Yes.

[00:39:49] Rivera: I laugh because I think, "Wow, in the '90s, we really got this." Remember the TV show, Ally McBeal? They had a bathroom where both the men and the women could use the same bathroom. This was a TV show in the '90s. It was something we were able to talk about, and it was not a problem. Also understanding what people are saying in these narratives. When we talk about bathrooms, the concept of there is going to be someone who is going to pretend to be a woman to get into the bathroom to assault a woman. When you think about that, that's very fearful, this narrative of fear that someone is going to try to assault you or your child or your daughter or your mother or whatever it is, that's a scary narrative.

When you think back at that, you're like, "Okay, so someone whose sexual orientation is that they want women and someone whose gender identity is male and someone who we're presuming their anatomy is sex assigned at birth is male is going to pretend to be a woman, not actually feel like they themselves are a woman, they are going to pretend to be a woman to go into a bathroom and assault a woman, that is a cis-het male. That is a straight man going into a bathroom to assault a woman." What you are asking people to do is to legislate away the rights of transgender or gender non-conforming individuals to protect women from straight men. Right?

[00:41:14] Host: Right.

[00:41:15] Rivera: We have to understand what people are asking for is not the solution to the problem. We need to have these conversations, and this has to be the dialogue to show the ridiculousness of it, that the idea that we pass laws and legislation to restrict the bodies or the places people can go or whether people can get passports that match who they are or driver's licenses, these are all ways of trying to further harm an already harmed community and make their identities more public. Most of these people would just rather live their normal lives and not have their identity be the center of focus of who they are as an individual. Most people just want to exist and do their daily lives.

Medically, we have to do a better job of educating medical clinicians of how to care for transgender patients, how to be respectful of people's identities, how to understand what are the risk factors for disease or infirmity that we should be aware of, the screening tools, and how to have difficult conversations around people's bodies and ask somebody who might have gender dysphoria if they're comfortable talking about their body with us. Then we have to recognize that these disparities exist and actually try to fix them instead of making them worse, because I think that's the big problem is we have all this evidence that disparities exist, and we don't necessarily have the fixes in place to make things better.

I always try to say the last thing that we should try to do as humans is this idea of unconditional positive regard, which is this idea Carl Rogers and his group in the 1950s put together, which was basically, in order for us to enter into healing relationships or good relationships with people, we have to presume that they have some sort of positive influence in the world or that they can somehow impact the world in a way that is needed, so that whether it's a positive example of showing us a kindness or a way to do things the correct way, or whether they're a negative example, showing us the harms of doing things a certain way, we can learn something from every single person.

We have to recognize that this wide world web that we are creating of a global society where everyone is interacting with each other at all times of the days, we have to respect what people do for the world and the way that they impact the world around them and recognize what we can take from that and what we can learn from that and see them as having a positive place in the world because if we can't see them as positive, how can they see themselves as positive? Especially for me, as a physician, how can someone feel good about themselves or enter into a relationship with healing, or want to heal themselves if other people don't see that value or worth inside of them? I think that's a really great place for us to start as humans is looking for that unconditional positive regard.

My favorite quote with this is from Cornel West. It's, "Justice is what love looks like in public." If we can find that kindness, we can find that love, then we have to work backwards to find ways to make justice for individuals. That's through our legislation, our healthcare, our friendships, and our understanding of their lives.

[00:44:19] Host: We'd like to thank Dr. Ronnie Rivera and UC Irvine School of Medicine. If you would like to continue the conversation, visit chapman.edu/wilkinson to learn more. To access recommended books from our guests for further learning and for more socially conscious content, visit us at pastforward.org, or follow us at Apple, Spotify, or wherever you podcast.