Affirming Care with Dr. Kellan Baker | Crooked Media
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July 18, 2023
America Dissected
Affirming Care with Dr. Kellan Baker

In This Episode

What is gender-affirming care — and why is the far right trying to ban it? Abdul reflects on the way misinformation intended to flatten and decontextualize gender-affirming care has been critical to driving a cycle of hatred against trans people. Then he talks to Dr. Kellan Baker, the Executive Director of Whitman-Walker Institute and an expert on gender-affirming care about what it is, the impact of bans, and what everyone who believes in freedom can do to push back.

 

TRANSCRIPT

 

[sponsor note] [music break]

 

Dr. Abdul El-Sayed, narrating: The FDA approves the country’s first over-the-counter oral contraceptive pill. Johnson and Johnson bows to public pressure over access to a critical tuberculosis medication. The state of Indiana, a red state, just increased its public health funding 15 fold. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Today we’re talking about gender affirming care. What it is and what it’s not. I’ve been wanting to do this episode for a while now, in large part because the question of health care for trans kids, kids has emerged as one of the most pressing political lightning rods among the MAGA movement. I have to put my cards on the table here. I’m a cis straight man. I’ve never had to worry about violence directed at me because of my gender or sexual orientation. And I’ll admit, at times that’s left me with a bit of a blind spot when it comes to the climate of hate and marginalization LGBTQ+ people so often face. Though I have known my fair share of hate for other reasons. There’s absolutely no way to ignore the white hot rage coming off the far right in this country. The clip I’m about to share could be triggering, but I’m sharing it because in some ways it’s precisely why this episode is so important. 

 

[clip of Michael Knowles] For the good of society, and especially for the good of the poor people who have fallen prey to this confusion. Transgenderism must be eradicated from public life entirely. [applause] The whole preposterous ideology at every level. 

 

Dr. Abdul El-Sayed, narrating: That was Michael Knowles. A proto fascist political activist calling for the eradication, yes, eradication of a whole group of people. That is nothing short of a call to violence, genocide even. When political activists say things like this from a microphone at a political conference, all of us should take heed. Because the attention over transgender health care is bigger than the 1.4 million Americans who identify as trans. It’s about the kind of America we all of us want to live in. The first step of political violence is dehumanization. It’s an attempt to flatten the inherent complexity of human beings into attributes that are then mercilessly targeted. That dehumanization is intended to do two things. First, it creates a permission structure that validates interpersonal hatred. It’s a call for a climate of open discrimination intended to terrorize people simply because of who they are. But it’s also a call to drive public policy that sanctions those people. Anti-trans laws targeting health care have already passed in 20 states. These two, discrimination through hate and discrimination through public policy are meant to feed off each other to validate each other. One creating a justification for the other. And at the core of it all is a blatant misrepresentation of a basic set of facts, which is why we’re talking about gender affirming care today. What is, at its core, individualized, age specific, multi-modal health care delivered by licensed experts, has been deliberately mischaracterized by those seeking to hate and marginalize to justify that cycle of discrimination they’re perpetrating. So today, I wanted to talk to someone who has been studying gender affirming care for decades. Dr. Kellan Baker is the executive director of the Whitman-Walker Institute, the research advocacy and policy arm of Whitman-Walker, a system of clinics serving the LGBTQ+ communities in the D.C. area. We discuss what gender affirming care is and is not, why the far right is demonizing it, and how we address the misinformation about it in our networks. Here’s my conversation with Dr. Kellan Baker. 

 

Dr. Abdul El-Sayed: All right. Um. I am recording. Are you recording? 

 

Dr. Kellan Baker: Yes. 

 

Dr. Abdul El-Sayed: Perfect. Can you introduce yourself for the tape? 

 

Dr. Kellan Baker: My name is Kellan Baker. I am the executive director of Whitman-Walker Institute, which is the research policy and education arm of Whitman-Walker, a community health system in Washington, D.C.. 

 

Dr. Abdul El-Sayed: Kellan, I want to I want to step back because our subject today has become very quickly one of the most politicized parts of health care, I’d say right, right there with reproductive uh care. Um. Trans care is uh at the very top of the set of overly politicized um parts of health care. And, you know, I think I want to I want to come into this conversation recognizing that everything that we’re going to be talking about has been the subject of a whole lot of waxing philosophical by folks who don’t necessarily understand the technical facts about which they are speaking, but um carry a whole lot of emotion, oftentimes informed by um by all kinds of things that that have really nothing to do with what exactly it is that we’re talking about. And so a lot of our goal today is um to actually get back down to the, to the brass tacks. What are we talking about when we talk about gender affirming care? 

 

Dr. Kellan Baker: When we talk about gender affirming care, we are talking about a wide range of services and supports that help transgender people live fully, safely, and authentically as who they really are. Gender affirming care has been provided in the US by licensed clinicians for more than 50 years, and it’s guided by a number of expert standards of care, in particular the standards compiled by the World Professional Association for Transgender Health, which actually had their first edition in 1979. And those standards of care outline a really individualized and age appropriate approach to whatever it is that, again, helps a transgender person feel at home and be at home in who they are as they’re moving through the world. So there’s a variety of considerations that go into that individualized and age appropriate determination that doctors, in conjunction with patients and for young people with their parents, they have a lot of conversations to make sure that that pathway is individualized. And there’s a lot of misinformation out there about exactly what gender affirming care is, to your point. And it really is based on nothing but fear mongering um and really that exploitation of the fact that relatively few people in the U.S., at least until recently, I think, knew a transgender person or could say they knew much about transgender issues. And so, unfortunately, what we’re seeing now is this really poisonous politics kind of rushing in to fill that gap. 

 

Dr. Abdul El-Sayed: There are a couple of aspects that you shared there that I um really want to bring out, which is, one, it’s been practiced for a very long time. There’s literally nothing new here. Two, it is age appropriate. And three, it is individualized. And that is entirely the opposite of how the conversation tends to collapse this very broad, individualized, long practiced um space in health care. And oftentimes when you see um a one size fits all conversation for a individualized, very specific, um highly tailored practice, it is intended uh to fearmonger about that, as you discussed. So I want to um walk through the age appropriate piece, as you talked about, thinking about what gender affirming care means across the life course. So what what do we think about when we think about gender affirming care pre puberty? 

 

Dr. Kellan Baker: Pre puberty, when we’re talking about gender affirming care, we actually don’t need medical care at all. There are no medical interventions at all for trans kids before puberty. The only conversation that they might have with, for example, a medical provider about some sort of specific type of care might be a mental health professional to help make sure that the young person and their family have the support that they need to navigate some really complicated conversations for many people around identity. It’s something new for a lot of parents and for young people who are figuring out who they are and navigating the experience of sharing that with parents and other family members and peers. So mental health professionals might be involved, but there’s absolutely no medical intervention for kids before puberty at all. When young people do reach puberty, that’s a really scary and difficult time for transgender young people because you’re talking about irreversible physical changes that are really at odds with who these young people know themselves to be. And that’s exactly why puberty delay medications are the standard of care. These medications are safe and effective. They’ve been used for transgender young people for many, many years and also for cisgender young people. The idea is to do exactly what the name says, to pause puberty, to temporarily hit a pause button, to say, we need to make sure that this young person has the time that they need without the ticking clock of puberty, of these irreversible physical changes that can be a real source of intense distress for transgender young people who are watching their bodies change in ways, again, that don’t align with who they are. So at puberty, that’s when puberty delay medications are the standard of care to allow young people, their parents, their doctors, that time to make the right decisions and ensure, again, that they’re not being pressed by a ticking clock. 

 

Dr. Abdul El-Sayed: And Kellan, there are a couple pieces I want to uh pause and speak to here. And this question is going to sound pedantic, but I know that many of our listeners um are tuning in to to understand specifically what this means is they have conversations with folks who may have a um misinformed viewpoint of what we’re talking about. So when we talk about pre puberty, gender affirming care, we are not talking about irreversible surgery among children. 

 

Dr. Kellan Baker: We are not talking about surgery at all. We’re not even talking about medical care at all. Again, you’d want to be talking to your pediatrician to make sure that you have a plan for once the young person reaches puberty. If puberty delay medications are going to be the right next step. And certainly you would want a mental health professional to make sure that the young person and their family has support. But there are no surgeries ever being performed on transgender children before puberty. And there’s absolutely no other medical intervention that happens before puberty at all. 

 

Dr. Abdul El-Sayed: See, and the reason I ask that is because those who want to politicize this would have you thinking that that is happening all the time. There was a survey done– 

 

Dr. Kellan Baker: Yes. 

 

Dr. Abdul El-Sayed: –that uh where people asked what proportion of the population do they think is trans? And people said something like 23%, which would mean that one in four people were trans. But most of these people had never met a trans person. So how would it be that a quarter of the population is trans and you never met one? Right?

 

Dr. Kellan Baker: It’s it’s fascinating, really, when you think about it. I mean, you could have met a transgender person without knowing that someone is transgender. Um. And that’s one of the things actually that puberty delay medications and early support for transgender young people makes possible. It really allows people to better navigate the process of making sure they’re in a body that feels like home and makes it possible for them to avoid some of the things that can make gender affirmation or transition difficult for adults who didn’t have access to early support and the types of interventions like puberty delay medications that can really buy that time to make sure that people are taking the right next step for them. So if you look at the population numbers, the best estimates that we have are that about 0.6% of the US population, that’s about 1.4 million people is transgender. There simply aren’t that many transgender people. And when you look at the amount of vitriol and the amount of political harassment and outright attacks that are being targeted at this really small population, to what end? Why are we terrorizing children? 

 

Dr. Abdul El-Sayed: Yeah. And the reason I ask this question is and pose those statistics is exactly this, is the attempt to collapse this conversation into this non-existent extreme statement exists in in a circumstance where there is this somehow imagined sense that the world is not really as it is. And it’s that ability to imagine the world um as being this place that does that literally contradicts itself in the sense that people have that create this um almost like emotional pearling effect, right. Where people create a circumstance intended to fearmonger over circumstances that do not exist. And what’s forgotten is that the real people you’re talking about are a a tiny minority who, by definition, because of the lack of numbers, uh are very much put on the back foot and are children. Right. So that they don’t even have the capacity by law to fully and 100% advocate for themselves. They can’t vote, you know, just the basic um entry point into our politics that that doesn’t exist for them. Um. The second point I wanted to I wanted to bring out here was was the conversation about about about puberty blockers. And you said something that’s really important here, which is that puberty blockers are used in in medicine, in pediatrics, even in circumstances when you’re not talking about gender affirming care. Can you expound a bit on how they’re used? 

 

Dr. Kellan Baker: Definitely they are uh routine intervention for children with precocious puberty, which is when puberty is starting early, too early. There are instances of puberty, and this is in presumed cis gender children, right. This is has nothing to do with gender affirmation, nothing to do with being trans, but instances where puberty starts really early. Um. In some cases, as young as two years old or you have a five year old, eight or nine years old, when it’s really too early for a young person’s body to be going through those types of changes. So puberty delay medications were originally developed and used in order to appropriately time puberty for cis gender, presumed cis gender young people to make sure that, you know, typically you’re looking at an age of around 11, 12, 13 years old. That’s the, you know, the sort of standard time, if you will, um when young people tend to go through puberty. And so making sure that that is what’s actually happening for young people, making sure that they’re not going through puberty too early. So it’s a totally standard uh intervention that has been used safely and effectively with cis gender children for decades and also has been used with transgender children for a long time. And there’s no reason to believe and there’s no evidence at all that these medications work differently in cis gender versus transgender young people, because all you’re doing, again, is hitting pause on that process of the beginning of puberty. Once you go off these medications, puberty starts. And so for cisgender young people, it’s timed, they get to the age 11, 12, 13, and they go off these medications and puberty resumes and there are no ill effects. There are no side effects that are unknown about these medications. Puberty does induce a lot of changes around, for example, bone density. And so it’s a standard practice to monitor bone density. It’s a standard practice for cisgender young people on these medications. And it’s a standard practice for transgender young people on these medications. 

 

Dr. Abdul El-Sayed: And another one of the uses um is when you have growth stunting, right? Because one of the things that happens with puberty is that your growth plates tend to fuse. And if you have somebody who has not um grown as as you might expect, uh you will delay puberty just simply to give them time to grow before those growth blades start to fuse. So there are uses to these medications that are completely non politicized and there are uh uses to these medications that are completely politicized, despite the fact that you’re talking about the same exact medication in the same exact age group. And all of this is to say that when you actually step in and think critically about what you’re talking about, when you talk about gender affirming care, you start to appreciate that a lot of this is built out on a preexisting sense of who and whose medical care is allowed to be centered and who’s medical care is not. And that introduces a tremendous space where all of us should be worried about the politicization of health care. Even if uh you or someone you love does not identify as trans. 

 

Dr. Kellan Baker: Exactly. Yeah. I mean, it’s I would think that this is something that any parent would want for themselves and for their children. If you’re a parent, you want what’s best for your kid. You want to be able to take care of your child, make sure that they’re getting the health care that they need. The last thing that you need and I would hope the last thing that you want is some politician who has no idea who your kid is, has no idea what their medical needs are, is not your child’s doctor saying from some distant state capitol, well, you can have access to this care, but you can’t have access to that care. You can support your kid in this way but if you support your kid in this way that is in accordance with expert standards of care, that’s under the guidance of a clinician. There are states that are calling this child abuse. They’re accusing parents of child abuse for taking care of their kids and wanting to make sure that they get the health care that they need. And that’s something that should scare everyone. The last place that politicians and politics really belong is between a parent and their child or between a patient and their doctor. These are relationships that we hold sacred. These are sacrosanct places where we as Americans are accustomed to freedom and privacy and the ability to make the decisions that we as parents need to make for our kids where we trust doctors to operate according to expert evidence based standards of care. And the last thing that we need in the middle of those sacrosanct relationships is politics. 

 

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Dr. Kellan Baker after this break. 

 

[AD BREAK] 

 

Dr. Abdul El-Sayed:  I want to um ask now about about gender affirming care after puberty. What what what does that look like? How um how does that manifest? And um what what do we understand about the long term implications across the board, frankly, of gender affirming care for physical and mental health? 

 

Dr. Kellan Baker: The overall outcome of gender affirming care at any age is real tangible improvements in mental and physical health, gender affirming care for young people, for adults, improves overall well-being, it improves mental health, it improves life satisfaction, quality of life. It improves one what’s called gender uh sort of there are various terms for it, but gender dysphoria, which is the clinical term that describes the distress and impairment associated with the difference between someone’s gender and the sex that they were assigned at birth. Gender dysphoria is a serious medical condition. It’s recognized as such by every major US medical association, including the American Medical Association, as well as the World Health Organization. When you treat gender dysphoria, when you provide gender affirming care, then people’s overall health and well-being improves. When you’re talking about young people who are on puberty delay medications. So what that does, as we’ve discussed, is it buys time. It gives the young person an opportunity to work with their providers, with mental health providers, as well as their pediatricians, to talk with their parents and to make sure that they’re on the right path, that this is something that they need in order to be authentically themselves. And so for those who are transgender, then the next step after puberty delay medications is hormone therapy, gender affirming hormone therapy. And what that does is it starts puberty. So transgender young people who begin taking testosterone go through, quote unquote, “male puberty.” Well, you know what we think of as male puberty and uh transgender young people who take estrogen go through female puberty. And that is a major contributor to overall health and well-being and quality of life for these young people because they’re seeing their bodies change in ways that make sense to them. So hormone therapy is really the next step after puberty delay medications. And that typically begins it varies how long young people are on puberty delay medications. You know, what’s it’s again, as you were mentioning earlier, it’s very individualized. And so the young person works with their provider, works with their parents to identify when is the right time to stop puberty delay medications and begin gender affirming hormone therapy. The other type of gender affirming care that people frequently think about is gender affirming surgeries. And it’s really important to know that gender affirming surgeries are not part of the standard of care for minors, for people before they become adults. There are very, very, very rare cases in which somebody who is younger than age 18 might have a gender affirming surgery. For example, top surgery for a transgender boy who has grown breasts. That’s incredibly rare and is only done on a case by case basis when there’s no other solution, no other treatment that has been effective for the young person’s gender dysphoria. So it’s not something that the standards of care recommend, because typically you’re waiting until the young person is an adult. And any instances when young people, adolescents have had gender affirming surgery is incredibly, incredibly rare and done in very close and intense consultation with mental health providers, with parents and with other clinicians who are experts in treating gender dysphoria. 

 

Dr. Abdul El-Sayed: I’m asking this because it is a common trope among folks who want to politicize this care. How often do people pursue irreversible treatment and then regret it? 

 

Dr. Kellan Baker: Regret of gender affirming care of any type is incredibly low. So we have, for example, in that analysis that looked at almost 30 studies and found rates of regret that varied anywhere from 0.3 to around 3%. And this is for any type of gender affirming care and a lot of gender affirming care, puberty delay medications, for example, is entirely reversible. So we see very, very low rates of regret. And by comparison, if you look at other types of medical interventions that we routinely provide support, consider to be really important. For example, I had a hip replacement surgery last summer because apparently I’m not 41, I’m 81. Um. But the uh the regret rate for some of these orthopedic procedures, knee replacement, hip replacement, lower back surgeries, regret rates for those procedures can range anywhere from 15% to upwards of 30%. In fact, there was an investigation a couple of years ago that looked at regret rates for knee replacements and found that fully about a third of people reported regretting having the procedure. And when we look at regret rates for gender affirming care for any type of gender affirming care, it is in the very low single digits, if even that high. 

 

Dr. Abdul El-Sayed: So and I use this term um only because it’s the medical term for something that um you could choose to. But if you think about uh gender affirming care as elective, what your arguing is that the rates of regret for other forms of elective procedures are a substantially higher order of magnitude higher than regret for gender affirming care. 

 

Dr. Kellan Baker: Yeah. And I really think in terms of elective, you know, when I think of elective in this context, really what I’m thinking of is that you have some choice in the timing. You know, my hip replacement surgery was unfortunately medically necessary. It was elective in the sense that I could have tried to make it another couple of years with the original hardware, but my quality of life was so low that I elected to have a hip replacement surgery [something slams in background] earlier than I might otherwise. And I would put gender affirming care, I would define it similarly in relation to the word elective, that it’s medically necessary. Treatment for gender dysphoria is medically necessary. It is lifesaving and gender dysphoria, if left untreated, can progress to really intense rates of psychological distress, depression, anxiety and even suicide, suicidal ideation, suicide attempts. So it’s not elective in the sense that people are choosing whether or not to get it at all. It’s elective in the sense that making sure that the timing is right, that the person, whatever age they are, has the support that they need in place to make sure that they are surrounded by love, that they are surrounded by people who support them, that they have the financial means, they have, for example, good insurance coverage that covers the care that they need. That’s the sense that gender affirming care is elective, in the sense that you want to make sure that you’re accessing it at the time when you have the right support systems set up. Um. But it does not mean that it’s not medically necessary. It’s every bit as medically necessary as my hip replacement was. 

 

Dr. Abdul El-Sayed: Yeah, and I appreciate that clarification. And that, you know, what I meant by elective is the sense that you um you’re not getting it under uh the duress of emergency. Right. 

 

Dr. Kellan Baker: Yeah. 

 

Dr. Abdul El-Sayed: Um. Uh.

 

Dr. Kellan Baker: Although for some young people or actually for trans people at at any age it really can be a state of emergency. Untreated gender dysphoria, the experience of not being at home in your body, the experience of the psychological distress is really intense and can be life threatening. And so gender affirming care provided at the right time by licensed providers, as has always been the case in the United States, can be a life saving intervention and can really be something that people can be in pretty serious dire straits um in terms of, for example, depression or anxiety or suicidal ideation if they’re not able to access it. 

 

Dr. Abdul El-Sayed: I’d love to hear a bit about the contrast between um rates of of uh mental distress and as you talked about, um suicidal ideation among folks who pursue gender affirming care versus folks who don’t. 

 

Dr. Kellan Baker: For people who are not able to access gender affirming care, rates of gender dysphoria and associated depression, anxiety, suicidal ideation are extremely high. There is a very serious mental health component, mental health consequence, I would say, of untreated gender dysphoria. When people are able to access gender affirming care, those rates of mental health concerns drop dramatically. It is still very difficult in many cases to be trans in the US today. It’s very difficult to be trans in a society where so many politicians have apparently dedicated their careers to taking away your access to medically necessary lifesaving health care and the way that trans people get treated in school, sometimes at home, on the job while walking down the street, while trying to play on a sports team, while trying to go to the restroom in a public place. Trans people are often subject to really vicious and intense discrimination in the United States today, and discrimination, no matter who you are, has mental health consequences. The framework that we use for describing that in public health and medicine is the minority stress framework, which is that the experience of being treated poorly, the experience of being subject to stigma, prejudice and discrimination has health impacts. It’s not just sticks and stones may break my bones, but words will never hurt me. No words hurt. Words get under the skin. Treatment that is discriminatory, that tells you that you’re less than, that you’re not worth it. Not worthy of love, protections, safety, dignity. That hurts. And that is directly related to higher rates of mental health concerns, depression, anxiety, again, for transgender people, even sometimes when they’re able to access gender affirming care, it can alleviate that experience of gender dysphoria. But unfortunately, there are times when it can’t alleviate the experience of being trans in America and being treated the way transgender people are being treated right now, which is as a political football. 

 

Dr. Abdul El-Sayed: I really appreciate that point because we’re not just talking about a form of health care that treats the specific uh challenge at the core. We’re talking about a form of mental health intervention. And when we talk about mental health, the challenge is that sometimes we don’t appreciate that mental health or mental illness kills. And so if we are taking away people’s access to a form of health care that will protect their mental health, we are talking about life saving care. 

 

Dr. Kellan Baker: We are. 

 

Dr. Abdul El-Sayed: And the problem is that when we forget that that is life saving care, when we treat it as being entirely capricious in the way that is implicit in the way that the right talks about this, we forget the fact that there are a lot of people whose lives we are putting at profound risk when we as a society ban a certain kind of health care. 

 

Dr. Kellan Baker: Mm hmm. 

 

Dr. Abdul El-Sayed: I want to jump now uh to the to that question exactly. The degree to which this issue has been politicized, because it seems like over the past two years, we’ve just seen this epidemic of politicization and anti-trans bills. Can you tell us how many states have passed anti-trans bills that specifically target gender affirming care? 

 

Dr. Kellan Baker: 20 states as of July 2023 banned gender affirming care, mostly for minors. But increasingly, we’re seeing these restrictions creep towards adults as well. 

 

Dr. Abdul El-Sayed: And in those states, what has been the consequence for trans folks uh in in their states and what are we seeing over the over the course of um what are we seeing in terms of how these laws have played out for trans folks in these states? 

 

Dr. Kellan Baker: People are panicking. People are terrorized. Parents are terrorized. They’re being told that they’re committing child abuse by supporting their kids. And kids are being told young people, adolescents, for example, on puberty delay medications who are thriving, who are doing well, who are under the care of their clinician, they’re being told that they have to stop, that they cannot have access to this care. That for them is life saving and so important. So what we’re seeing, again, is panic. We’re seeing terror. We’re seeing people who have the means to do so picking up and leaving these states. We’re seeing families being made into refugees in the United States having to flee these states where state governments have decided that parents who love and support their kids are child abusers. We’re also seeing providers leave these states. This is not just about criminalizing parents. This is also a campaign of terror that is criminalizing providers for upholding their oath to provide evidence based ethical best practice health care to their patients. They are being told that they are criminals and they are increasingly picking up and leaving those states that have signaled clearly that they are prioritizing politics over the practice of good medicine and over again the sanctity of that patient provider relationship. So this has effects not just on transgender people, but on everyone who needs health care. Because, for example, if you’re a pediatrician who works with trans adolescents, you help them with puberty delay medications. Maybe you help them transition to gender affirming hormone therapy. Then you’re also doing a lot of other health care for cisgender adolescents with a lot of different complex conditions. And when you pack up and you leave the state because that state is criminalizing you for the care that you provide according to the evidence that according to the best practice standards in your field, then that leaves those kids, those cisgender kids out of luck. And that is, I think, a particularly untold piece of this or something that not a lot of people are thinking about or talking about, that this isn’t just about terrorizing trans kids and depriving them of access to really important health care services. It’s also depriving cisgender kids of access to health care providers who are providing them with really important health care for a variety of conditions. And so this idea that we can just sort of surgically target transgender people and no one else will be hurt, that’s not true. It’s having knock on effects again, not just on trans people and their families, but on cisgender people as well. 

 

Dr. Abdul El-Sayed: I really appreciate you highlighting that. The other piece of this is that when we decide that a certain number of politicians can make decisions about the kind of health care that anyone can have, we are setting a very dangerous precedent, and this has to be called out. We only do this in circumstances where you’re talking about regulating bodies that are not cis male bodies. Right. Um. And the consequences um can be profound because at the end of the day, uh we tend to to to, we tend to isolate ourselves from those assaults on rights that don’t directly affect us. And when we do that, we don’t realize that we’re stepping into a future where we may be setting ourselves up for a target. And I say this because I know that the vast majority of our listeners here are supporting trans rights. But may not appreciate the implications that personalized them to them as well. Right. It’s one thing to say I support this and– 

 

Dr. Kellan Baker: Yes. 

 

Dr. Abdul El-Sayed: –I really wish the world would be better, but ah is the world a terrible place versus saying actually, you know, they’re an assault on a set of rights is an assault on all of our rights to make our own health care decisions. That in a circumstance, of course, in a country where we haven’t even guaranteed the basic right to health care in the first place. Right. Um. But but but but that that question of targeting any particular form of health care itself opens up a set of doors that I really want folks to to think a bit about. Um.

 

Dr. Kellan Baker: Yes. I mean, this is you know, what we’re talking about here is a really fundamental personal freedom. Privacy. Making health care decisions, making decisions about your own body. This is a fundamental freedom. And it’s not going to stop with transpeople. There’s already we’ve seen the renewed assaults on reproductive health care, people’s ability to make their own decisions about their reproductive lives, about having children or not having children. There’s no real difference. And I would unfortunately say that it’s part of a coordinated strategy, which is to push huge swaths of the U.S. population out of public life to make it impossible for so many people, not just trans people or not just women, but so many people, to make fundamental personal decisions about what happens to our bodies. And what that does is it makes it impossible for us to participate in public life. It makes it such that we are off to the side, that we are excluded from this fundamental human right and human need really, to be able to make these really intensely personal decisions about our own bodies. And again, it’s not just about trans people. It is a coordinated effort to strip whole huge groups of us, whole huge groups of Americans, of the ability to make those personal, private decisions for ourselves and to not have the government intervening, not have the government coming in and trying to make those decisions for us. 

 

Dr. Abdul El-Sayed: Yeah, I really appreciate that point. Now, I am a cis straight man and in so many ways I benefit from the privilege of that in ways I can’t fully enumerate every single day. I also do walk through the world as a Brown Muslim guy. Um. And, you know, when I think about the ways in which targeted political efforts to discriminate work, oftentimes it’s not just the specific thing that they’re trying to take away. It’s that it creates a permission structure for open discrimination in every other way in society. 

 

Dr. Kellan Baker: Yes. 

 

Dr. Abdul El-Sayed: And so that point that you you’re making is, one, it’s not just that they’re taking away trans health care. It’s that they’re giving a society the permission to dog and discriminate trans people in daily life in ways that are really intended, as you said, to exclude people from public life. But that’s even a sterile way of saying it. It’s about terrorizing you into shutting up being quiet and not showing up. Right. That’s that’s really what it’s about. And that piece of it where we assent to the targeting of of any group of people, whether we may identify with them or not should force us to be asking, do I assent to a society where my government, in theory, for the people and by the people, targets a particular group of people to open and sanction in effect, civic terrorism against them. Because because that’s how that shows up. You know, I think about– 

 

Dr. Kellan Baker: Yes. 

 

Dr. Abdul El-Sayed: –uh my wife, Sarah, who is a mental health professional who wears a hijab. And I never really appreciated the degree to which she has to be asking when she goes into public. There’s some piece of her mind that has to calculate around a certain set of risks in a certain set of ways that, you know, I become very aware of when we’re together. That I can forget in some respects when I’m alone. And, you know, that’s not to say that I don’t get targeted racially. But that is to say that I don’t stand out as fast as easily. And because of that um, you know, cis het privilege, I am not as targeted in terms of my own physical safety in the same way. 

 

Dr. Kellan Baker: Mm hmm. 

 

Dr. Abdul El-Sayed: And so that question about what kind of society we want to live in is one that all of us ought to be invested in. And then beyond that, what kills me really grinds my soul is that folks who pursue this kind of politics pursue it in the name of freedom. [laugh] Which is to say, you want the freedom to be able to target and demonize anyone you want. It’s not about whether or not we have personal freedom, about autonomy of our own bodies. No, it’s about whether or not you have the freedom to aggress against a particular group of people. Or in ways that allow you to arrogate yourselves over others. Like it it’s what they’re talking about is the freedom to think yourself better than someone else. 

 

Dr. Kellan Baker: Yeah, could mean anyth– 

 

Dr. Abdul El-Sayed: And that seems to me a really bastardized sense of freedom. 

 

Dr. Kellan Baker: And it’s a campaign of eradication. I mean, make no mistake about it. There have been a number of commentators, the most recent and maybe highly publicized speaker at the Conservative Political Action Conference that literally said transgenderism must be eradicated. This is genocide, right? This is calling for the destruction of an entire group of people. And it’s not going to stop with transgender people. Transgender people are in many ways kind of just a convenient target for the moment, because there are relatively few transgender people, because as we’ve talked about earlier, a lot of Americans aren’t very familiar with transgender people or transgender issues, which makes it possible for this sort of hugely distorted, demonized idea of who transgender people are to be projected into people’s minds. And then the call comes that has to be eradicated. We have to stamp that out. We have to stamp it out. We have to eradicate transgender people. These are people that we are talking about here. And to your point, there are so many elements of America’s history where we have demonized, targeted and tried in some cases to eradicate groups of people. And it is a danger that we all need to be aware of because the purpose of our government needs to be about protecting each and every one of us in our ability to live freely and safely and authentically as who we are, whether we’re transgender or not, whether we’re white, Black, Brown, whether we’re men or women, or whether we’re non-binary people, we don’t have to understand each other perfectly in order to, I would hope, accept the premise that every single one of us is human and every single one of us deserves to be safe and loved and to be able to move through the world without constantly doing that calculus that you were mentioning, that sense of am I visible today to someone who wants to hurt me because of who I am? And that is a terrible way to have to go through life. And that is exactly what we’re doing to transgender people. And worse, we’re doing it to transgender young people. We’re telling young people that we hate them for who they are, and that has really serious mental health impacts all the way through someone’s life. To be told that who you are is wrong, to be told that who you are is so bad that the government is going to try to step in and call your parents child abusers is going to step in and try to arrest your health care provider just for listening to you, just for believing you when you tell them who you are. That’s a terrible thing to do, a terrible message to send to anybody, but especially to kids. 

 

Dr. Abdul El-Sayed: We are in a moment right now where it is all hands on deck. And I think, you know, among our listeners, folks have a good sense of the tool set of activism and the responsibility to stand up and fight. One of the things I, I think we don’t often do enough is to project the kind of love and hope that we are advocating for in conversations with folks who are deeply misinformed. And I want to ask you, you’re um one of the most prolific um contributors to the public conversation in this space as people are having conversations with loved ones and acquaintances who may be misinformed on this topic. Can you share two or three things um that you use in your discussion with folks that that can change a mind and change a heart about what we’re really talking about here? 

 

Dr. Kellan Baker: I think two really important things are one, following the science. I’m a scientist. I have a Ph.D. in health policy and management, health services, research and health economics from the Johns Hopkins School of Public Health. And I oversee a research institution where we do a huge amount of research that, for the most part, is not focused specifically on transgender people, although that is research work that I’ve done in the past, trying to better understand the experiences of transgender people and both in society and in health care settings. So following the science, there are facts out there. A lot of us, I think, are feeling like we’re living in a post fact world where there’s so much misinformation out there about just look at COVID, for example, so much misinformation about COVID and this idea that all of a sudden facts don’t matter, but facts do matter and facts are real. And you can follow the science. You can actually look at the expert standards of care. You can look at if it’s your jam, you can read the journal articles that will tell you the incredibly positive impact that gender affirming care has on transgender people. So the idea that we have so often, I think in our society these days that on one side there’s a fact and on the other side is an opinion. And these things are so often presented these days as if they’re the same thing. They’re not the same thing. 

 

Dr. Abdul El-Sayed: They’re both takes, that’s the problem, right, is that we’ve like we’ve we’ve flattened it all into takes. And you’re like, no, it’s not the same. 

 

Dr. Kellan Baker: Right. 

 

Dr. Abdul El-Sayed: Your opinion is not the same as my fact. 

 

Dr. Kellan Baker: Right. 

 

Dr. Abdul El-Sayed: Your 5 minutes on the internet on some hell hole wormhole is not the same as my Ph.D.. Not the same. So sorry. 

 

Dr. Kellan Baker: Exactly. There’s nothing wrong with science and medical expertise. People go to medical school, people get PhDs for a reason so that they can deeply study and deeply understand something. And when there’s an entire body of scientific and medical evidence that is telling us that being trans is real, that gender dysphoria is real, and that gender affirming care helps people, then that’s what we need to follow, not some completely uninformed person’s hot take on some television show or some YouTube clip. So that’s one thing I think is following the science, following the facts. And there are a number of articles out there, you know, in various media outlets that will walk through the facts of what do we know? How long has gender affirming care been being provided in the United States? Again, more than 50 years. Are there expert standards of care? Yes. Is there a substantial body of scientific evidence that shows that gender affirming care benefits the health and well-being of transgender people? Yes. So we can stand on that. We can stand on that foundation of facts, not that shifting sea, if you will, of opinions. Another thing that I think is particularly important is elevating and listening to the voices of transgender people themselves. We are so often arguing about people and people’s lives in a vacuum as if they don’t exist. But transgender people do exist, and transgender people have the actual experience of being trans, of needing health care. And for those who are fortunate and don’t live in some of these states that are criminalizing the provision of care, have the experience of getting gender affirming care. So we can listen to the voices of transgender people of any age who are telling us this is what it’s like to be trans. This is who I am. This is what I need. This is what has helped me and this is what has hurt me. We can listen to those voices and we can listen to the voices of parents and doctors as well. Talking about, you know, I think some of the most powerful stories come from parents who of course had no I don’t think most parents expect a young person to come out as transgender. But when they do, there are so many parents who are loving and supportive and listen to that young person when they’re saying who they are. And so we can listen to the stories of those parents that you don’t have to get it right the first time. You don’t have to get it right every single time. You don’t have to know everything about gender and gender theory and medicine and all of this, that and the other. All you have to do is be willing to listen and to ground your response to what somebody is telling you about who they are. Ground your response in love. And I think that remembering that there are so many parents who just want the best for their kids, whether they’re cisgender, whether they’re transgender, parents just want the best for their kids. And so taking the public policy steps that support those parents in being able to do what every parent wants to do, support and love their child. 

 

Dr. Abdul El-Sayed: Kellan, we really appreciate uh your perspective and and uh you coming on the show to give us a crisp, evidence driven uh perspective on what gender affirming care is, what it means and why it’s become uh such a political hot button and demagogued uh by folks for their own political gain. Our guest today uh was Dr. Kellan Baker. He is the executive director of the Whitman-Walker Institute. Kellan, thank you so much for your time today. 

 

Dr. Kellan Baker: Thank you so much for having me. [music break]

 

Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. A friend of mine got on me this week for always ending the show with tough news. It’s a public health podcast. There’s not that much to be positive about. But hey, in honor of said friend, I hope you’re listening. It’s all good news today. 

 

[clip of unspecified news reporter] The first ever over-the-counter birth control pill in the US has just been approved by the FDA. 

 

Dr. Abdul El-Sayed, narrating: OTC, OCP. I love it. Let me decode. Over-the-counter oral contraceptive pills. That is what the FDA approved this week in one of the most important wins for reproductive justice in well, let’s just say it a while. For far too long, oral contraceptives have been hostage behind the pad of a physician, meaning that’s been incredibly difficult for folks with limited health access to get them. That inaccessibility has led to unwanted pregnancies that could have been prevented. And now with this new medication called Opill, anyone can get access to safe, effective oral contraceptives by walking into a pharmacy. That’s particularly important in a post Dobbs world. But as if to tell them themselves, the same folks who architected the fall of Roe are up in arms over this new over-the-counter contraceptive. I mean, you would think that people who hate abortion would also love a pill that stopped unwanted pregnancies, right? No, because it was never about abortion itself. It always has been about control. A few weeks ago, John Green of YouTube fame posted a critical video sounding the alarm over how pharma giant Johnson & Johnson was attempting to use patent rights to keep profiteering off of a critical TB medication. 

 

[clip of John Green] Good morning. It’s Tuesday, so a week from today marks a huge moment of progress for human health as the patent on the drug Bedaquiline expires, allowing less expensive generic versions to be produced that can cure far more people living with multidrug resistant tuberculosis. Wait, what’s that? Oh, well, that’s unfortunate. What will actually happen next Tuesday is that the company, Johnson and Johnson, will begin enforcing a secondary patent, thus denying access to Bedaquiline to around 6 million people over the next four years. 

 

Dr. Abdul El-Sayed, narrating: The grift is called evergreen. It involves claiming a second patent on a different chemical piece of a drug right before the first patent is set to expire. Entirely to keep the drug under patent and to charge way more for it than you otherwise might. The drug in question Bedaquiline, is a critical life saving medication for multidrug resistant TB, and that second patent is a bold faced attempt to extend their ability to price their drug far higher than most lower and middle income countries with high TB rates can pay, and therefore keeping it out of the hands of nearly 6 million people who need it. But this week, bowing to the public pressure, J&J announced a new deal to provide generic bedaquiline in 44 lower and middle income countries. Turns out that 3.7 million YouTube subscribers can get shit done. Finally, the state of Indiana, a red state, just increased its public health funding 1500 percent. That’s right. A 15x increase in public health funding. Wait in a red state? Yup. Indiana had been one of the states with the lowest public health funding in the country, and they had some of the worst health statistics on smoking, obesity and mental health to show for it. But with this new budget, that’s all changed. The state is making a $225 million dollar investment in local health departments over the next two years. How’d it happen? Strong gubernatorial leadership, albeit from a Republican and a recognition that all health is local. And strong local government had traditionally been a conservative idea, well, traditionally. This is unequivocally a win. But you know what? I’d love to get back to a world where public health was nonpartisan again. That’s it for today. On your way out, don’t forget to rate and review. It really does go a long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa, and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.