Dr. Deb Thorp, medical director of gender services at Park Nicollet, answers questions about the unique health care needs of people who are transgender, the difference between sex and gender, and the care she and her team have been providing for decades.
Dr. Deb Thorp, medical director of gender services at Park Nicollet, answers questions about the unique health care needs of people who are transgender, the difference between sex and gender, and the care she and her team have been providing for decades.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Deb Thorp, MD
HealthPartners website: Off the Charts podcast
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Kari Haley:
He is a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Kari Haley:
This is Off the Charts.
Steven Jackson:
Welcome to our show. We have a special guest with us today. We have Dr. Deb Thorp, who is by training an OB-GYN physician, but she's also medical director of gender services here at HealthPartners. Welcome.
Deb Thorp:
Thank you.
Kari Haley:
Give us a little bit of a background on where you came from and how you got to where you are now.
Deb Thorp:
I trained at the University of Minnesota for medical school and then did my OB-GYN residency as well at the University of Minnesota. Came into contact with some of my GYN staff who were doing gender-affirming hysterectomies way back in the '80s. And when I joined Park Nicollet, one of the senior partners was also doing gender care, and he knew I had an interest in LGBTQ care, so he was of an age where he would spend winters elsewhere. And this was a whole different time of medicine where you could actually take off for four months out of the year.
Steven Jackson:
I missed out. Go ahead. I'm sorry.
Deb Thorp:
Yeah, I missed that, too. But Dr. (Mario) Petrini, that's who that was, was also doing gender care at that point, and I inherited his admittedly small practice. And as I saw more patients, then I saw more patients and then I saw more patients and pretty soon it turned into being about a third of my practice. And now it's a good half of my practice, most of which is done at the Minneapolis office, which is where we do... Park Nicollet does the gender care and that's where the gender clinic is. But I also see all kinds of trans patients in the women's center, mostly people who were male assigned at birth and have transitioned to female or are so early in the process that they feel fairly comfortable in a gendered space.
So there you have it, and that's how that started. And then we kept recruiting people as the demand went up. And now as we've joined with HealthPartners, HealthPartners doesn't have a centralized clinic like we do. They take care of patients within the context of specialty care or primary care throughout the system. And we are getting more people on the Park (Nicollet) side that do that as well, which is good because it shouldn't always need a specialty clinic. Everybody who does primary care should at least be comfortable with knowing what the medications are and why you would do that.
Steven Jackson:
How are gender and sex different?
Deb Thorp:
OK, great question, that I think is one of the biggest misconceptions of the general population. Sex refers to your physiology. So we are assigned a sex at birth, and it's usually based on what is between the legs, because that's the only thing that is markedly different at birth. There are a small percentage of patients, less than 1%, that are intersex people who are born with ambiguous genitalia. But usually it's pretty obvious what the physiology would tell you, male or female.
Gender is your personal experience of how you perceive yourself to be in the world. And that might be male, it might be female, it might be gender non-binary, it could be agender, meaning you don't identify with any of the genders. You could be what's called gender-fluid where people feel a little bit more masculine, maybe one day, a little bit more feminine another day. I mean, to some degree we're all a little gender-fluid and we're all a little gender non-binary.
That's kind of normal. It's a rare person that is way over on one end of a spectrum or way over on another end of a spectrum. We used to put this all on one spectrum, so you got male on one end and female on the other. And as we've studied the concept of gender, what really has come to light is that if you start from a neutral position, you might go way out in one direction as female and on another plane, you go out in another direction as male and maybe a gender non-binary person is going to be a little bit more less out that far direction.
Steven Jackson:
What is gender non-binary? What is the definition of that?
Deb Thorp:
The definition of gender non-binary is basically somebody who doesn't identify as male or female. And so it's not uncommon to have somebody say, I'm transmasc or transmasculine non-binary. And what that really means is they can use either they them pronouns, he him pronouns, and they're comfortable with either of those. What they're not comfortable with is she her pronouns.
Steven Jackson:
In that example, transmasc (or transmasculine).
Deb Thorp:
In that example.
Steven Jackson:
OK. Transmasc.
Deb Thorp:
Yep. So if you had somebody who was transfemme non-binary-
Steven Jackson:
They'd be comfortable with everything except the he/him pronouns.
Deb Thorp:
Correct.
Steven Jackson:
OK.
Kari Haley:
Some of the terms can be confusing. Is there a way that people can know more or hear more? Is there resources out there for people to learn more terms and what the terminology means?
Deb Thorp:
Yes. Yeah. There are good resources that you can find online. And actually it's pretty much as simple as googling it.
Steven Jackson:
Google it. Talk about maybe some of the personal challenges in the practice that you've had.
Deb Thorp:
Increasingly we're seeing younger and younger people. And I think part of that is over the last 10 to 15 years, we've seen the growth of the visibility of the trans and gender-diverse people on this planet. We've seen it on TV. And also with the growth of the internet, people are able to access information that they never could access before. So when I first started, it was pretty common for people to say, I just figured out this was a thing and I thought I was the only one. And they're coming in my office at 30, 50, 60. Now they're coming to their parents at age 9 or 10 and saying, I know you think I'm a boy, but I'm not a boy. And then trying to work that through with their parents. If the parents are really obstinate and saying, "No, you're a boy. This is the way God made you. This is the only way this can be" or "No, you're a boy. This is just the way life is." Even if they don't take a religious background on it, those kids have twice the suicide-attempt rate as kids whose parents do affirm them. If they have even one affirming adult in their lives, that cuts their risk of mental health problems, including the risk of suicide attempts substantially. So gender-affirming care is lifesaving care in many ways. And I think the current rhetoric around "it's child abuse, it's not proven" is just plain wrong. There's good data to show all of that. And in adults, there's really good data as well that you cut the suicidality risk, that you improve the mental health. The latest standards of care from the World Professional Association for Transgender Health came out in September of 2022, and it's about 250 pages long, a third of which is references.
So that's a pretty decent body of data that would suggest that it is efficacious. And as the standards of care have evolved over time, kids and adults have better access to care because they have less hoops to jump through. But there's still a lot of hoops for some of the more irreversible things, especially for kids. Gender-affirming care for kids is essential, and you don't go through this lightly. Nobody chooses to be transgender. You just are. Nobody chooses to be a gender different than what they were assigned at birth because that's a really tough road to hoe. Nobody really wants to do that, but it is necessary when that is the situation to provide care as needed. For kids, if they are going through this and say they want to play a sport. That seems to be a big thing that people are like, especially kids who are assigned male at birth and then they want to play on the girls' basketball team.
Well, if they're really, say in high school, they're on gender-affirming hormones, most likely. Those gender-affirming hormones decrease the testosterone levels to the same or lower than their assigned-female-at-birth teammates. So they're not going to necessarily be stronger. And especially if they started with puberty blockers when they were barely into puberty. They never got those muscles, right? In my not-so-humble opinion, (it's) ridiculous to keep girls off of boys sports teams, especially if they identify as male. And likewise, to keep the people who are assigned male at birth off the girls' sports teams, if they identify as female.
Kari Haley:
And as a health equity podcast, thinking about what does it mean to have health equity in gender-affirming care, what does it mean, particularly thinking about our state versus some other states who may not have the same access to care. What things do we need to think about as other clinicians or even as just citizens in ensuring that we have equitable care for everyone, including people who are pursuing gender-affirming care?
Deb Thorp:
So thankfully, we live in Minnesota because all of the states around us have made it very difficult to access care, with the exception of Wisconsin, and it's not as easy there as it used to be. So I'm seeing kids in clinic. I didn't used to see very many kids, but with the increase my patient population is shifting to late teenager for start of hormones. I don't personally do the puberty blockers, but we have a few people at HealthPartners and Park Nicollet that do puberty blockers. Really getting that ability to get the kids in here and having their parents be safe here is huge. It's absolutely huge. We're seeing people who are moving, picking up and moving the entire family to save a life of one kid.
Steven Jackson:
Like moving to Minnesota?
Deb Thorp:
Yeah, they're moving to Minnesota. The other thing that I'm seeing is people wanting reproductive health care, which you can get in Minnesota, but in other places if you are not the gender... If your sex assigned at birth and your gender don't match, in the old days, you had to be sterile to get testosterone. It was crazy. Forty years ago, 50 years ago, that's what you had to do. Over time, that's gotten better. And now insurance is covering gender care. The Affordable Care Act made it illegal, actually, to not include gender care in state and federal based programs. Because of ERISA (Employee Retirement Income Security Act) laws, you can still have some places that have employer-based care that does not cover gender-affirming care, but that from an equity standpoint, that's a big deal.
The other thing that's an important big deal is on the pediatric side, they actually screen for gender dysphoria when the kids go in now as teenagers. Insurance covers it, the biggest inequity though is the perceived inability to access care and then the real inability to access care because there aren't enough clinicians that do gender care. So that's why we're working hard to train a lot of people.
Steven Jackson:
You talked about the neighboring states or the surrounding states with respect to Minnesota. Are there, I guess, regulations in those different states that prevent some of the care we're talking about?
Deb Thorp:
Right. So North Dakota, South Dakota, Iowa all prevent you from getting gender-affirming care if you're under age 18, of any kind.
Steven Jackson:
OK, and is that-
Deb Thorp:
That's based on the perceived idea that there's no data or that it's child abuse or it's the misconception that it's a phase and the kids are going to outgrow it, and in fact, what's going to happen is they're going to be more likely to have significant mental health deterioration. And if they can't access puberty blockers, especially people going through their natural puberty, if they were assigned male at birth and they get those kinds of changes going on, those are not reversible. So then you've got somebody behind the eight-ball that maybe didn't need to be in terms of passing as female as they age. That's actually causing them harm. That's what causes the harm, not the gender-affirming care.
Steven Jackson:
Like the irreversible nature of having the wrong puberty.
Deb Thorp:
The irreversible nature of having gone through puberty, especially if you were assigned male at birth. Because if you're assigned female at birth, I can give you testosterone and you will get facial hair, body hair, and especially if you start it pretty young, you'll get more muscle mass at an early age and you just have a very different body habitus. But if you've gone through puberty and I give you estrogen, it doesn't reverse any of those changes.
Steven Jackson:
What happens in those cases? I mean in terms of-
Deb Thorp:
So then they need more surgery, so they need mechanical hair removal all over the place. They need-
Steven Jackson:
So it's a big to-do at that point.
Deb Thorp:
It's a big to-do, yeah, that wouldn't have had to be, and that's unfortunate. I can't reverse the voice change. So remember when you went through puberty and your voice dropped?
Steven Jackson:
I was a late bloomer, but go ahead. Sorry. TMI. Go ahead.
Deb Thorp:
TMI. But your voice dropped.
Steven Jackson:
Right. I mean, right.
Deb Thorp:
And you can't reverse that with any hormone. The only thing you can do to reverse that and then is a dangerous surgery, which is a voice surgery and it doesn't work all that well.
Steven Jackson:
And I know there's like voice therapy, I think, right?
Deb Thorp:
Right. There's voice therapy.
Steven Jackson:
But that-
Deb Thorp:
And that's teaching you to use an upper range and speaking with more feminine habits of voice.
Steven Jackson:
Like inflections or-
Deb Thorp:
Inflections.
Kari Haley:
Like learning a new language when people do dialect-type training.
Deb Thorp:
Correct.
Kari Haley:
But doesn't change the actual pitch or tone necessarily of the voice if it's gone through puberty?
Deb Thorp:
Right.
Kari Haley:
In Minnesota, so because we are in Minnesota and we do have kids who are able to access gender-affirming care, what sort of involvement do parents have or is there a mandate for parent involvement or what does it look like? What does the landscape look like in Minnesota?
Deb Thorp:
The landscape looks like, all the kids under 18 have to have their parents help with this. They have to be behind it, otherwise it's not going to happen. Just like I couldn't take a kid to the operating room and take care of an ovarian cyst without their parents saying, yes, that's okay to do. This is medical care. It's not under the category of reproductive care, like prenatal care or birth control or substance abuse care, mental health therapy. I mean, to the degree that they can see their therapist without their parents agreeing to it. But in terms of medication, I got to have both parents on board and we have a consent form that has the kids sign it because the kid has to understand what they're doing. Both parents have to sign it, and then I have to sign it and it says, we've covered all these topics and it's 10 or 11 font, both sides of the page. So it's a lot of stuff.
Kari Haley:
It's a lot.
Deb Thorp:
There's a lot of fine print there.
Kari Haley:
It's a lot.
Deb Thorp:
But we do cover that, and it's not uncommon for kids. Usually that's not a one-time event. That's a, you come in, you have a conversation, go home, talk about things as a family, you come back, you have another conversation and maybe you have a third conversation before you start whatever hormonal blockade or intervention you're going to do, and there has to be a mental health involvement to try to-
Steven Jackson:
Yeah, I was just about to ask that.
Deb Thorp:
Especially for kids. It doesn't have to be for adults. Adults can do informed consent. They're adults, they can make their own decisions. Now, if you have an adult who is for some reason under conservatorship, then you kind of have to use a different model. But that's pretty rare. There are a lot of backstops along the way to prevent kids from accessing care, a portion of which might have irreversible changes that their parents aren't aware of. It's like almost impossible to do.
Steven Jackson:
Is there an aspect of gender care or gender-affirming care, I should say, where it is reversible? Like you go through maybe hormone therapy where you go through a procedure and now you're having second thoughts?
Deb Thorp:
So that's pretty rare. I can actually count on one hand in over 30 years of doing this, where people have actually changed their minds, especially people after a surgical procedure. So the things that are reversible, if you are assigned male at birth, most of the changes that estrogen will induce, like softer skin, fat distribution, changes in how your brain processes information in a more feminine way, decreased facial and body hair regrowth from what you already have. Those things are all reversible except the breast growth, which you got, you got. They might shrink a little bit if you stop the estrogen, but they're not going to go all the way back to baseline and fertility is not going to go all the way back to baseline potentially. It's feasible, but not real likely.
Steven Jackson:
In those cases where a person had second thoughts, how are they doing mentally, like mental health wise?
Deb Thorp:
So the standard of care for people who want to detransition is you have a multidisciplinary team that involves mental health and preferably somebody who is really experienced in gender mental health. You don't want to just take somebody who is their therapist but doesn't really understand gender-affirming care because that's not going to be helpful. You really want to get a multidisciplinary team, and if the patient really wants to detransition, then you can stop their hormones if they're on them. You can occasionally say somebody had masculinizing top surgery, so they've had bilateral mastectomies, they can get breast implants. I can't put a uterus back and you can't put the testicles back, can't put a penis back after somebody's had a penectomy and a vaginoplasty. But on the top part, you can reverse that with more surgery.
Kari Haley:
Can you talk to us about some of the successes and what some of the joys that you've been able to see from your work over the years, and how it's changed over the years in particular? You kind of alluded to it, people have more access now and have more information now than they did 30 years ago, but what have you seen in terms of the mental health as a whole community or how have things changed in that way and the joys that have come from your work?
Deb Thorp:
There are a lot more clinicians on both the mental health and the physical health side of things that are really understanding of what gender dysphoria is and the basic treatment of gender dysphoria or in the rest of the world, they call it gender incongruence. So if you're reading online, you might see gender incongruence. One of the best successes I've ever had was about 20 years ago, I had a patient come in to get gender-affirming care who had figured out how to get their estrogen and spironolactone online. Their mom figured out what was going on and said, you have to do this under the care of a clinician. You can't be doing this yourself. I will take you in. That patient had not been out of their bedroom except to the bathroom for two years, and until that patient had gender-affirming surgery, they didn't really... I mean, they got better and better, and I would see them a couple of times, but this is before the days of telehealth visits, and I was doing phone visits with this patient because that's the only way this patient could function.
Over time, we got this patient better mental health. I found somebody who would do phone mental health visits with them, and then actually somebody went to their house to do their care. They got their letters that they needed that said that their mental health was as good as it could be. They got their gender-affirming surgeries. They went on to get their PsyD, so they're now a PhD-level therapist.
Steven Jackson:
Oh, OK. I'm like slightly... Sorry.
Deb Thorp:
So they're a PhD-level therapist. They run a gender program, they do podcasts. They're out in the world doing all kinds of things. I mean, that is the kind of thing, while maybe a little bit more extreme, those are the kinds of successes I see every day. Because I see patients who were unable to function because their dysphoria was so bad. They were so uncomfortable going out in the world and they transition and they're much more confident in their bodies. They go out in the world and they're productive members of society. They come off of Medicare, disability.
I see, not everybody, but I see that in a fair number of patients, and it's very gratifying. It's very gratifying to know that you've really helped give somebody their life by being able to give them affirming care. And so really all of gender-affirming care is helping guide the patient in what it is that's going to make them feel comfortable in their bodies and therefore in the world, and that's a different road for every single patient. And then also helping, in the case of younger folk, helping their parents and the rest of the family and setting them up for success to the best of our ability to do that.
Kari Haley:
You truly, it sounds like very, truly and literally to an extreme in a good way, meeting patients where they are and giving them the care that they need.
Deb Thorp:
That's what you have to do. Yep. That's exactly what you have to do.
Steven Jackson:
Well, we want to thank you for educating us, educating our listeners, hopefully clearing up some misconceptions, clearing up some definitions.
Kari Haley:
I think it's great that our organization supports gender-affirming care for our patient population and that there are people like yourself and your team that are so passionate about the work.
Deb Thorp:
And I'm grateful for that backup.
Kari Haley:
Well, thank you for spending some time with us on our podcast and hopefully even a chance to come back again. I feel like we've only really touched the very surface of the subject, and I think there's a lot more to be said, right?
Deb Thorp:
Correct. There's a ton. We could do days' worth.
Steven Jackson:
Well, thank you so much. Thanks for your time.
Deb Thorp:
Thank you.
Steven Jackson:
Off the Charts is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production Services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.