Since Chris is on vacation this week, we’re revisiting and providing an update on our episode with Dr. Izzy Lowell, who runs Queer Med, a private clinic that specializes in providing accessible health care to trans patients ranging from kids to adults.
From the original description:
What is gender-affirming health care? Around the country, there’s a Republican campaign to legislate and regulate the lives of trans youth. The most destructive of these efforts would bar trans youth in certain states from accessing gender-affirming treatment. Lowell’s practice covers 10 states across the South — and half of those have anti-trans health care bills on the docket. If they pass, it would become criminal for her to provide this care to many of her patients. Lowell joins this week to break down what exactly we mean when we talk about gender-affirming care, how the decision is made for kids and teens ready to transition and the potentially devastating impact this legislation would have on their lives.
Note: This is a rough transcript — please excuse any typos.
Izzy Lowell: These kids are 15, 16 and 17 and their state is saying that they’re wrong, their existence is wrong. And I don’t know what that does to the psyche of a 16-year-old to have your state basically say that who you are and what you’re doing is illegal.
Chris Hayes: Hello and welcome to “Why Is This Happening?” with me, Chris Hayes. So, right now as I’m speaking to you, it’s current Chris Hayes…and I’m jumping in before you hear past Chris Hayes because am going to be on vacation for a week, so we thought we’d bring you one of our favorite episodes from last year – one we actually mentioned in our Mailbag – Treating Trans Youth with Dr. Izzy Lowell. We recorded this conversation about nine months ago in May of 2021. I’ve gotta say it’s really stuck with me. So we reached back out to Dr. Lowell to see how things have been since we last spoke. Ultimately, that proposed Alabama bill that we discussed in the episode did not end up passing and since then, Dr. Lowell says things have been quiet for them on the legal front. One thing she brought up when we checked in on her – she said she’s been seeing more conversations around requiring teens to have mental health counseling before starting hormone therapy…which she says would be great ideally – but there are so many barriers to accessing therapy, it shouldn’t be an absolute requirement. And while her practice is continuing its work, she says she still sees a country deeply divided on the treatment of trans teens. But, some good news here. Dr. Lowell’s practice has only grown in the past 9 months –- she now has three nurse practitioners, two physicians, and an office manager as her patient numbers go up.
Well, as we’ve been covering on the show, and a bit here on the podcast, it’s been fascinating, not to mention kind of disturbing, even horrifying to watch the priorities of the Republican Party post January 6 and post the- election because, obviously, they can’t set the agenda at the national level, because they don’t control either house of Congress of the White House, but they do control a lot of state legislatures. There’s two dozen states or maybe a little fewer than that where they have both houses and the state legislature and the governorship and so they can set the agenda.
Basically like the two big agenda items, for Republican state governments are, changing voting laws, by and large, making it harder to vote, knocking people off voter rolls, reducing the amount of hours the polls are open, as they did in Iowa the infamous Georgia bill, which made it a criminal infraction to give water to people on line to vote, et cetera, et cetera, so that’s one bucket of things.
And the other are legislating and regulating trans children in two specific ways; one, a real obsession with trans sports, barring trans students from participating in sports and trans healthcare. Healthcare basically barring making either more difficult or in some cases, just explicitly criminalizing what’s come to be known as gender-affirming care for trans youth. You’ve seen this in a number of states, in some states, you’ve had a situation, for instance, in Arkansas in which people were successfully able to lobby the Republican Governor into vetoing legislation like this, but then that veto was overridden by super majorities in the state legislature.
There’s been several states in which Republican governors themselves have at the last minute vetoed this legislation regarding trans health care because it is so destructive, it can have such calamitous, unintended consequences. But one thing that I’ve found in talking about this issue on air, and in reading about it is, the particulars of what this actually means, like on the ground are a little obscure.
I think there’s these sort of twin balances, I think, one is that folks understand that there’s this sort of long and gross obsession in mainstream culture and among folks who are not trans with like the specifics of the biology of trans folks, like what exactly is happening physically with trans folks. There’s this kind of like fetishistic and gross and dehumanizing aspect to that.
So people are wary of engaging in that rightly so, but there is also this sort of real question about like what does this healthcare mean and what does it look like and what do you say to people who raise objections to it. Sometimes who don’t sound like bigoted monsters, they sound like people with maybe good faith objections or worries about the hands that children will be in terms of making decisions about their bodies.
And so I thought it would be great just to talk to someone who just on the ground does this health care, like what are we talking about when we are talking about gender-affirming care, what does it mean, how does the process work, how are decisions made, what do children say and do and what is and isn’t reversible, and then how this legislation would affect trans kids and their families across the country and Dr. Izzy Lowell is just such person.
Dr. Lowell is a family medicine physician at a place called Queer Med, the Dr. Lowell founded which specializes in transgender medicine, and treats trans patients in Alabama and across the southeast, and a lot of places where their health care is now under assault. Dr. Lowell, it’s great to have you in the program.
Izzy Lowell: Chris, thanks so much. It’s really an honor to be here. Yes. I’m Dr. Izzy Lowell, my pronouns are she and her. Before we get started, what pronouns do you use?
Chris Hayes: I use he and him.
Izzy Lowell: Awesome.
Chris Hayes: Thank you. I was repeating Dr. Lowell, because I was actually not sure, so thank you.
Izzy Lowell: Absolutely. You can call me Izzy. I’ll call you Chris, you can call me Izzy.
Chris Hayes: Great. I’ll call you Izzy. Yes. So maybe let’s start with a little bit of your personal story where you grew up and how you how you got into medicine, how you became a doctor.
Izzy Lowell: Well, I grew up outside of Boston in Massachusetts. Originally wanted to be a math teacher. I thought it’d be a math teacher. So I do want you to do that podcast on the on Gödel’s incompleteness theorem when you get a chance.
Chris Hayes: Oh, my god. You really are a fan and I will try to do that although I will embarrass myself because that’s like lost forbidden knowledge of a 20-year-old version of myself that I can’t reclaim.
Izzy Lowell: But then after college, I sort of searched around for the thing that fit and came up with medicine as a way to really help people in the sort of most fundamental way. And so, a couple years after college, I went back to school and became a family physician. After my training, after my residency training, I moved down here to Atlanta, to be closer to my partner’s family, and joined the Emory, their family medicine program. I was a faculty member there.
While I was there, I realized that there was an unmet need for transgender people in the southeast, so I started the gender clinic at Emory in about 2015. And at first there weren’t very many people there and then word sort of spread and became very popular and people were traveling from all over the southeast to see me. I was just a family doctor providing this clinic once or twice a month.
So I said there’s got to be a better way, so I eventually left Emory in 2017, to found Queer Med, where we provide telemedicine services now across 10 states in the southeast to just get people better access to this care.
Chris Hayes: Well, that’s fascinating. I know this is not at all the point of this podcast, but it is interesting, you mentioned telemedicine, because I do feel like one of the effects of this pandemic is acclimating people to it and getting more comfortable with it. I’ve actually found it really useful like in the kind of most banal circumstances. It’s like there’s a nagging thing that you would put off a doctor’s appointment too, because it’s a big commitment of time that I would do a telemedicine.
But for what you’re talking about, it must be kind of a game changer, I would imagine to have access to you in your consultations and your practice and not have to drive seven hours.
Izzy Lowell: Absolutely. The patient who sticks in my mind, who really inspired me to start this, I remember, they were the last patient right before lunch and I was hungry and cranky, and they were a couple minutes late, they were like 15 minutes late, and finally got him in the room. I went in grumpy. Right away, he stood up and he said, “Dr. Lowell, I’m so sorry to be late. I’ve been driving for six hours from Western Tennessee. I’m so sorry.”
That really put things in perspective for me and kind of changed how I was thinking about it and this was back 2015, 2016, before the pandemic. Telemedicine was kind of an equalizer and such a game changer for access for people for all sorts of different things, but especially for sort of generally discriminated against or disregarded populations by the major medical field.
Chris Hayes: It strikes me as you talk about your patients and the kind of sacrifices they’re making to come see you in person and the sort of degree to which there’s an unmet demand in underserved patients. One of the things, I think, one of the sort of stories of people particularly on the right, but not exclusively on the right have told about the development of trans rights and trans equalities.
There’s essentially a kind of like a fad or a sort of cultural fashion, that’s like seizing the minds of young people who like want to fit in and I just wonder if you could talk about like what the circumstances of the lives of your patients are throughout the southeast when they are coming to you and what their life world is like as the backdrop for what they’re experiencing vis-a-vis their gender and their selves?
Izzy Lowell: Well, to start with, that’s a great question, to start with some of the statistics, over a third of patients have been discriminated against or refused care or verbally or even physically abused by medical professionals according to large nationwide surveys done in 2014. That’s just the data.
Personally, my patients I’ve had dozens and dozens of patients describe some of their experiences. For example, someone said she had a broken arm and she went to see her doctor for hormone therapy and the doctor said, “Sure, I’ll treat you for a broken arm, but I’m not going to treat you for that.”
That was one of the most benign examples. Other patients have been kicked out of the doctor’s office, I had a patient who reported that when they called our office, we were the 11th provider, they had called that morning, and nobody else would agree to treat them. This is in the Atlanta area.
For patients in rural locations, there are just zero options. People get told highly unpleasant things when they call and try to ask for an appointment and so it’s real, and my patients have experienced being turned away by multiple practices in the areas that they live.
Chris Hayes: I want to talk about gender-affirming care, both for adults and for children. Obviously, children has been the emphasis of this kind of real political attack and legislative and regulatory attack. But I wonder if you can just talk us through like what’s that term mean in real terms? What’s the sort of portfolio of care that you’re providing and that patients are seeking from you?
Izzy Lowell: Well, it depends a lot on the patient’s age. Gender-affirming care for a child who hasn’t entered puberty yet, really is all about the social environment and there’s something called social transition so that child can live in their desired gender, wear clothes like that gender, adopt a name more consistent with that gender, be – for all intents and purposes – treated as a member of that gender. Things start to change once they start puberty.
That’s when we would talk about starting a puberty blocker to either gain them a few years more of making sure that their gender identity is certain. Then, at some point for a teenager or for an adult, we would start them on cross hormone therapy. For someone assigned female at birth, that would be testosterone and for someone assigned male at birth, that would be estrogen.
Chris Hayes: What are those consultations like? I mean, I think to the extent that people, again, I’m trying to sort of speak to an audience that I know is out there, because they’re in my inbox, who I think consider themselves enlightened and open-minded people, but have some anxiety or worries about the decision-making of children, which I think is not crazy, but just to talk through like what that actual conversation and consultation is like when you’re talking about 10 year olds or 11 year olds, and the choice to go on puberty blockers or begin cross hormone therapy.
Izzy Lowell: It’s a great question and it’s something that I take very seriously and have thought at length about in my career. It’s a long consultation. Initially, we go through their whole medical history, their whole gender history, and in terms of making it the ‘diagnosis’, even though it’s not a medical problem. In medicine, we like to diagnose everything, even if it’s normal.
So we ‘diagnose’ gender dysphoria is the medical term for that for the discomfort of being in the wrong gender. In brief, the components of that of gender identity that’s consistent, meaning that it’s been consistent over time, persistent and insistent. So it’s something that has been there for a long time for that person and causes distress, the insistence of it.
If someone came to me and said, “I’m in a male body, but I feel like I’m a woman, but it doesn’t bother me.” I’d say, “Great. We don’t need to do anything.” But it’s that distress, it’s that extreme discomfort of feeling like you’re in the wrong body that we can do something about with hormone therapy.
And it’s a great question, it’s a question that everyone wants to talk about is how can we let a 10-year-old, 11-year-old make a decision about this something so momentous. It’s tough, but what I would say to people is, yes, I didn’t know a lot of things when I was 10 or 12 or 20. I didn’t know my sexuality. I didn’t know if I wanted to have kids or not. I didn’t know some huge decisions about major life things. But I did know what gender I was.
If you think back, when did you first know that you were a boy? It’s early on. It’s beyond the extent of our memories. We just grow up always knowing that.
Chris Hayes: Yes. Right. Exactly. You can’t kind of identify it, right?
Izzy Lowell: Yes.
Chris Hayes: I mean, I’m actually thinking back now and it’s like it’s an invisible essence that is there before any conscious knowledge of it is, in my own personal case.
Izzy Lowell: Right. The vast majority of people have always known that and no one ever asked you when you were 12 or 11 to say, “Are you sure you want to continue on to become a man? Is that really what you want to do?” It’s something that’s so given that was your gender and that was your path through puberty and developing into an adult.
I think it’s the same as for a lot of these children, not all of them, but many children, parents bring them in and say, oh, we’ve known that she’s a girl since she was four. The child knows that. The parents know that. Many of the cases are absolutely straightforward. Everybody knows that this person is a girl. She just needs some medical assistance to become a woman.
Some cases are more complicated, but in a lot of cases, it’s pretty simple.
Chris Hayes: This is a sort of devil’s advocate question and it’s also a question that I think about a lot because we’re getting, I think, to some of the root here. Again, I think it’s just important to distinguish, I think there’s people who have very kind of close-minded reactionary and bigoted views about this and are engaged in something fundamentally like kind of in bad faith and dangerous that I don’t really want to engage with and then I think there’s sort of a category of people that aren’t that way and are still sort of confused or conflicted, so I’m sort of speaking to those group.
But there’s this question where we’re talking about like what gender is and what its essences are and we say a girl or a boy. I do sometimes wonder, there’s almost a part of it that feels like reifying of certain specifics. When you say, well, part of the way that we know this person is a girl is this person wants to wear girl clothing or play in certain ways with certain ‘girl toys’.
I guess part of me sort of feels like, well, are we reifying the boundaries of gender insofar as we’re saying that says something essential about what this individual child’s gender is?
Izzy Lowell: That’s a really good distinction. I’m glad you brought that up, because there are two different things we’re talking about here. What you’re talking about is gender non-conforming, so that could be like the way that someone dresses or the toys that they choose to play with or the career that they choose to go in or how they interact with people or any number of things could be gender non-conforming, like a boy who likes to play with dolls and wear dresses.
But that boy might say, yes, I like to play with dolls and wear dresses, but I’m a boy. The difference comes when that person says, I am a girl, and I want to have a girl body and I want to grow up to be a woman, a woman.
Not all transgender people are gender conforming toward their target gender. I have a patient who told me, yes, I put on my pants and my boots, and I go out and mow the lawn, just like any other woman, not all transgender people become extreme versions of their target gender either. They can be gender non-conforming as well.
So the key difference is gender non-conforming behavior, but still wanting to remain in their gender assigned at birth versus someone who says I am this or I am that.
Chris Hayes: The adjective you use of it, insistence, that it’s insistent. Can you talk a little bit about what your patient’s subjective experience of that is like, particularly as children or as teenagers?
Izzy Lowell: The typical trajectory is sort of as, as children, especially people who are allowed to socially transition, there’s not a lot of issues until they hit puberty, and that person’s body starts going in a direction that is totally different from where they either thought they were headed or wanted to go. Some patients have described thinking that when they grew up, they were going to become the other gender, because that’s what they wanted and that’s what they knew they were and they thought when is this thing going to happen to me and just assumed that it would.
Many children don’t even realize that they are transgender. Some children have supportive families and socially transitioned since they were four and that’s lovely. Many don’t quite realize that they are transgender until they start puberty. They always sort of felt something was different or uncomfortable in certain ways, but it wasn’t that bad kind of and then puberty starts and things really hit the fan at that point.
That’s when we see teenagers attempting suicide, doing really badly in school, developing behavioral, problems becoming severely depressed, having symptoms that mimic anxiety disorders and sort of agoraphobic even. Patients don’t want to go outside. They don’t want to interact with people. They have social anxiety and that’s where I meet a lot of teenagers.
Typically, unfortunately, when the parents realize my kid is at risk and if I don’t bring them in, a lot of worse things could happen than they’re being transgender, so maybe I should find out a little bit more information about this. That’s where I meet a lot of families is at that moment and that’s the opportunity to really – not even hyperbolizing here – but to really save a life.
Chris Hayes: Yes. I mean, I think that’s why the stakes here feel so high. I mean, it’s essentially a moment of crisis you’re describing. The crisis brought on by the biological processes of puberty, pushing a person whose self-conception is one way, pulling them away from that and the availability of a medical intervention that can either forestall that or alter that trajectory, and the inability of accessing it creating this crisis.
I’m curious what the parents say and when you’re talking about areas throughout the southeast, obviously, it’s politically heterodox, like all kinds of places. there’s diversity and there’s liberals, and there’s conservatives and everything in between, secular or religious. But I do wonder like what those parents coming to you with teenagers who maybe didn’t think this was real or they thought it was a fabrication of the libs or et cetera. Like what those conversations are like when they’re coming to you recognizing the child they love and care for is in crisis?
Izzy Lowell: Those are complex conversations and difficult in some cases and often require many conversations. A common way this goes is that the child’s been thinking about it for a long time for months or years and then tells the parents and they have to catch up, they have to go through the whole process that the child has been going through for years to come to the same place and they kick it quite right away.
So I meet families where the parents have just found out about this and everybody’s panicking. Often parents are saying, I support my child, I love them, but I don’t want to do something permanent to them. They’re too young. They don’t know what they’re doing. I can relate. I’m a parent. I wouldn’t want to do something that’s permanent to my child that I was skeptical about.
So there’s a lot of talking and most of the conversation at that point is around what’s permanent and what’s not, what the timeframe looks like, what the risks are, what the potential benefits are. It takes some time and some processing to get to a point where one or both parents are willing to try a medicine for their child.
We don’t always get there, but in most cases we do, particularly when the child speaks out at a visit, sometimes they haven’t even told the parents exactly how strongly they feel about this and parents get to see their child telling me how they feel.
Then the most remarkable thing is when we do get a child on the proper medication, whether it’s puberty blockers or hormone therapy, that next visit, the visit three months later to check labs and check in is one of my favorites to a person, the child or the teen who was secluded didn’t talk to anybody, would look at the floor or mumble, you couldn’t hear them, they wouldn’t make eye contact, they come back, just brighter. They’ll speak loudly. They’ll look at you. They sit up straight.
It revolutionizes who they are and they get to become themselves. It’s not even like they become someone different, they just get to get to be themselves and parents see that and that convinces them that this is the right track.
Chris Hayes: Yes. I’m curious of that parent trajectory. I mean, obviously, they’re coming to you in the first place, so they’re already in a place where —
Izzy Lowell: Right. They’re in the door.
Chris Hayes: — they’re in the door. Do you have resistance throughout? Do you have resistance? I would imagine resistance is about reversibility, so the difference between puberty blockers and cross hormone therapy, I can imagine for some parents, it’s like, okay, we’re going to forestall and maybe he or she grows out of this as opposed to we are now beginning a course of a biological trajectory that’s more interventionist, essentially.
Izzy Lowell: Definitely. There’s a big difference in terms of reversibility with puberty blockers, which are basically completely reversible with a few caveats if you’re on them for a long time, but typically, we don’t put people on them for really long periods of time. But, yes, it’s a big difference, cross hormone therapy versus puberty blockers. More so kind of emotionally and psychologically than in reality in a lot of cases, because of the time it takes for hormones to act.
I mean, if you think about puberty, a cisgender person, i.e. someone assigned male at birth, who grows up to be a man or vice versa, cis being on the same side of trans being opposite and (inaudible) sort of transgender and cisgender. A cisgender person going through puberty, it takes two or three years, it’s a very slow process with imperceptible changes.
Chris Hayes: It took me longer than two or three years.
Izzy Lowell: It took more, yes.
Chris Hayes: I would love to get through it in two to three years.
Izzy Lowell: Everyone is different, but it’s a slow process or a very slow process. And people think if I expose my child to testosterone, they’re going to become a man overnight, it’s kind of the emotional thinking about it. Everybody knows that’s not really true, but it’s sort of how people think about it and that’s not at all the case.
We can start teens, especially younger teens, I start them on extremely low doses and I say to the parents, not much is going to happen, really, we’re not doing anything that’s going to cause permanent changes for the next three to six months and I say to the teen, “You’re going to be frustrated. You might notice something, but you’re not going to notice much with this dose. So don’t get discouraged, because I’m starting you on a teeny tiny dose to see how you feel and see if you like it.
If you like it, great, we can give you more. Or you might say, you know what, actually this doesn’t feel right. This wasn’t for me and we can stop it with no consequences.
So I sort of explain it to everybody what the plan is and then invariably, that person, the teen says it’s great, I want more and the parents see them improve socially, emotionally, everything they see things get better. Whether it’s even because of the medicine or because progress is being made towards something it’s hard to say, but we start them on almost homeopathic dose to begin with and then go from there. Especially with the younger teens, we’re not incurring irreversible changes within the first six or even 12 months.
Chris Hayes: Do you have people who decide, “You know what, I don’t want to do this.”
Izzy Lowell: So far, I haven’t.
Chris Hayes: Really?
Izzy Lowell: That’s not true. I’ve had one teen who was on testosterone for a couple of years and then eventually decided to stop. But interestingly, during the time that they were on testosterone, they changed their name and gender marker to male. When they stopped testosterone, they did not want to change their name or gender marker back to female.
I think that person ultimately had more of a non-binary identity and the patient and me and family didn’t recognize that early on. But also interestingly, that patient had no regret. They didn’t say I wish I’d never done it. This was all part of their journey. They weren’t going back to female, they were going from assigned female at birth to someone who’s more masculine to something else next. It wasn’t seen as reversal of something and they were happy to have been on testosterone. So that’s the one example that comes to mind. Other than that person, I haven’t had any teens say, “Actually, I don’t want to do this anymore.”
Chris Hayes: I want to talk about what the sort of state of the medical literature is in this area and the sort of degree to which the protocols are pretty well established right after we take this quick break.
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Chris Hayes: I wonder if you could just sort of sketch out the history of this kind of care, how long it’s been offered and what the state of the medical literature in terms of peer review and consensus amongst doctors about the sort of protocols in providing this kind of care are?
Izzy Lowell: Well, I think the Netherlands where it was the country in which this care was first provided decades ago. They were early on providing hormone therapy for adults and a lot of the research that we do have, there’s chronically not enough data, I’ll say that over and over. There’s just not enough data for a lot of these things. But the data that we do have, a lot of early data is coming out of Netherlands.
That’s where some of the guidelines originated like, for example, many guidelines recommend not starting cross hormone therapy before the age of 16. We get that number, not because it makes physiologic sense. Most people, especially people assigned female at birth start puberty way before 16.
Chris Hayes: Yes, definitely.
Izzy Lowell: It’s 10, 11, 12.
Chris Hayes: Yeah.
Izzy Lowell: But we get the number 16, because that’s the age of majority in the Netherlands, so that’s when people could make their own decisions. So that’s how that number ended up in the guidelines, not because of any medical reason.
So that was in the guidelines for a long time, now and more recently in the past five to 10 years, many of the leading guideline creating societies have been decreasing that age gradually and sort of hedging. Some guidelines say start at 16 or in some cases you might want to start earlier.
UCSF is doing a lot of research on this, particularly. They have an amazing pediatric trans center, adolescent medicine center and they advocate starting much earlier as early as 13 and that’s some of the protocols that I follow is having a more physiologic model where that person can stay on course with their peers. You don’t want to puberty block someone until they’re 18 and they can make their own decision.
On the face of it, that makes sense. We’ll just wait until you’re the age of majority and you can decide whatever you want to do. But then you’re a prepubescent person starting college. If you’re before, now you’re really, really off track with your peers. The guidelines are evolving rapidly for medicine where guidelines evolve extremely slowly.
Now in this country, every major reputable American Medical Association, including the American Academy of Pediatrics, the American Medical Association, the American Psychological Association, the Endocrine Society, College of Obstetricians and Gynecologists, everybody recommends affirming care, including when appropriate puberty blockers and hormone therapy.
It’s become very clear in medicine that the medical guidelines for what to do that’s best for the patient is to provide affirming care and that includes puberty blockers and hormone therapy.
Chris Hayes: What is the community of healthcare providers giving this kind of care like, I mean, particularly this moment where you’re now finding yourselves. I mean, I’m sure it was always the case and in some ways you’re sort of a political target, but now probably as much as ever recently.
Izzy Lowell: Yes. I’m like the most introverted person you’ll meet and all of a sudden I’m in the middle of a lot of things. I just like to go to work, work hard, do a good job, go home and that’s not my current job. I never quite anticipated that I would be in this position.
But when I started Queer Med in 2017, I thought this will be a temporary solution to making sure that people have access until this becomes widespread. Because hormone therapy is not actually complicated medically, it’s much simpler, for example, than diabetes. Managing diabetes is complicated, that’s actually pretty difficult. But every primary care doctor you go to manages diabetes that’s assumed.
But gender-affirming care is not widespread, even with all the medical society backing it, there’s still lots of physicians who say, “I wasn’t taught that in school.” “I don’t feel comfortable doing that.” “I’m not against people being trans, I just don’t provide that care.” That’s a very common thing that I hear, which sounds like, yes, you wouldn’t want a doctor who doesn’t have expertise in something providing care, which makes sense.
But if you apply that to other things, like, in the past 20 years, dozens of new medicines for diabetes have come out. You couldn’t get away with saying, I went to medical school 20 years ago, so I don’t prescribe any medicines that came out since then. Or, I’m not against diabetes, I think people who have diabetes are fine, I just don’t choose to treat them.
You couldn’t say that. It’s expected in the medical profession, that we’re constantly learning about new things and learning about new medicines that come out and new techniques and improvements and new data. We adjust how we manage things based on new data.
I naively thought in 2017, I’ll start this clinic and fill a gap until everybody else starts doing it and I go out of business. Here we are, four years later. I thought the lifetime of Queer Med was going to be about five years and it’s been four so far.
Chris Hayes: That’s a great fascinating point about diabetes, which I guess I hadn’t considered before that that’s a difficult and complex chronic disease to manage. But it’s an expectation that all primary care physicians can manage that.
Izzy Lowell: Yes, absolutely. Interestingly, type 1 diabetes, which it could be argued as the most complex form of diabetes, type 1 diabetes is about as common as being transgender. Being transgender may even be more common than type 1 diabetes.
Chris Hayes: That’s fascinating too. I mean we think about diabetes as actually quite common, right?
Izzy Lowell: Right. Type 2 is more common, but type 1.
Chris Hayes: No. But type 1 is childhood, right?
Izzy Lowell: Yes.
Chris Hayes: I mean, type 1, I think everyone has had some – well, I don’t know everyone, but you–
Izzy Lowell: Almost everyone.
Chris Hayes: –you know kids.
Izzy Lowell: Yes.
Chris Hayes: Yes. So what would these laws mean, for you? Obviously, these laws, meaning, there’s a bunch, it’s a little hard to track because it’s a kind of whack-a-mole and there’s different iterations in different places. There are different points in their trajectory in different states, which some they’ve been signed into law. I think in Arkansas, as I mentioned, over the veto of the governor in other states, they’re making their way through. Just talk a little bit about what they would mean for the kind of care you provide.
Izzy Lowell: Yes. Well, it would be devastating for our patients and for me as well. I mean, we cover 10 states. I think five of them, maybe four or five, of those states have laws that are on the docket. What that would mean if they’re passed in those states is that it would become criminal for me to provide care to those patients.
Now, that makes me incredibly angry and sad if that were to happen to have to choose between going to jail for 10 years and continuing to care for my patients. But what’s also interesting and nobody’s talking about, I think, is that it’s also a physician’s responsibility. There’s a code of medical ethics where I’m responsible to take care of my patients. If I can’t, I have to find a good place for them to go. I have to notify them long enough in advance for them to find other care and I’m supposed to find another physician for them to see.
So I’m going against the core of my medical oath to patients that I will take care of you, it’s called abandonment, which is a form of negligence and that’s understood in the patient-physician relationship that I won’t abandon them.
Chris Hayes: I’m sorry, I know that you’ve now got this very bad chronic illness or you’re managing diabetes or you’ve now been diagnosed with cancer, like, sorry, nothing I can do. Like that’s just not acceptable for a doctor.
Izzy Lowell: Right. That’s not the thing.
Chris Hayes: Yes.
Izzy Lowell: No. Abortion, for example, if I said I’m not comfortable providing an abortion. It’s my responsibility to help that patient find another provider who is or any other thing. Cancer, for example, I have to help them get to a place that could treat them for something if I don’t treat that.
In this case, I’m stuck. All the other doctors would be doing something illegal too, so I’m not allowed to provide care to my patient who’s in Alabama, let’s say. But I also can’t help them find care anywhere else, so I’m effectively – if this law goes into practice – I will have to perform my duties unethically.
Chris Hayes: You will either have to commit a crime or violate your ethical oath.
Izzy Lowell: Right.
Chris Hayes: There’s basically no choice between the two.
Izzy Lowell: You can actually get sued for malpractice for patient abandonment. It’s a form of negligence.
Chris Hayes: Have you talked to policymakers? Have you had interactions with folks in the midst of this sort of raft of legislation?
Izzy Lowell: I haven’t talked to policymakers. Like I said, I’m one of the most introverted people you’ll meet, so I haven’t gone out of my way to talk to anybody. I just keep my head down and try to help my patients through this. But I have spoken with a legal team – to several legal teams, actually – who I’m working with to keep figuring out what my options are here and to make sure I don’t break the law.
I’m getting advice about what I can and can’t do before they pass some of these laws. So I’m helping patients get set up as best as I can within the legal bounds of medical practice to be prepared for this.
Chris Hayes: I mean, you have ongoing patient relationships that are on the verge of being criminalized by the state.
Izzy Lowell: Many. Many.
Chris Hayes: What are those interactions with patients like? I mean, how much is this now a present thing in the room or on the call when you’re talking about their care?
Izzy Lowell: It’s the main thing. I mean, many of my patients, for example, in Alabama, I have a handful of teens, who I care for in Alabama. For them, like most of them are older teens and stable on hormones. It’s not even like we don’t even talk about their hormone therapy anymore, they’re just like, “Yes, I’m great.” “So your labs look fine, let’s get you a refill.”
That takes like two minutes and then we spend the rest of the time talking about what is going to happen. These kids are 15, 16, 17 and their state is saying that they’re wrong, their existence is wrong. I don’t know what that does to the psyche of a 16 year old to have your state basically say that who you are and what you’re doing is illegal.
Chris Hayes: I’ve been on SSRIs, I’ve been on Lexapro and I have been since, I don’t know, 2007. I don’t think I’ve ever talked about it publicly before, but it’s been a really incredible thing for me. It really has helped me just reduce a certain amount of kind of like ambient, I think, biologically-driven anxiety that I used to experience.
There are times when I’ll forget to refill and start to run out and if you start to go a few days without it, like you have really bad withdrawal. I mean, not withdrawal in the sense of like an addictive drug, but like you start to feel kind of causey and confused. It’s unpleasant. It’s the kind of thing that if you’re going to go out it, you have to titrate.
The specter of being cut off from it is a little panic-inducing. I can only imagine what it’s like for your 16 year old patients like what would it actually mean in terms of their course of therapy?
Izzy Lowell: Yes. Well, thank you for sharing that. Exactly, it would be devastating. So if someone has been taking estrogen for several years and then they stop it, they would go through like instantaneous menopause symptoms. Menopause takes a year or two to go through and they would go through menopause overnight, basically, as a teenager.
They would have hot flashes, irritability, night sweats, incredible mood swings. They would no longer continue developing breast tissue. That wouldn’t regress exactly, but their estrogen level would drop and they would have basically no sex hormones in their body until their body started reproducing testosterone.
Testosterone and estrogen both play a role in brain development and intellectual development and social development. They would have no hormones in their body for a period of time until their body started reproducing testosterone. At that point, they would start to transition into a man. They would start growing hair in all sorts of places they didn’t want it. They would become more muscular. They might even grow taller at that point and basically go onward with male puberty, which they had never wanted in the first place.
For someone who’s on testosterone, similarly, they would have symptoms of low testosterone. It’d be like an adult man who has a normal testosterone level one day and a level of zero a week later. The half-life of it is fairly long, so it would take about a week or two to get to a testosterone level of zero and they would have brain fog. They wouldn’t be able to focus. They wouldn’t be able to concentrate on anything. They would be moody and have no energy, and later they would start growing breast tissue once their body starts producing estrogen. A month or two later, they would start having periods, start developing breasts, basically go back toward female puberty and either of those outcomes is devastating.
Chris Hayes: Basically, either way forward under these conditions would be sort of an awful trauma to experience.
Izzy Lowell: Absolutely. Not only that, but they would need more medical treatment in the future.
Chris Hayes: Right. You can’t just walk away and be like, okay, figure it out.
Izzy Lowell: Right. So, for example, someone who’s assigned female at birth who goes on puberty blockers, when they hit puberty and then get started on testosterone, and then grows up to be a teenage boy, they never grew breast tissue, in that whole process. We can prevent them from ever having breasts. Therefore, they don’t need chest reconstruction surgery, which is major surgery, at great expense when they’re older.
So if they have to go off hormone therapy for a year or two, they would develop breast tissue and then require surgery.
Chris Hayes: Right. That’s huge. I mean, when you talk about the medical interventions here like what I’m hearing from you is that medical interventions made at this crucial juncture reduce medical interventions that the patient may need later on in life.
Izzy Lowell: Absolutely, and chest reconstruction is just one of them. Very commonly, trans feminine people need facial reconstruction surgery, which is extraordinarily intensive and costly if they develop sort of the facial features of a man, like the square jaw, hair in places, sort of the Adam’s apple, nose structure. We don’t gender people by their bodies and what parts they have, we gender them by their face.
If you look at a face, you know right away whether that’s a man or a woman without seeing the rest of their body. So the face is a major source of dysphoria and of getting misgendered. It’s dangerous, in fact. So if you have someone who’s 6’4″ and has a really masculine looking face, who is a woman and wants to use the women’s room, they’re going to get some looks. They might not even be safe.
So if we can prevent them from being quite so tall, prevent them from having such hard facial features, get their body to not develop in such a broad way and develop so many muscles, they’ll have a much more safe, not only successful transition kind of ‘aesthetically’, but they’ll be safer because they won’t stand out as someone who’s clearly transitioned later in their life.
Chris Hayes: This is such an obvious point, but it’s just useful to hear it from the sort of care provider perspective, like literally what will happen to your patients. Like will they just get cut off? Will they be able to get, I’m assuming, like a black market for hormones? Like I’m just thinking about what’s going to happen?
Izzy Lowell: Well, I’ll tell you my contingency plans just don’t go to the authorities.
Chris Hayes: Okay.
Izzy Lowell: I’ve been thinking a lot about this and I’ll circle this pass my legal team, but it’s all state-based so some of these laws are on the docket in Alabama, Tennessee, North Carolina, South Carolina and Virginia. I think I may have gotten those states wrong, but I think those are the states that we cover where this is that in play.
What a patient could do then, we’re back to the old model, they could drive from Alabama into Georgia and telemedicine is all about where the patient is located. So I have to have a license in every state where my patients are located. So if they drive into Georgia or into Mississippi where I’m licensed, they could sit in a parking lot, have a telemedicine visit with me and I can now provide care to them, because they’re not in the state of Alabama.
Chris Hayes: Wow.
Izzy Lowell: And I could find a local pharmacy wherever they are in Georgia border town and send them a prescription. They could wait there and pick it up. They could travel back to Georgia or Mississippi or Tennessee to get their blood drawn, so that we can monitor their levels appropriately so that I can provide responsible care. Then they just have to drive out of state every time they want to talk to me.
Chris Hayes: Jesus. These recalls, I mean, obviously these are precisely the workarounds that have been created over abortion, right?
Izzy Lowell: Yes, very similar.
Chris Hayes: And I think the targeting is very similar, the sort of playbook. I mean, the difference being that abortion is a single procedure, when you’re talking about surgical abortion. Obviously, there’s like follow-up and aftercare, but it is not recurring chronic treatment.
Izzy Lowell: That someone’s been on for years and doing great.
Chris Hayes: Right.
Izzy Lowell: Like these kids are thriving and they’re doing fine, they’re doing well, and then we have to do all this to make it just harder for them to (inaudible) themselves.
Chris Hayes: You said that you’re introverted person and you’ve been incredibly game in our conversation here. I mean, I obviously enjoy this because I’m a very extroverted person, but I know that that’s not everyone, but I do wonder what your emotional experience of this is like. I imagine actually the work you do must be incredibly fulfilling in many ways, but this must be really upsetting and kind of fear-inducing.
Izzy Lowell: Yes. I mean, it’s draining, even seeing patients I find draining because I put so much of myself into it that it can be draining. And there’s so much emotion and vulnerability with patients and families that even that’s draining, but this is on a new level. I mean, basically, and I have three nurse practitioners who are amazing who work with me now and we sort of talk with each other about this and how we’re all coping.
But the bottom line is that I just keep my head down. I never wanted to be a celebrity or a part of this or anything. Throughout my career just kept making decisions that seemed obvious. Well, this care doesn’t exist, so let me see if I can provide it. It doesn’t exist in that city there or at that state and every decision just kind of seemed obvious. It wasn’t like I set out to be the transgender crusader or anything. So this is new for me and not my sort of chosen role, but something that’s obviously the right thing to do.
Yes, I cope basically. I don’t watch the news. I don’t follow any of this stuff and–
Chris Hayes: Wait, really?
Izzy Lowell: No. No. I’m waiting for my lawyers to tell me that something is passed, basically. No, it was great to find your podcast because I don’t like anything too political, too upsetting. Like you’re talking about Bitcoin, I was like, “I don’t know anything about Bitcoin.” Great. This is awesome. Wikipedia. I’m fascinated, I want to get on Wikipedia so that we can have a better visibility for our practice, so I was like, oh, this is great.
It’s just the right level for me, just sort of protecting myself to be maybe it’s head in the sand, but for me it’s kind of what I do to cope and show up at work every day and put my head down and do my job and hopefully help people and then go home.
Chris Hayes: I mean, that makes total sense. I actually, personally, steer like completely clear of politics as much as I can on the weekends, just because they’re only so much.
Izzy Lowell: Yes. You have to for your sanity.
Chris Hayes: Only so much (inaudible). How long do you keep in touch with patients? What year did you first start providing this kind of care?
Izzy Lowell: 2014, probably when I was at Emory.
Chris Hayes: Yes. So you’ve had you’ve had patients go through high school and then go off to college. I wonder if you keep in touch with them and what kind of things you hear?
Izzy Lowell: Oh, yes. I mean, they’re still our patients. So we see children, teens, adults, everybody, so I’ve had patients since 2014, 2015 who’ve grown up, who’ve grown into adults. Now that they’re grownups, I only see them once a year, which is kind of sad and it’s like a 15-minute visit once a year, because they’re like, “I’m fine.” And I’m like, “Your levels are fine. Great. Here’s a refill. Carry on.” It’s regular. That’s the best way I can describe it, just regular people and it’s great to see them go from someone who was really upset and unhappy with everything, grow up to be someone who’s regular.
Chris Hayes: Regular, that’s an interesting word. There’s a great Freud quote. He said something once about like the goal of analysis was to turn abject misery into ordinary unhappiness.
Izzy Lowell: Great. Yes, exactly. Yes.
Chris Hayes: It’s like in the end we’re all going to be human beings like dealing with our stuff, right?
Izzy Lowell: Yes. Yes. People are too happy, that’s a different kind of disorder.
Chris Hayes: They try to get us to that place.
Izzy Lowell: Yes. No, I’m intentionally not using the word normal, because I think that has so many different meanings and be so weighted.
Chris Hayes: Totally.
Izzy Lowell: But just average in the best way.
Chris Hayes: Yes.
Izzy Lowell: A person who goes about their life totally regularly.
Chris Hayes: Yes. Dr. Izzy Lowell is a family medicine physician at Queer Med. They specialize in transgender medicine and they treat trans patients in Alabama across the southeast, as you heard. That was so wonderful and I learned so much from that conversation, so thank you so much for doing it.
Izzy Lowell: Thanks so much for having me. It’s really an honor.
Chris Hayes: Once again, my great thanks to Dr. Izzy Lowell, who very gamely soldiered through her introversion, which she mentioned multiple times, which was just great. I really learned so much from that conversation. I hope you did too. We’d love to hear what you thought. Tweet us with the #withpod. Email us at the address withpod@gmail.com.
Why Is This Happening is presented by MSNBC and NBC News produced by the All In team, features music by Edie Cooper. You can see more of our work including links to things we mentioned here by going to nbcnews.com/whyisthishappening.
Tweet us with the hashtag #WITHpod, email WITHpod@gmail.com. “Why Is This Happening?” is presented by MSNBC and NBC News, produced by the “All In” team and features music by Eddie Cooper. You can see more of our work, including links to things we mentioned here, by going to nbcnews.com/whyisthishappening.