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Op-Med is a collection of original articles contributed by Doximity members.

Op-Med Podcast Ep2: An Interview with Steve Rosenthal, MD

Illustration by Jennifer Bogartz

In this second episode of the Op-Med Podcast, we spoke with UCSF pediatric endocrinologist Steve Rosenthal about how he found his calling caring for transgender patients and making sure that trans health is part of the discussion. We hear about what led him into pediatric endocrinology and then trans health, the things he’s learned to (or not to) say and do over the last four decades of his career, and we learn just how he became a saint.

Listen to Episode 1: “Treat us like you treat anyone else.” Find the Op-Med Podcast on Soundcloud and iTunes.

Among his many accomplishments, Dr. Rosenthal recently finished his term as President of the Pediatric Endocrine Society and is now Vice President of the Endocrine Society. He was an important part of the task force that revised the Endocrine Society Clinical Practice Guidelines.

A transcript of the episode, select reviews by Dr. Rosenthal, and additional resources are below.

Transcript of Episode 2

Doximity: Welcome to the Doximity Podcast, where we talk to people who are transforming healthcare. This is part two of a two-part special on LGBT health. UCSF hosted their 10th Annual LGBTQIA Health Forum at the end of February. This year’s forum focused on transgender health. Doximity had the opportunity to sit down with one of the presenters. He is current Vice President of the Endocrine Society, a premier transgender health specialist, and a saint.

[The Sisters of Perpetual Indulgence enter Dr. Rosenthal’s lecture.]

Steve: My name is Steve Rosenthal, and I am a pediatric endocrinologist at UCSF. I am the Medical Director of our Child and Adolescent Gender Center.

Doximity: Can you tell me how you initially got into transgender health care and research?

Steve: I’ve been at UCSF since July of 1979.

Doximity: Dr. Rosenthal has spent 35 of those nearly 40 years at UCSF on the faculty. During that time, he has served as the Pediatric Endocrinology Program Director and the Director of the General Pediatric Endocrine Clinic.

Steve: And it was in that capacity in January of 2009 that we were approached by the first family with an early adolescent that was assigned female at birth but that identified as male, and they were seeking help. And I had no formal training in transgender care — I didn’t know what options were even available for someone that age. There was very little that was even published at that point.

Doximity: In fact, so little was known about transgender health nine years ago that the first Endocrine Society Clinical Practice Guidelines wouldn’t come out for another five months after Dr. Rosenthal’s first encounter with that family.

Steve: But there were some studies that were coming out of the European medical literature that basically began to show two things: 1. The potential of using a pubertal blocker for really improving quality of life and also (2) the harm in not affirming a young person’s gender identity. And when I became aware of those two things and what this family was really asking for — because they actually knew more about this than I did — it just resonated with me.

Doximity: This case spurred nine dedicated years of transgender health research. And it was both very different and in some ways very similar to the case that had led Dr. Rosenthal to specialize in pediatric endocrinology in the first place, three decades prior.

Steve: What drew me in actually had to do with gender, because it was dealing with babies with an intersex issue. And one of the interesting roles a pediatric endocrinologist has traditionally played in the care of a baby with a difference in sex development was assigning a — not a gender identity, certainly, but a gender or sex of rearing. I remember being trained that if you “normalize” the genitalia and simply raise a person according to a standard gender stereotype, that nurture will trump nature, and everybody will live happily ever after. I remember hearing that and thinking, No, things have to be more complicated than that. That drew me into pediatric endocrinology, but the pediatric endocrine role was really to make the diagnosis and establish a treatment plan. But the really interesting stuff about gender identity was really in the realm of the mental health experts, and they weren’t even that involved three or four decades ago.

So when suddenly this came back, and it had to do with gender, it was like, Oh my goodness. Everything just sort of went full circle, and suddenly I saw this was always what I had been looking for, in a sense. To be able to get involved and bring together my experience as a pediatric endocrinologist and be able to have that interface with what we understand about gender and to work with wonderful, competent mental health colleagues, education and advocacy, legal experts, etc.

Doximity: You mentioned there was some personal resonance for you. Can you touch on that?

Steve: Well, what can I say. I would just say that… I think… Yeah, sure, I’ll say it. As a gay person, I grew up in the 50s, and I’ve had the experience that any number of people have — whether it’s related to their sexual orientation, their gender identity, the color of their skin, the religion they practice — the experience of not being mainstream or experiencing (sometimes intentional, sometimes not intentional) discrimination. When I started to meet these kids and these families, I was just so overwhelmed by the courage that these kids have that just want to be themselves, nothing more. And the struggles, but also the incredible support that so many family figures, friends can play in their lives, and the impact that that can have — and so it just all has meant a lot to me.

You know, I’m at a point in my life where I could completely retire, but I’m so engaged by this work. Every time I go to clinic — not that I don’t leave really exhausted and often quite drained, but almost always, if not absolutely always, I feel so grateful to be part of our team that gets to do this work.

Doximity: I asked Dr. Rosenthal to reflect on what has changed since he started his work on transgender health.

Steve: Within the transgender world, there are now interventions that can radically change the horizon for a transgender person. With the use of pubertal blockers, you can take a person who is transgender and give them the opportunity not to have to go through the wrong puberty and the irreversible physical effects of that wrong puberty and the damaging mental consequences of going through the wrong puberty. So you can actually do that now.

Doximity: Do you see a lot of patients accessing these interventions?

Steve: I would say that it’s certainly much more than anyone would have ever expected.

Doximity: Dr. Rosenthal says he gets new transgender patients every month. These patients range in age from young children to adults in their twenties.

Steve: I think that if you take a closer look at that population, one will find that the majority of those people had a sense of being different, certainly well before being 13.

Doximity: An estimated 0.7% of adolescents are transgender. That’s one out of every 140, though the actual numbers may be higher.

Steve: And that’s not trivial at all.

Doximity: You sort of touched on this during your talk, but since you yourself are not transgender, and you’re working with transgender patients, what are some things you’ve learned to do or not do?

Steve: Well, that’s a really great question, and I feel like I’m always learning in that case. I think we live in a very heteronormative, cis-gendernormative world, and we don’t even recognize the privilege that people have. Being not transgender, I don’t think that I realized at first when I was talking about the benefit of using a pubertal blocker, for example, as it might make it easier for someone to “pass” in the world. And then I learned from one of my dear and respected colleagues who is openly transgender that using the word “pass” sounds like you’re trying to get away with something. And it’s better to use a word like “blend.” So just starting to think a little bit more about the words that we use and the impact that the wrong word can unintentionally have — these little — what sometimes people refer to as microaggressions — and when that happens time and again, that can add up and really have an impact.

I think one of the things I’ve tried to do is put myself in a position of continuously learning. I just came back from a two-day conference that was completely devoted to transgender health. One of the things that was most powerful about that whole experience was that they had a panel for older adolescents/young adults who were transgender who were basically telling their own individual stories. And you just learn so much from listening directly to people who have the courage to really share very openly and honestly.

Doximity: Can you tell me a little bit more about that and what you learned from them?

Steve: What you realize is that for a significant number of people, there’s still what some have referred to as gender noise. Imagine you’re going to start on a pubertal blocker — let’s say you are born with testicles, and you have a penis, but you identify as a girl. And you have the relief of knowing that you’re not going to have to go through boy puberty, but you still have a penis, and you feel like — many of these kids hate that, and putting them on a pubertal blocker doesn’t take away the fact that they still have what some people refer to as body dysphoria. But then, even when you get those procedures, what if somebody finds out? Or let’s say you take someone who has gone through male puberty by the time they come in, and they don’t even want to even have what sometimes people call a “real-life experience,” like changing your name or your pronouns or wearing female clothing, because they know they look like a male. Or maybe they start on estrogen, but they’ve gone through male puberty. And maybe they’re thinking, Is someone talking about me? Can they tell that my voice is low? Or when I go into a bathroom to pee, what if someone looks under, and they see that my feet are facing one way and not the way a non-transgender woman’s feet would be facing?

So one of the things that I have learned from listening to these young people and even transgender adults is that it’s not quite so simple. It’s not like, oh yeah, make a determination, start the right treatment program, and like take two aspirin and call me in the morning. No, it’s not like that. There needs to be ongoing support and listening.

Doximity: Those are some great examples. I think those are things that most people just don’t even think about.

Steve: Right. I mean, I was one of those people that didn’t necessarily really think about that in the beginning. Because if you haven’t lived that experience yourself, it’s hard to really know. And so that’s why I think if you want to be of help, you have to figure out the best way to be of help, and that’s to become as knowledgeable as possible and to listen and to work with people who have complementary expertise. You don’t have to feel like you have to know or do everything. That’s why I think a team approach is so important, and that’s why I feel so grateful to be a part of a team.

Doximity: Reflecting upon his career helping to address disparities faced by an oft-neglected community, Dr. Rosenthal shared these words associated with Dr. Martin Luther King Jr.

Steve: The arc of the moral universe is long, but it bends towards justice. So I always like to hold onto that optimism — that yeah, it can take time, but we’re slowly moving in the right direction.

Doximity: A big thank you to Dr. Steve Rosenthal for this interview. Thank you to UCSF and the organizers of the LGBT Health Forum. And thank you for listening to the Doximity Podcast.

Selected Reviews by Dr. Rosenthal

1. Transgender Youth: Current Concepts

  1. Approach to the Patient: Transgender Youth: Endocrine Considerations

Additional Resources

1. Gender Spectrum

  1. The Fenway Institute

  2. UCSF’s Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

  3. The AMA’s Guide to Creating an LGBTQ-friendly Practice

The Op-Med Podcast can be found on Soundcloud and iTunes. Listen to Part 1: “Treat us like you treat anyone else.”

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