Speaker 1: Also media, Hi everyone, and welcomed. It could happen here
Speaker 1: a podcast about things falling apart and the people putting
Speaker 1: them back together. And today Garrison and I are joined
Speaker 1: by Haley and Dan. Both Haley and Dan are gender
Speaker 1: affirming care providers in the Northeast, and they both work
Speaker 1: at federally qualified health centers. Welcome to the show, guys,
Speaker 1: thank you so much in care. Okay, So for people
Speaker 1: who are not familiar, right, maybe they've been fortunate enough
Speaker 1: to have like really good healthcare their whole life, or
Speaker 1: fortunate enough to not live in the United States and
Speaker 1: have this bizarre like web of healthcare provision. Can you
Speaker 1: explain what a federally qualified healthcare center is?
Speaker 2: Sure you mind if I take this with Hailey?
Speaker 3: So I would start by saying that our industry, our
Speaker 3: advocacy arms would riot if they assumed that federally qualified
Speaker 3: health centers weren't good care.
Speaker 4: Right?
Speaker 2: So ye smiths with that to start.
Speaker 1: Oh, yeah, I get yeah, I guess good is a
Speaker 1: relative to Yeah. I've relied on a federally qualified healthcare
Speaker 1: center for a while.
Speaker 2: It was great. They were very nice.
Speaker 1: Actually, my prescriptions cost a lot less now than they
Speaker 1: do with my very expensive eyeigh insurance.
Speaker 2: Yeah.
Speaker 3: So around the nineteen sixties there was the sort of
Speaker 3: free clinic movement that got started, and what grew out
Speaker 3: of that became the federally qualified health center system in
Speaker 3: the United States. So there are roughly sixteen hundred unique
Speaker 3: federally qualified health centers all over the country and we
Speaker 3: as in sort of you know, confederated set of health
Speaker 3: centers all across the country, are responsible for treating those
Speaker 3: most in need in the United States, so the Medicaid population,
Speaker 3: those without insurance. We cannot turn anybody away if you
Speaker 3: do not have insurance, people in rural areas where healthcare
Speaker 3: is very difficult to access and to get, undocumented folks,
Speaker 3: and really everybody in between. At the health center that
Speaker 3: I work at, we mostly treat folks on Medicaid, which
Speaker 3: is pretty typical, although you'll find in states with no
Speaker 3: Medicaid expansion it's a lot more uninsured and less Medicaid.
Speaker 3: But we are the nation's safety net healthcare provider, and
Speaker 3: without us, there are roughly one in ten Americans would
Speaker 3: not get their healthcare.
Speaker 1: Jeez, well, I guess people who are not in the
Speaker 1: United States, do you want to go and give us
Speaker 1: a go one minute speedrun of what Medicaid is medicare Sure.
Speaker 3: So America does not have a nationalized insurance program, as
Speaker 3: we are very frustrated with.
Speaker 2: Most of the time.
Speaker 3: It's mostly commercial insurance that you mostly get through your job.
Speaker 3: But if you are not fortunate it's not the right word,
Speaker 3: but if you're not fortunate enough to get that. Medicaid
Speaker 3: is the system that gives health insurance to people who
Speaker 3: are living at or below the federal poverty line. With
Speaker 3: the Affordable Care Act or the ACABAMBACARE, that level raised
Speaker 3: a little bit, so you could still get Medicaid if
Speaker 3: you were at above the federal poverty line.
Speaker 2: But this is mostly for the working poor. That's who
Speaker 2: gets Medicaid.
Speaker 4: Cool.
Speaker 1: Yeah, it's a great system. Let's talk about how this
Speaker 1: is funded them And you said the US doesn't have
Speaker 1: like a single pair healthcare system. So how are these
Speaker 1: healthcare centers funded right now? Or maybe how were they
Speaker 1: funded like six weeks ago.
Speaker 3: Yeah, So most of the work that we do is
Speaker 3: fee for service. We're not a lot different than a
Speaker 3: lot of other places in that regard. Right, if you
Speaker 3: have Medicaid patients, we are a fee for Service program.
Speaker 3: We give provision of care to them on a per
Speaker 3: visit basis, same as anywhere else in the country and
Speaker 3: how that works, and we get reimbursed for it. What
Speaker 3: makes FQS different than everywhere else is two things. One,
Speaker 3: we get a special rate that is designated because of
Speaker 3: our willingness to take on these more expensive, more complicated
Speaker 3: patients and to ensure they are healthy enough to keep
Speaker 3: out of expensive.
Speaker 2: Systems of care like emergency rooms and things of that nature.
Speaker 4: Yeah.
Speaker 3: And two is that we have a grant called the
Speaker 3: FED three thirty And this is a sort of like large,
Speaker 3: sort of use it as you need to grant that
Speaker 3: depending on the agency, is anywhere from five to twenty
Speaker 3: five percent of your total annual funds and is to
Speaker 3: cover all of the folks who can afford care and
Speaker 3: are uninshort.
Speaker 4: Part of my funding also, I do a lot of
Speaker 4: work with HIV and HIV prevention, so a lot of
Speaker 4: my work is done via Ryan White funding, and there's
Speaker 4: some other kind of separate funding streams that's applicable specifically
Speaker 4: to gender firming care. However, it's all kind of messy
Speaker 4: and tied up in a lot of those other funding
Speaker 4: streams that Dan mentioned, and there's some specific limitations because
Speaker 4: of those funding streams again historically because who knows right now,
Speaker 4: but through something called the High Amendment, it means that
Speaker 4: our funding would be at jeoparty if we provided abortion care.
Speaker 4: So there are some kind of limitations. A lot of
Speaker 4: what we do as an FQT is providing really comprehensive,
Speaker 4: expansive care. We're kind of some of the few clinics
Speaker 4: that do everything that we do under one roof, but
Speaker 4: there have been some limitations specifically abortion to that.
Speaker 1: Yeah, it's more of a healthcare experience. So I'm used
Speaker 1: to with someone from Europe like going to one of
Speaker 1: these centers and like the American one where you get
Speaker 1: referral and then yeah, get it approved and blah blah blah,
Speaker 1: and like a lot.
Speaker 4: Of the ways that I talk to friends who live
Speaker 4: in other countries, Like, I feel like my role is
Speaker 4: kind of more similar to like a GP as a
Speaker 4: nurse partitioner. There isn't necessarily an equivalent, but I feel
Speaker 4: like a GP is kind of a very similar universal
Speaker 4: way to understand a lot of what I do.
Speaker 1: Yeah, that makes sense. So can you explain Ryan White funding?
Speaker 1: Like where does that come from? Why is it called
Speaker 1: Ryan White?
Speaker 4: So basically, Ryan White Funding was initiated in I believe
Speaker 4: the early nineties during the AIDS crisis and was a
Speaker 4: large government initiative. It's named after Ryan White, who was
Speaker 4: a patient who contracted HIV through a blood transfusion. Yeah,
Speaker 4: so Ryan White funding right now is a major source
Speaker 4: for funding things like PREP, which is medication for prevention
Speaker 4: for HAV as well as direct HIV treatment.
Speaker 1: Yeah, so a number of these things, right, gender affirming care,
Speaker 1: perhaps care for people with HIV or preventing people from
Speaker 1: getting HIV through pre exposure prophylaxis. Like you said, like
Speaker 1: these are things that have been like like at the
Speaker 1: center of the culture war for the current government, right,
Speaker 1: like that they're like the things that they point to
Speaker 1: is you know whatever they're sort of like Impacton's impacts
Speaker 1: in Sunstruction of Fascist and he talks about moral decline, right,
Speaker 1: and this is their moral decline that this is what
Speaker 1: they use when they're constructing their kind of we will
Speaker 1: save you narrative. What does that mean for funding? And
Speaker 1: like what does that mean more importantly for your patients
Speaker 1: of people who come to you for these different types
Speaker 1: of care I mean, I.
Speaker 4: Think it's terrifying. I think I'm more on the fusion
Speaker 4: facing side. So a lot of the conversations I've been
Speaker 4: having are just about the uncertainty. I'm a prescriber for
Speaker 4: a lot of tras, youth adolescents and young adults, and
Speaker 4: so moreover, the uncertainty of just being able to get
Speaker 4: their medication. The stress of being publicly named and targeted
Speaker 4: in this culture war has just created a climate of fear.
Speaker 4: As my job, I want to be able to reassure
Speaker 4: patients that I am going to fight for them and
Speaker 4: do all that I can. But it's really scary. As
Speaker 4: Dan mentioned, a lot of our patients don't have financial
Speaker 4: safety net, they don't have a medical safety net. We're
Speaker 4: really the one option for them, and if our clinic
Speaker 4: does not continue to offer this type of care, these
Speaker 4: are our kids who are going to go without hormones.
Speaker 4: I prescribe puberty blockers. My work as a gender forming
Speaker 4: care provider isn't just blockers and hormones, but those are
Speaker 4: medications that we know are life saving. We know that
Speaker 4: that unfortunately, kids will suicide if they don't have access
Speaker 4: to those mendications, and so I think you know, talking
Speaker 4: about funding, talking about kind of these bigger shifts politically,
Speaker 4: you know, are sayings that unfortunately a lot of the
Speaker 4: conversations I'm having are really coming just down to safety
Speaker 4: and safety planning and figuring out support networks and talking
Speaker 4: about creative ways to get hormones if if we can't
Speaker 4: prescribe them.
Speaker 3: Yeah, I think it's worth talking about the fact that,
Speaker 3: like there are there are so many angles of attack
Speaker 3: on this right, there is the one that is just
Speaker 3: very clearly aimed at trans kids, right, the EO that
Speaker 3: specifies like protecting children it's nonsense, but that is aimed
Speaker 3: at ending this care everywhere.
Speaker 4: Yeah.
Speaker 3: Now are they going to be able to do it everywhere?
Speaker 2: I don't know. Maybe, but not quickly.
Speaker 3: But they can end it for FQHCs all across the
Speaker 3: country by simply making it like the High Amendment. If
Speaker 3: we were to perform abortion services at the place that
Speaker 3: I work, then we would lose our three thirty funding
Speaker 3: and we would lose our a FQ designation, which would
Speaker 3: cut our rate in half, and that would devastate the
Speaker 3: business and put us out and mean that we could
Speaker 3: not care for the thousands and thousands and thousands of
Speaker 3: other people that we care for besides those kids. Right,
Speaker 3: then there are also the just the doge fuckery that
Speaker 3: is going to harm all of this and may create
Speaker 3: a lot of the same outcomes, right, which is they
Speaker 3: turned off grants kind of just across the board. Yes,
Speaker 3: some of them were targeted on things like gender affirming,
Speaker 3: most of them were just like it's a grant, we're
Speaker 3: turning it off. And then there was the tro but
Speaker 3: much of that funding has remained frozen. We have been
Speaker 3: told that the system is up and running and that
Speaker 3: they undid what they did, and the courts stepped in,
Speaker 3: and oh don't we have the courts still here in
Speaker 3: the United States. Isn't that a good thing? But they
Speaker 3: just kept the funding off. Whether because they're incompetent or
Speaker 3: because they're actively defying the law doesn't really matter. And
Speaker 3: as a result, federally qualified health centers all across the
Speaker 3: country have laid people off, They have closed clinics and
Speaker 3: have entirely gone underwater in some cases. And then those
Speaker 3: people are not there to treat the community that needs
Speaker 3: them so badly. And all of these systems are grounded
Speaker 3: in their communities. So when you lose you know the
Speaker 3: clinic that's in LA that had to close its doors
Speaker 3: for the office that's on one side of town. The
Speaker 3: people there knew that place. It was part of their community,
Speaker 3: part of their existence. It was grounded in that community
Speaker 3: and its community's needs. And that's just gone. And this
Speaker 3: puts us in the very difficult position, and you know,
Speaker 3: leadership in the very difficult position of figuring out, well,
Speaker 3: do I worry about these trans youth and the fact
Speaker 3: that they might kill themselves, or do I worry about
Speaker 3: the impact that standing up on principle and saying I
Speaker 3: won't toss them to the wolves might have on the
Speaker 3: rest of the system. And it becomes a very difficult
Speaker 3: sort of situation for us as providers to navigate. But
Speaker 3: you know, in fairness to leadership, which I disagree with
Speaker 3: for them too.
Speaker 2: Yeah, that's tough.
Speaker 1: Can you briefly explain that, maybe lay out a timeline
Speaker 1: because we talked about executive order, Say we talked about
Speaker 1: a tro like there was a large dumber of executive
Speaker 1: orders right in the last three weeks, so like maybe
Speaker 1: people miss them. Can you explain the pertinent executive orders?
Speaker 1: And then what's a tentative?
Speaker 2: Is training order. Yeah.
Speaker 3: So on Trump's first day in office, on the day
Speaker 3: of his inauguration, so January twentieth, he signs one hundred
Speaker 3: some odd executive orders. The ones that are particularly of
Speaker 3: interest to us in healthcare were protecting children against chemical
Speaker 3: and surgical mutilation is the name of it, which is
Speaker 3: a disgusting and vile name. Yeah, and then protecting women
Speaker 3: something something something defending women, Yeah, defending women, which is
Speaker 3: similarly aimed at transgender individuals and I think will be
Speaker 3: used after we are under attack for trans youth, to
Speaker 3: come after trans adults in federally qualified health centers as well.
Speaker 3: Those eos led to Later that week, on Friday, we
Speaker 3: got emails to every PI which is principal investor gator
Speaker 3: on every federal grant that we had. That said because
Speaker 3: of those two, and there was one about DEI which
Speaker 3: also in executive order, you are not allowed to use
Speaker 3: any of these grant dollars in service of anything in
Speaker 3: defiance of these three executive orders. So that was the
Speaker 3: first shot we got, and it came only four days later.
Speaker 3: It's threatening, but it wasn't specific right, It didn't specifically
Speaker 3: say we're going to do X, Y or Z but
Speaker 3: it was here's a threat. The following Tuesday, dog is
Speaker 3: let loose and announces that they are freezing federal grant
Speaker 3: funding tied to anything that is in opposition to those things.
Speaker 2: If you actually looked at.
Speaker 3: The excel file that they released with the actual grants,
Speaker 3: it froze everything. Like it was not just the stuff
Speaker 3: that they felt was in opposition to this, it was
Speaker 3: like everything. We have a ton of grants that were
Speaker 3: on that list at the agency that I work at,
Speaker 3: and boy, oh boy, oh boy, was there a lot
Speaker 3: of panic going around. Wednesday rolls around and they get
Speaker 3: a judge come in and sort of put a halt
Speaker 3: on it. And then later that day a press secretary says, oh,
Speaker 3: we're just going to send the memo. We're still going
Speaker 3: to freeze everything, and then the judge comes back and
Speaker 3: puts a temporary straining order. So in theory, what that
Speaker 3: should have meant is that all of that grant funding
Speaker 3: once again flows. And it did not importantly too for us,
Speaker 3: given how much medicaid dollars we take in Medicaid portals,
Speaker 3: and all fifty states went down, so we could not
Speaker 3: get any of those dollars in service of what we
Speaker 3: were doing for twelve hours, but still it was this
Speaker 3: very concerning situation because medicaid was not on their list
Speaker 3: of things that they were after, and yet we couldn't
Speaker 3: even access it on the state level.
Speaker 2: A few more weeks.
Speaker 3: Go by and there's news popping about, Hey, you said
Speaker 3: you unfroze stuff, but it's still frozen. Another judge issued
Speaker 3: an order saying that, like, no, for real, I meet
Speaker 3: at this time unfreeze everything. I know some of the
Speaker 3: grants that we had that we couldn't access seem to
Speaker 3: have come back online, but I don't know, you know,
Speaker 3: I think it would be an impossible thing to do
Speaker 3: an accounting of like every single one that might have
Speaker 3: been turned off that might might or might not be
Speaker 3: back on right now. But I am doubtful that at
Speaker 3: this point every single grant across the federal agency is
Speaker 3: potentially available for folks.
Speaker 2: Just seems unlikely to me.
Speaker 1: Yeah, we should pivot to advertisements here, So I'm going
Speaker 1: to do that and then we'll.
Speaker 2: Be right back. Okay, we are back.
Speaker 1: So you talked about like these grants being turned off
Speaker 1: or not coming.
Speaker 2: What does that mean?
Speaker 1: Does that mean people don't get care? Does that mean
Speaker 1: providers don't get paid, does that mean they can't access
Speaker 1: their prescriptions? Like, what does it look like if I'm
Speaker 1: trying to access care through one of your clinics.
Speaker 4: So yeah, I'll speak to that a little bit on
Speaker 4: the prescriber side, because I think, you know, having direct
Speaker 4: contact with someone who works into the administration is really
Speaker 4: the only way that I I have really been able
Speaker 4: to get any updates. So as a healthcare provider, it's
Speaker 4: been out or chaos. Basically every day we've gotten different
Speaker 4: messaging around whether or not appointments can be scheduled, new patients,
Speaker 4: can you know, schedule intakes, whether or not we're able
Speaker 4: to prescribe these life saving medications, and no one knows exactly.
Speaker 4: Gender firming care is basically healthcare. There's nothing that separates it.
Speaker 4: There's no hard line, there's no clear distinction. It is
Speaker 4: medically indicated, evidence based care. So saying you can't do
Speaker 4: gender firming care, it literally doesn't make any sense in
Speaker 4: terms of you know, what we do as prescribers. And
Speaker 4: on my end, I've been faced with intimidation, I've been
Speaker 4: faced with kind of whisper networks of misinformation coming from
Speaker 4: administration trying to get us to stop prescribing because they
Speaker 4: do see this type of care as a liability. I'm
Speaker 4: still prescribing. There is no state law in the state
Speaker 4: that I am in that prevents my ability to act
Speaker 4: as to the full extent of my scope. There are
Speaker 4: also no medical indications for me to stop prescribing, and
Speaker 4: I'm ethically bound as a nurse practitioner to do what
Speaker 4: I believe is best for my patients, which is to
Speaker 4: continue to provide them with a care that they need.
Speaker 4: But it's terrifying.
Speaker 3: I think importantly, Haley and I have the eventage of
Speaker 3: working for a more economically stable institution. There's a lot
Speaker 3: of health clinics out there that have a week's worth
Speaker 3: of working capital, right, so if all of a sudden
Speaker 3: they lose access to every grant dollar, it lose access
Speaker 3: to their three thirty. They were scheduled to draw down
Speaker 3: on a grant that was going to cover a whole
Speaker 3: bunch of upcoming expenses, but they haven't done it yet,
Speaker 3: and then they can't, Like in very real ways, that
Speaker 3: may mean that the doors are closed and the place
Speaker 3: goes under and that no one can get care there.
Speaker 3: And there is this real challenge of you know, how
Speaker 3: do we decide what is the best thing to do.
Speaker 3: But for me and what sort of started working with
Speaker 3: in our agency at least to organize around this is
Speaker 3: that like, this is an anti fascist practice. That is
Speaker 3: the right medical thing to do, It is the right
Speaker 3: ethical thing to do, But it is also our chance
Speaker 3: to take an anti fascist stance against this government because
Speaker 3: if we don't stand now for the very first group
Speaker 3: they're coming for, then the next group, which is without
Speaker 3: question trans adults and undocumented people, then those groups will
Speaker 3: fall just as quickly. And then at some point we're
Speaker 3: doing the poem the first they came for, the socialist thing,
Speaker 3: and I just refused to be a part of that.
Speaker 1: Yeah, let's talk about what that means then, Like, like
Speaker 1: you said, it's difficult to get any response from administration
Speaker 1: right in terms of what you can do, in terms
Speaker 1: what you can't do. How are staff and providers organizing
Speaker 1: to make sure that they're able to keep providing for
Speaker 1: their patients?
Speaker 4: So just to provide also like a little bit of
Speaker 4: a peek into kind of the broader landscape of this.
Speaker 4: Our clinic is not alone in their confusion on how
Speaker 4: they've been handling this not only FQHCs, but also hospital
Speaker 4: affiliated clinics, academic medical clinics have basically clinic by clinic
Speaker 4: decided on their own plan on how to manage this,
Speaker 4: which is also incredibly confusing for providers and for patients.
Speaker 4: But something that was really heartening was that NYU laying gone.
Speaker 4: This was in the news recently. They canceled appointments for
Speaker 4: two kids, literally just two kids, which is more than enough,
Speaker 4: and it sparked this enormous outcry and protests. And so
Speaker 4: I think there's also, on my end, a lot of
Speaker 4: solidarity building with other providers who are doing this work,
Speaker 4: and a lot of inspiration. There are clinics out there,
Speaker 4: some who are FQHCs like us, who have stood firm
Speaker 4: and they've said our doors are going to stay open,
Speaker 4: We're going to keep providing this care, and so I
Speaker 4: think they're there are models out there, and I think
Speaker 4: that there are networks of healthcare providers who are committed
Speaker 4: to continue to advocate and just continue to do this
Speaker 4: right because a lot of what we're facing right now
Speaker 4: is intimidation. It's not actual legal threats.
Speaker 2: As of yet.
Speaker 3: Yeah, I think the organizing side has been challenging but
Speaker 3: also hugely rewarding. Right, it became really obvious really early
Speaker 3: on that both from the federal government's perspective as well
Speaker 3: as from our organization's perspective, that the uncertainty was where
Speaker 3: they wanted us all to live and die. That was
Speaker 3: the place that served them and their goals the most.
Speaker 3: And so how does uncertainty sort of foster Well, people
Speaker 3: don't talk to one another, right, Like this is true,
Speaker 3: kind of an organizational census across the board. Right, if
Speaker 3: you're in the union, you don't talk about your salary
Speaker 3: doesn't benefit you, it benefits the boss. And so if
Speaker 3: we're not talking to one another about where our lines are,
Speaker 3: who we're going to treat, whether we're going to keep
Speaker 3: doing it, or listen to them what we're being told,
Speaker 3: we're not being told that we're consulting lawyers all these
Speaker 3: other kind of things, then we're all just alone in
Speaker 3: the dark kind of you know, trying not to scream
Speaker 3: and cry about the horrors that are happening around us.
Speaker 3: So we pulled together folks with conversation here, conversation there.
Speaker 3: Folks who before anything was going on internally, you know,
Speaker 3: made really bold statements about what they would and would
Speaker 3: not do around this kind of stuff, And now all
Speaker 3: of a sudden, there's an internal network that's looking at well, Okay,
Speaker 3: So individually we can keep doing this care because it's
Speaker 3: the right thing to do. But as a group, if
Speaker 3: they start coming after us, we have a lot more power.
Speaker 3: There's a lot more that we can do. And I suspect,
Speaker 3: and you know, Hayley's getting at this point that like,
Speaker 3: there are probably a network of us across the entire
Speaker 3: country in these kind of settings that are not talking
Speaker 3: amongst ourselves at our workplace, but are really not talking
Speaker 3: about it amongst.
Speaker 2: Ourselves on a national level.
Speaker 3: And I think we have some power that could be
Speaker 3: used there to really make a difference in all of this.
Speaker 3: And I am optimistic that if we talk about this,
Speaker 3: we get to out there, we make sure everyone's communicating
Speaker 3: openly about it, that there's a real possibility that we
Speaker 3: can work together to prevent this from being the first
Speaker 3: of many dominoes to fall.
Speaker 4: And one thing that's interesting, I think is that with transhealthcare,
Speaker 4: transhelscare is inherently radical, Like transhalscare is not something that
Speaker 4: came from the kind of medical hierarchy. This is by
Speaker 4: and large a field that was communal trans people were
Speaker 4: doing their own trans healthcare before it became kind of
Speaker 4: institutionalized into a lot of these spaces. So I think
Speaker 4: we also have a lot of providers who are willing
Speaker 4: to function up right. Like the community and the providers
Speaker 4: are intertwined, and I do think there is a real
Speaker 4: kind of radical bent to this type of work, which
Speaker 4: is why I think a lot of us have been
Speaker 4: so easily able to collectivize and strategize and kind of
Speaker 4: come together. It's a pretty small.
Speaker 2: World as well.
Speaker 3: We sat down on a call and talked about, you know,
Speaker 3: what are we going to do? And I made mention
Speaker 3: that like, oh, through my other organizing work, I've got
Speaker 3: a DIY connection for us to dial. So that's a
Speaker 3: huge thing that will help us if we can't prescribe
Speaker 3: this anymore, if Medicaid stops covering it, yah, YadA, YadA.
Speaker 2: I was like, but I don't have a you know,
Speaker 2: a DIY solution for TEA.
Speaker 3: If anyone knows of anybody, that'd be great, And immediately
Speaker 3: someone's like, oh, yeah, absolutely, I do.
Speaker 2: It's tested.
Speaker 3: It's a ninety nine point nine percent pure we're ready
Speaker 3: to go.
Speaker 2: So now, like I wouldn't have done that.
Speaker 3: There was no way for us to know that that
Speaker 3: was the kind of radical work that people were doing
Speaker 3: if not for coming together on this kind of stuff.
Speaker 1: Yeah, maybe we should explain like the inherent risks, like
Speaker 1: legally and then then distinction between those two hormones legally, right,
Speaker 1: like if people are unaware.
Speaker 4: Yeah, so you know, as a medical provider again, I
Speaker 4: have to be a little bit careful here. But basically
Speaker 4: because the stone has been used by mostly the cistmail
Speaker 4: community as an anabolic steroid and used you know somewhat
Speaker 4: would call it like animalic steroid misuse or steried use disorder.
Speaker 4: It is a controlled substance. Estradial is not. They're both
Speaker 4: bioidentical hormones. Every human on this planet, their body makes
Speaker 4: estrogen and testosterone E and T estradyle and testosterone. However,
Speaker 4: in the United States, testosterone is considered a controlled substance,
Speaker 4: which makes it a little more tricky for folks to
Speaker 4: access without a prescription and also can put them at
Speaker 4: legal risk if they do so.
Speaker 1: Right, Like, there's a built in legal consequence for people
Speaker 1: who are trying to manufacture there or who are trying
Speaker 1: to obtain it like outside of the sort of prescription system,
Speaker 1: not that there aren't other probably legal threats coming down
Speaker 1: the pipeline, I guess.
Speaker 5: Also, testosterone is yes, it is a controlled substance. It
Speaker 5: does flow in the bodybuilding community.
Speaker 1: Yeah, it's not well controlled.
Speaker 5: Yeah, that is also like worth stating because yeah, so
Speaker 5: if you go to your average gym.
Speaker 1: Oh yeah, you can walk across the borders to Tijuana
Speaker 1: and see like gas stations have the prices like unleaded premium. Yeah,
Speaker 1: you can get testosterone prices like displayed in the same fashion.
Speaker 4: I mean, I'm sure you're you're huge fans of Joe Rogan.
Speaker 4: So many many of my other patients who are not
Speaker 4: trans have been influenced to purchase disasterone because of our
Speaker 4: good friends.
Speaker 1: Yeah, yeah, fascinating.
Speaker 3: Which is also gender affirming care for whatever that's worth,
Speaker 3: like gender firm in care too.
Speaker 1: Yes they do. It's a little easier for them. Right now,
Speaker 1: So let's talk about like what this organizing looks like
Speaker 1: on the ground, right, Like if someone's working, maybe they're
Speaker 1: not in an f QHC, right, maybe they're working in
Speaker 1: academic health center. Maybe they're working you know, in one
Speaker 1: of the many other places where you can access gender
Speaker 1: affirming care in this country, and they are feeling like
Speaker 1: alone or they're scared, and they're not receiving any affirmation
Speaker 1: or help from their management, and they don't know who
Speaker 1: they can talk to among their colleagues. Like how are
Speaker 1: people connecting? Like what are people talking about? And like
Speaker 1: how can people who are because you know, the healthcare
Speaker 1: system is vast in this country because it duplicates itself
Speaker 1: because's the nature of American privatized healthcare. Like, how can
Speaker 1: people who want to continue providing care for patients do that?
Speaker 1: How do they organize their colleagues? How do they contac
Speaker 1: people who are already organizing, Like, let's talk through that
Speaker 1: nuts and bolts of it.
Speaker 4: I mean, I think there's a lot of national orgs
Speaker 4: out there that are really doing the work. So if
Speaker 4: you're a medical provider, I would highly recommend to join Glamour,
Speaker 4: which is a gain lesbian medical association, because they have
Speaker 4: some lawsuits and as a member of GLAMMA.
Speaker 2: That could possibly give you some additional protection.
Speaker 4: Following other orgs like Lambda Legal Stage, which is an
Speaker 4: organization for an elder gay lesbian and queer folks. Trans
Speaker 4: people have existed and have built organizations. A lot of
Speaker 4: those organizations are fighting this on a national level, and
Speaker 4: some of those are more geared toward healthcare professionals like Glamma.
Speaker 3: I would say, there's two conversations that we all need
Speaker 3: to be having. Like those external organizations are huge and
Speaker 3: necessary for direction within your own space, you have to
Speaker 3: talk to your colleagues in a way that's honest and
Speaker 3: talk to them about risk taking. Talk to them about
Speaker 3: where you will and will not budge on some of
Speaker 3: these kind of things. Talk to them about the value
Speaker 3: of the work that you all do, because there's more
Speaker 3: of you doing it. Talk to your trans colleagues. They exist,
Speaker 3: they're out there like they have very strong opinions on this,
Speaker 3: I am sure. And then talk to a lawyer. Talk
Speaker 3: to an employment lawyer, because your corporate attorneys have very
Speaker 3: different goals than you do. Their goal is simply to
Speaker 3: protect the company and its bottom line, and both they
Speaker 3: and the federal government and the sort of DOJ are
Speaker 3: spewing absolute bullshit. So don't let them flood the zone
Speaker 3: with nonsense. Get a lawyer who can tell you what's nonsense,
Speaker 3: and stand firmly in that because it is. And then
Speaker 3: when you start thinking about as an organization, as a group,
Speaker 3: as a set of employees communicating with you know, leadership
Speaker 3: about these kind of things, know that the law is
Speaker 3: actually not on their side, it's on yours, and let
Speaker 3: them know that they are exposing themselves to vulnerability for
Speaker 3: malpractice and for civil rights violations and any number of
Speaker 3: other things that they probably don't want to be on
Speaker 3: the hook for. This is the leverage that we've got
Speaker 3: right now. It seems to have slid things down a
Speaker 3: little a little bit internally for us that they've had to
Speaker 3: confront like a very well pointed out legal opinion that
Speaker 3: said that like they were exposing their providers to civil
Speaker 3: lawsuits if they didn't do this, and that the FDCA,
Speaker 3: the Federal Tort Claims Act, didn't protect people under these guides.
Speaker 3: That has been really beneficial to us. The other thing
Speaker 3: I would say is like there's a real union sort
Speaker 3: of feel to a lot of this, And as we
Speaker 3: started coming together, a bunch of us realize, well, we
Speaker 3: all kind of had union conversations somewhere along the way,
Speaker 3: but corporate unions and like SEIU represents a lot of
Speaker 3: like individual sort of arms of companies like the ones
Speaker 3: that we work at. They aren't interested in the politics
Speaker 3: of the work you do. They are interested in your benefits,
Speaker 3: they are interested in you as a worker, but they're
Speaker 3: not interested in like your relationship to the work. And
Speaker 3: so we are approaching this not necessarily as a union,
Speaker 3: but from the perspective that if we need to strike
Speaker 3: on behalf of patients and their access to care, that's
Speaker 3: a tool in our toolblocks, and we don't have to
Speaker 3: do anything more than declare it to strike to be
Speaker 3: protected under the NLRB and some of these various different things.
Speaker 3: And we can do it for political reasons instead of
Speaker 3: for pay reasons, which means we could do it as
Speaker 3: a diverse group instead of as all the nurses, all
Speaker 3: the advanced practice providers, all of the psychologists and therapists
Speaker 3: and lcsws, where they break us apart by discipline instead
Speaker 3: of by.
Speaker 2: You know what sort of managerial status you are.
Speaker 1: Yeah, yeah, I think that's a very good point. I
Speaker 1: read a book recently about how the long shoremen in
Speaker 1: San Francisco stopped weapons going to the gil by striking
Speaker 1: and refusing to load weapons onto ships and like that's
Speaker 1: a union energy we could use right now. Yeah, yeah,
Speaker 1: I think people be well advised to, Like I will
Speaker 1: say that they'd be well advised to check with federal
Speaker 1: and local law because like some state legal landscapes can
Speaker 1: be very different. Right. I want to end with like,
Speaker 1: people are probably afraid of accessing care, right, Like people
Speaker 1: are probably afraid of going to see their providers, like understandably,
Speaker 1: like you said before, like especially kids or people under
Speaker 1: eighteen are like right in the center. The President of
Speaker 1: the United States called out a friend of mine personally
Speaker 1: by name recently. She's a trans athlete, and like they're
Speaker 1: really coming up to people. I understand that people are afraid,
Speaker 1: Like what should they know if they're concerned about their
Speaker 1: hormone supply or they're own puberty blockers? Right now, like
Speaker 1: people are listening, what would you Maybe they don't know
Speaker 1: where their provider stands, you know, Yeah.
Speaker 4: I mean I tell my patients, says, But I'm in
Speaker 4: awe of them. They're incredible. And a lot of them
Speaker 4: are nerdy theater kids who love cats and they want
Speaker 4: to just exist. And some of them are also incredible
Speaker 4: outspoken activists. They are just amazing, And I will fight
Speaker 4: with everything that I've got for them, and I really
Speaker 4: hope they know that.
Speaker 3: I think one of the mantras I've been given to
Speaker 3: fellow colleagues as well as to our leadershift to like
Speaker 3: get their heads on straight, is that like pascism is messy, right,
Speaker 3: Like it's a scary messy. There are a lot of
Speaker 3: throwing stuff with the law on sea and what sticks,
Speaker 3: but the things that in theory are still in place,
Speaker 3: like when and if they fall, we have different problems
Speaker 3: than the ones we're facing now. Right, So we still
Speaker 3: have in this country protections for your healthcare information. So
Speaker 3: if what you worry about in going to the doctor
Speaker 3: is that someone will find out that your trends and
Speaker 3: put you on a list, like, I can't tell you
Speaker 3: that's never going to happen, but I can tell you
Speaker 3: that if it happens through your healthcare clinic, Like, we
Speaker 3: have significantly changed the threat model that we're all living
Speaker 3: in because HIPPA doesn't matter anymore and doesn't exist. Your
Speaker 3: providers are spending enormous amounts of time thinking carefully about
Speaker 3: how they document, where they document, how much of a
Speaker 3: deal they want to make it, whether or not they
Speaker 3: can change the thing they're prescribing for you and what
Speaker 3: diagnosis is for We are finding ways to sort of
Speaker 3: throw as much cover and shade and you know, camouflage
Speaker 3: over this as we can. But you shouldn't not come
Speaker 3: get care. Your life matters. You being in the body
Speaker 3: that you were meant to have matters. Come talk to us,
Speaker 3: come ask for help. We're here to do it, and
Speaker 3: we're not going to stop until they make us. And
Speaker 3: right now they can't make us, and so we're going to.
Speaker 2: Keep doing it.
Speaker 4: And I think the mantra of trans people have always existed.
Speaker 4: Trans people exist, and personally, I'm going to do my
Speaker 4: best to make sure that for every single one of
Speaker 4: my patients that they continue to get what they need.
Speaker 4: However that looks like.
Speaker 5: Then it is good to hear. I know a lot
Speaker 5: of trans people have essentially trauma with aspects of the
Speaker 5: medical community, establishment, whatever, and like you know, not not
Speaker 5: all practitioners, maybe as much in our camp as maybe
Speaker 5: you are. And I would encourage people as they are
Speaker 5: if they're still looking for care through like these these
Speaker 5: sorts of channels, you should you should try to find
Speaker 5: out where other trans people in your city are already going. Yes,
Speaker 5: there's certainly like clinics will have stuff on the website
Speaker 5: that indicate that they either specialize in this or they
Speaker 5: offer this as opposed to you know, maybe just a
Speaker 5: general general practitioner who may not be you know, the
Speaker 5: greatest in this vein, and like this, this still happens.
Speaker 5: I've I've talked to a lot of friends recently who've
Speaker 5: spoken about having increasingly uncomfortable experiences with nurses or doctors
Speaker 5: where they're trying out like different clinics or different or
Speaker 5: different providers, university providers. So it is definitely worth doing
Speaker 5: some research beforehand so you know the place you're going
Speaker 5: is going to be like with you. Which is just
Speaker 5: an unfortunate reality of being trands. But that is that
Speaker 5: has been the case for for a long time and
Speaker 5: it only continues to be a factor when when considering care.
Speaker 3: Absolutely it's really important to ask ask your friends that
Speaker 3: that's that's really solid advice, in part because whether I
Speaker 3: like it or not, a lot of organizations are taking
Speaker 3: the stuff that says, hey we treat trans people down
Speaker 3: off their website, off their marketing materials.
Speaker 2: We are not trying to draw that attention.
Speaker 3: It doesn't mean we don't do it doesn't mean we're
Speaker 3: not skilled and trained and educated and smart and passionate
Speaker 3: about it.
Speaker 2: It just means we.
Speaker 3: Don't really want to totally fly a trans flag on
Speaker 3: the roof right now because it's just going to cause
Speaker 3: everybody harm. So talk to your friends, talk to people
Speaker 3: in your community. They know us, we know them. I
Speaker 3: have a lot of activism experience outside of my work,
Speaker 3: and it's amazing how many of those people end up
Speaker 3: being the same people that are in this conversation because
Speaker 3: of the way that this all works.
Speaker 2: Yeah.
Speaker 4: Yeah, I was just going to say, I think, unfortunately,
Speaker 4: it is the norm, and evidence shows that, like large
Speaker 4: evidence of studies show that trans people are treated pretty
Speaker 4: horribly by the healthcare system, and most of my patients
Speaker 4: have experienced that in some way or another. But like
Speaker 4: I was talking about before, a lot of trans healthcare
Speaker 4: kind of comes from a DIY community, and there's a
Speaker 4: lot of really good community information about, you know, kind
Speaker 4: of who to trust and who you can go to
Speaker 4: in terms of finding an allied provider.
Speaker 1: Yeah, yeah, I think that's really good.
Speaker 2: I think that was really great.
Speaker 4: Guy.
Speaker 1: Thank you so much for your time and for your
Speaker 1: words for people is there anything else you want to share,
Speaker 1: or perhaps if people want to support your efforts somehow
Speaker 1: or support people's access to care, there's an organization you
Speaker 1: could direct them to, or maybe like the way people
Speaker 1: coming shout out to you, or I know a lot
Speaker 1: of people. There are people in my family who are
Speaker 1: healthcare providers who have substantially changed their outlook on the
Speaker 1: world and politics by how terribly their trans patients have
Speaker 1: been treated. So like, if you know, like some of
Speaker 1: us have been organizing for a minute, some of us
Speaker 1: have been organizing for like literally a minute, and like
Speaker 1: how do those people access these networks? Like how can
Speaker 1: people who are not in healthcare support you and what
Speaker 1: you're doing and reach out.
Speaker 4: The gender liberation movement is incredible. They're doing a lot
Speaker 4: of work, kind of public feasing to really get point
Speaker 4: across on why this is so essential and also why
Speaker 4: everybody should have the right to their own bodily and
Speaker 4: gender autonomy. I think I mentioned earlier, but Lama, if
Speaker 4: you're on the healthcare side, and you know there are
Speaker 4: also kind of if you're in an academic setting looking
Speaker 4: to wpass the World Professional Association for Transgender Health, kind
Speaker 4: of going to the experts in this field and really
Speaker 4: following and mirroring what they're doing.
Speaker 3: I think if you're looking as a SIS person who
Speaker 3: gets your care somewhere that might get federal funding, but
Speaker 3: this is the thing that you care about, would encourage
Speaker 3: you to sort of make people get on record about
Speaker 3: this kind of stuff, right, It's been the most distasteful
Speaker 3: piece of all of this is the kind of like
Speaker 3: weasel hiding in all of this.
Speaker 2: So force them on the record. Ask them.
Speaker 3: If they don't tell you, send them an email. If
Speaker 3: they don't know, respond to the email, send a follow
Speaker 3: up email, Like make people we'll get on the record
Speaker 3: about this so that we know where their values are
Speaker 3: and if their values don't align with yours, take your
Speaker 3: business elsewhere, because at the end of the day, healthcare
Speaker 3: is a business because the United States sucks, and so
Speaker 3: we have to use those dollars in the ways that
Speaker 3: we can, and it matters in a lot of ways.
Speaker 3: I don't know that anyone will care to and I
Speaker 3: certainly don't want to present us as the people with
Speaker 3: all the answers here because we just like are figuring
Speaker 3: this as we go to But you can email us
Speaker 3: at Community Health Resistance at proton dot me and maybe
Speaker 3: let's have a conversation. Maybe there's like a ton of
Speaker 3: people in the FQ world who want to do like
Speaker 3: an Amazon or a Starbucks like diy union project where
Speaker 3: we're all working on this together for the politics rather
Speaker 3: than the pay as the primary sort of reason for it.
Speaker 2: Let's let's let's be a red union and get something going.
Speaker 2: I don't know that we can.
Speaker 3: I don't know that it's the right call, but I
Speaker 3: imagine there's more of us out there feeling this way
Speaker 3: than not.
Speaker 1: So yeah, and like whatever it is, we're stronger together
Speaker 1: than we are apart, So like talking is how we
Speaker 1: fix this. Thank you so much, guys, I really appreciate
Speaker 1: you being so open about this. And yeah, I hope
Speaker 1: that you succeed. You'll be able to keep taking care
Speaker 1: of people.
Speaker 2: We hope so too.
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