Gender Identity, Medicine & Transitioning

By The Sex Ed

Illustrated by The Sex Ed

What is the difference between cisgender, gender-fluid, and non-binary? What happens when someone gets a vaginoplasty? What exactly does it mean to transition?

Do genital surgeries affect the ability to orgasm? Can transitioning affect someone’s chances of getting vaginismus? These questions can be awkward ones to ask, and not appropriate to expect someone who is or has experienced gender transitioning to answer. 

There's been a lot more support in the last five years, culturally, around nomenclature and understanding of all different types of gender and sexual identity. But much of this support exists within liberal, sex positive communities. So, we’re breaking some of these broad concepts down for people who are new to this space. 

The Sex Ed founder Liz Goldwyn sat down with Dr. Amy Weimer to get the answers. 

In 2016, Dr. Weimer founded the cutting-edge, revolutionary Gender Health Program at UCLA, which offers comprehensive medical and surgical care to the transgender and gender diverse community in Los Angeles and across the United States. Here, she and Liz discuss what it means to transition, and the medical, as well as non-medical, options available out there. how she discusses transitioning with parents of gender-diverse children; and how the medical community is evolving.

Gender, Pronouns & Transitioning 101

Liz Goldwyn: Is it correct that about 6% of US adults identify as trans, and California is the second highest population?

Dr. Amy Weimer:  California is the second highest population. It's actually 0.6% of US adults. This was based on a survey that was done by the CDC (Center for Disease Control) of about 27 states. Hawaii had the highest prevalence and California came in at 0.76% with the second highest prevalence.

Liz Goldwyn: Where do children stand in that statistic?

Dr. Amy Weimer: This particular survey did not look at children, but another survey [from 2019] called the Minnesota Students Survey looked at 9th and 11th graders, and found that 2.7% of them identified as transgender/gender non-binary. It's a much higher percentage in younger people. Whether that's a question of society being more receptive to it during the children's development or whether we're just not capturing the adults, we don't really know.

Liz Goldwyn: [There’s] a concept of binary that you and I grew up within the 1990s that is entirely different from anyone born post-1996.

Dr. Amy Weimer: Right. When we were raised, everything fell very neatly into male or female. There was no concept of having a gender identity other than male or female. People who identified as transgender still identified as strictly transgender male or transgender female to our knowledge. The new construct--which is particularly embraced by younger people--that there are plenty of people who fall outside of that binary; people who identify as not exclusively male or female. Those are what we call non-binary identities. But within that, there are a lot of different identities that people might claim: two-spirit identities, gender fluid, agender. I think it's really important to hear from each person what their description of their gender is. It may evolve with time.

Liz Goldwyn: Another relatively new concept is asking people their pronouns.

Dr. Amy Weimer: Yes, and recognizing those pronouns. Pronoun preferences may actually not match the way we would expect with gender identity. There may be people who identify as male, but are more comfortable with they/them pronouns. Or people who are non-binary, but more comfortable with, say, she/her pronouns. The most important thing, in my opinion, when we're interacting with people is to know what name they use and what pronouns they use. The rest of the information can be asked about if it's relevant. For most of us in society, we don't need to know all of that information about each other.

Liz Goldwyn: What is gender identity?

Dr. Amy Weimer: Gender identity is our internal sense of self-- of who we are as male or female, or both, or neither, or another gender altogether. It really is this sense of self, internally. Gender expression would be the outward display of that gender. That might be in style of dress, hair, mannerisms, even interests that you pursue, who your peer group is--all of those things are elements of gender expression.

Liz Goldwyn: And sexual identity?

Dr. Amy Weimer: Is completely unrelated, if we're talking about sexual orientation, right? Who we’re attracted to, based on gender. Typically, when a person describes their sexual orientation, they're using their gender identity--their affirmed gender--as the basis. Say I am a person who was assigned female at birth. I identify as male now and I'm attracted to males, I would most likely describe my sexual orientation as gay.

Liz Goldwyn: This is where I think some people get confused, right?

Dr. Amy Weimer: Many people, yes. The issues of gender identity and sexual orientation in general can be very conflated, certainly.

Liz Goldwyn: I think it's only in the last five years that culturally, we've started separating everything out and saying, "I can identify my gender identity this way and my sexual identity is this way," and just leaving space for that spectrum.

Dr. Amy Weimer: Right, and really embracing the fact that all of those sexual orientations and gender identities are normative. They're all normal. That whole spectrum.

Liz Goldwyn: Can you define transgender and cisgender?

Dr. Amy Weimer: Transgender will have different definitions according to who's defining it, but the most common definition is an umbrella term for people whose gender identity—their internal sense of themselves--does not match the sex that they were assigned at birth. A cisgender person is essentially a non-transgender person; a person whose gender identity does match the sex that they were assigned at birth.

Liz Goldwyn: What about gender non-binary?

Dr. Amy Weimer: Gender non binary is a term for people who don't identify exclusively as male or exclusively as female. 

Transitioning is the process by which a person expresses their true gender identity. I think transition is helpful to be thought about in a few different ways. One is socially transitioning-- being able to express yourself physically in your style of dress and hair, perhaps adopt a new name, perhaps changed pronouns. Those are all aspects of social transitioning. Legal transitioning would be legally changing documents to match the gender marker and name. Then medical transitioning are all the different interventions we have to help a person's body better match their sense of gender identity.

Liz Goldwyn: Can you tell me a little bit about your day-to-day, and working in that space?

Dr. Amy Weimer: I am a primary care doctor by training. I'm trained to see both adults and children. For quite some time, I did just that. I saw the general population of adults and children. Now, I've become more specialized in caring for people who have gender dysphoria, who are transgender, or gender diverse. The services that we offer them within our program are pretty broad. What I do, myself, is a lot of their primary care, just taking care of you as a person through the lens of understanding a bit more what the experience might be like because of your gender history. Then providing various hormone therapies within our office according to what your particular needs might be.

Liz Goldwyn: What do those hormone therapies look like?

Dr. Amy Weimer: For most people who--if you want to feminize your body--usually you're using a form of estrogen. We use one called estradiol, as well as another medicine to help suppress the body's own testosterone production. For people who are transitioning to a more male physique, we use testosterone. For younger people who haven't completed puberty, we also have the option of using medications that are referred to as blockers to halt the effects of puberty. That can be followed, and in most circumstances is followed, by then using hormone therapy to help the body develop more in line with the experienced or affirmed gender.

Liz Goldwyn: How does that work? Do kids have to have parental consent? Is it different state by state?

Dr. Amy Weimer: Every state is going to have its own parental consent laws in general. It can vary a bit state by state, but for the most part, absolutely. For any medical treatment, kids do need parental consent. There have been cases where it's been deemed really urgent for a child to be treated, and parents have not been consenting and court orders have overturned the parental objections. But that's never our goal, because we know that kids do better if they have the support of their parents or guardians. We do a lot of work with the families to try to get everybody on the same page. 

Liz Goldwyn: That must be difficult because the rates around rejection and homelessness are really high for trans youth.

Dr. Amy Weimer: Yes, that's definitely true. Being either a sexual or gender minority is the leading cause of homelessness for youth in America, in general. We're seeing those rates. It appears to be decreasing. I think as part of this move towards children, in general, being more aware of and accepting of a whole variety of gender identities, that is bringing this language more into homes. I think that, in general, parents are starting to become more aware, but it still is a tremendously significant issue. 

What Surgically Transitioning Entails, and What Treatments Are Available to Patients

Liz Goldwyn: Can you break down the different stages of transitioning that you deal with in your practice?

Dr. Amy Weimer: There used to be a pretty linear approach to transitioning, or if a person wanted to transition genders, this was the timeline by which they did it. We have a much more, what we call an “à-la-carte,” approach now, where people may or may not desire a whole variety of gender-affirming treatments. There are some people who don't feel comfortable socially transitioning until their bodies appear more masculinized or feminized. It used to be that people needed to live in what was called “the real-life experience” for a year before they were deemed to be appropriate for medical treatments. That's no longer a requirement.

Liz Goldwyn: When did that change?

Dr. Amy Weimer: The most recent standards of care are from the World Professional Association for Transgender Health, which is the body that produces guidelines that are the most often referred to. They released a version in 2011 that no longer requires “the real-life experience” really for any procedures with the recognition that real-life experience can be challenging if your body is not yet congruent with your gender identity. Many people do socially transition first. That can alleviate a lot of discomfort, typically. Then people will move on to medical treatment to using hormones, to start the process of modifying the body. Then they may or may not choose to pursue any variety of surgeries.

The most common surgeries that people pursue for trans-feminine patients--people who are feminizing their body--would include, potentially, a breast augmentation, if the hormones haven't been productive enough, some facial reconstruction to feminize facial features, and then genital reconstruction. There's a lot of nuances to genital reconstruction as well. For trans-masculine patients, top surgery. Chest reconstruction is by far the most-commonly sought procedure. Most people do pursue that. That's something that actually can be done without needing to be on hormones. Then a much smaller percentage will pursue genital reconstruction. Those techniques are not quite as advanced and well-studied as the techniques for trans-feminine genital reconstruction.

Liz Goldwyn: Why is that?

Dr. Amy Weimer: It is a matter, for the most part, of the material that's there to work with. It's much harder to create a penis. You can't create it with the tissue that's in the genital area already, so it needs to be created from a graft, with the exception of what's called a metoidioplasty, where the clitoris can be mobilized and made into a phallus, but it's pretty small even though it's been enlarged with testosterone. The options just aren't as robust. Whereas with vaginoplasty, most of the time that can be pursued with the tissues that are already in the genital area.

Liz Goldwyn: How do these surgeries affect sensitivity and ability to orgasm?

Dr. Amy Weimer: The goal and expectation is that orgasm should be preserved. With vaginoplasty, with the creation of a vagina and external genitalia, the clitoris is actually formed from the head of the penis, so it has a very good sensation. The expectation is that orgasm will be achieved. The rates that are being quoted are in the range of 85 to 90% of people can achieve orgasm. It takes some practice and some exploration to learn how to drive your new genitals, for sure. There's a learning process, but most people have very good long-term outcomes. Then, for people who have either metoidioplasty or phalloplasty—creation of a penis, the clitoris remains intact certainly for the metoidioplasty and orgasmic function should be completely preserved. With a phalloplasty, when they have to do a graft procedure to create a penis, the clitoris is preserved and placed at the base of the penis. Typically, there remains orgasmic function as well.

Liz Goldwyn: How often do you see things post-op like vaginismus, pelvic pain, or sexual dysfunction? Is it at a higher rate?

Dr. Amy Weimer: I have very few patients who have had phalloplasty. It's not a procedure that most people get. The sexual dysfunction hasn't been reported as much of an issue as issues of scarring, and formation of fistula, which are abnormal tunnels that can form in the skin. For people who have had vaginoplasty, they can have persistent issues with pain. Sometimes, there's some nerve damage that can create pain. Vaginismus, per se, probably wouldn't be a term that would be used because that has more to do with the typical anatomy, a muscular anatomy of the native vagina of the vagina-person, would be born with. Rates of vaginismus in transgender men are definitely significant.

Liz Goldwyn: Can you break down the process of having a vaginoplasty or a phalloplasty?

Dr. Amy Weimer: Sure. For a vaginoplasty, usually it's done as a single procedure. The most common technique now is to do what's called a “penile inversion vaginoplasty”. That basically takes the skin of the penis, and possibly the scrotum, to create the vaginal cavity. And then external genitalia are sort of reformed from that as well. There is an emerging technique to actually use the lining of the abdominal cavity--it's called the peritoneum--to create the vaginal canal, which is really promising because the feel of it is more similar to the lining of the native vagina. But that's not being done at many centers yet.

One other thing to note with the vaginoplasty is that there is an option for people if they feel like the vaginal canal is actually not important for them, either for sexual function or for a sense of gender wholeness, to have just the external genitalia formed and not have the canal. The benefit of that is, when you have that vaginal canal formed, you need to dilate it for the rest of your life in order to keep it open. And that dilation schedule is pretty intense right after the surgery. Usually within a year it's down to about once a week, but it is something that needs kind of ongoing maintenance. So, if it's not needed, there are some people that prefer not to have that created.

For the phalloplasty it's more a complex operation. So that's a graft procedure, and the tissue that's used to form the penis usually comes from the forearm or the belly or the thigh. The first surgery is generally to create that graft and attach it, but not to route the urethra--which is the tube you pee through--through the phallus yet. That's done in a subsequent surgery. And then, following that, then you can put in something for erectile function, like a rod, and create a scrotum with testicular implants as well.

Liz Goldwyn: So, that's a much more involved surgery.

Dr. Amy Weimer: Much more involved, multi-stage procedure, and anytime we do a graft we're taking tissue from one area and putting it on another area. There's always a risk that something goes wrong with the blood supply, and so it's a bit more of a risky procedure as well.

Liz Goldwyn: Who's leading the field, worldwide, in terms of either of these surgeries?

Dr. Amy Weimer: It's not that there is one country, per se, that's doing it, it's perhaps that there's one surgeon in a certain country. There are a few centers in Europe that are very advanced. Thailand has always been a big place, especially to get vaginoplasties done. One of the most prolific surgeons there is retiring though. And there are a few centers here in the US, or a few surgeons here in the US that have been providing this care for a long time.

Liz Goldwyn: Who are the top in the US?

Dr. Amy Weimer: I'm always hesitant to say "the top" because the number of surgeries does not always correlate with the outcomes. There are surgeons who have learned the technique more recently who are exceptionally skilled surgeons and they may not have the same numbers but that doesn't mean a person should automatically be wary of going to see that surgeon. The surgeons who have been doing this a long time have wait lists that are maybe two or three years long and some of them don't use insurance either. So, it can be really burdensome to feel that that's your only option. Meeting with surgeons is really important for people to do to get a feel for whether this is a person that you feel you can trust. Find out what their experience is like, have that conversation. It's really common for people to meet three or four different surgeons before they make a choice.

One of the most prevalent surgeons in the US is Marcie Bowers, who works up in the Bay Area. She, herself, is a trans woman. She's remarkable. She does really incredible work and so she has been a big forerunner in this field, and doing a lot of education of other surgeons to help them improve their technique as well.

Liz Goldwyn: What is the cost associated?

Dr. Amy Weimer: I don't know off the top of my head, but it's many tens of thousands of dollars. So, it's a very pricey thing if you don't have insurance coverage. The good news is, most insurances will cover it.

Liz Goldwyn: Does insurance have to cover it?

Dr. Amy Weimer: They are not required to. The Affordable Care Act statement says gender-affirming care needs to be provided, but does not specify exactly what type of gender-affirming care. There are a few health plans that don't cover genital reconstruction, but the majority do. They just may have some requirements about, first of all, who you can see--who they're contracted with. Most of them require a statement of support from behavioral health professionals that you indeed have general dysphoria and that you're ready for this surgery. There's some steps to go through but they're achievable, certainly.

Liz Goldwyn: Are there high rates of erectile dysfunction associated for people who have a phalloplasty?

Dr. Amy Weimer: So, there's no innate erectile function in the phalloplasty. The only way to achieve the erectile function is to actually have an erectile implant which we use in cisgender men who have erectile dysfunction as well. That’s the reason people gravitate towards the phalloplasty. Obviously, it's a larger penis than the meatoplasty option. The downside to it is that it doesn't have as much sensation, so it's not as innately functional, but most people, as long as they don't have complications from it, end up being very satisfied.

Liz Goldwyn: How far away do you think we are from perfecting these surgeries? Are they closer to what we see now with breast augmentation?

Dr. Amy Weimer: I think we're doing a really good job with vaginoplasty, with really thinking about new techniques. I think we're further away with phalloplasty. It's just an idea of, how do we get the tissue we need to get? So, I don't really know what the future holds for phalloplasty. I heard buzzings about maybe using stem cells to grow the tissue but I wish I had a more optimistic answer.

Dysphoria & How the Medical Field Needs to Evolve

Liz Goldwyn: We’ve been hearing from trans folks who are experiencing vaginismus and having trouble finding information, which leads me to ask about inherent bias in medical care.

Dr. Amy Weimer: I think that most providers, in general, and this is no secret, have very little experience and almost no training in providing care to people who are transgender. It's not something that I recall a single class on in medical school. I don't recall encountering it during my residency. For me, specializing in this area has been really self-driven. I have read voraciously on it. I've gone to conferences, but there really is no curriculum for learning about this. Part of our mission is to try to integrate it more into medical education. I think that it's hard to know whether it's implicit bias versus just plain ignorance and lack of experience, but it is very hard for people to get knowledgeable care in the medical community in general. A big change occurred in 2016, when the last section of the Affordable Care Act went into effect, and mandated that gender-affirming care be provided for any health system that's receiving any money from the federal government. Knock on wood. As long as the Affordable Care Act stays in place, and honestly, even if it doesn't, we expect that this care is going to become more and more prevalent--easier to find. Probably one of the oldest established centers is Fenway Health in Boston. It's a great center that provides a lot of education as well as care for anybody on the LGBTQ spectrum. They are definitely at the forefront of this care.

One of the unique things I think about our program, [The UCLA Gender Health Program], is that most places, even when they have a team of people who are experienced, can't provide a full breadth of services. They may not have all the surgeries at their institution. That's one of the things we've really driven to do here, is build up a team that can provide everything that a patient needs.

Liz Goldwyn: What are some of the issues surrounding reproductive health in this area? How is that addressed when people start to take hormones?

Dr. Amy Weimer: Fertility is a huge issue in this community and a huge issue from the standpoint of my perception. Most people, by the time they come to me, seem to have resigned themselves to the idea that they will adopt. They don't sound disappointed about it, but they sound very committed to adoption. The fact of the matter is that there's lots of fertility preservation and fertility assistance options that are available to people. We know that being on hormones can impact fertility. That's probably, at least in part, reversible if people take a pause in their hormones. But they can preserve eggs, sperm, or embryos prior to starting hormones. The whole variety of fertility assistance that's available to any person is also available to this population.

The biggest barriers are cost because it's generally not covered by insurance. Even though there's a very strong medical reason why people become fertility-impaired, and that many people can't really tolerate the idea of going through fertility procedures because of their genital or reproductive organ dysphoria.

Liz Goldwyn: Can we talk a little bit about dysphoria?

Dr. Amy Weimer: Dysphoria is basically a distress. When we use the term gender dysphoria—that's the diagnosis that we used to treat people. The two elements of gender dysphoria are gender incongruence. That mismatch between the sex assigned at birth and the gender identity, and that mismatch is causing significant distress or dysphoria. We know that gender incongruence is going to be a permanent issue until we can help with body modification. Dysphoria can be treated by all of these different measures. We have studies that are showing that as we provide different levels of care, dysphoria rates go down and down and down. The degree of dysphoria a person has is really individual. It can be related to many different things.

Some people have dysphoria about how society sees them. Some people have dysphoria about their anatomy. I think when I'm helping people decide what medical treatments are the best for them, that's one of the most important questions I asked is, what in your daily life is creating dysphoria distress or making you upset, so that we can figure out how best to manage you.

Liz Goldwyn: What if it's something that you have no control over, like the way society sees you?

Dr. Amy Weimer: You do have some control over that. We can't change the people, but in helping people present themselves more authentically in their gender. For instance, facial feminization surgery can help a lot of people not be "read" as transgender. By doing that, we are altering how society sees you. My strong preference would be to change how society sees you. That's a much more difficult thing to achieve.

Liz Goldwyn: Right, because there's a lot of people who may not want to transition in those ways, may not want to use hormones or undergo surgery, but want to express their gender identity through dress or cosmetics or however they choose.

Dr. Amy Weimer: Right, and they may wanna express their gender identity differently day by day. For some people, permanent body modification is a little bit daunting because they don't necessarily feel that they need to be that way all the time. I think that's where the advocacy branch of this work comes in, of really trying to get the message out of all of these different gender identities and gender expressions being normative, and really trying to change the way that we expect things from people based on how you read a person.

Liz Goldwyn: Well, we expect those things from people who identify as cisgender men or cisgender women to fit into these very strict roles as well, right?

Dr. Amy Weimer: Absolutely.

Treating Young Patients—and Their Parents

Liz Goldwyn: How do you approach young patients and parents when they come to you? Let's say if you have a child that's under 18. I'm sure you must get this argument: “Well, how do they know? They're too young. They shouldn't be able to decide.” Where do you start that conversation?

Dr. Amy Weimer: I would say that's almost universal. Parents are there to try to do the best they can for their child. They're terrified that the decisions that they help their child make now will backfire later. That's definitely one of our roles, is to help support parents, and how to make those decisions. We have data, actually, that really supports that if gender dysphoria, this discomfort either comes on or worsens around the time of puberty, that's a very strong predictor that it's going to persist through adulthood. That, and the degree, the intensity of the gender dysphoria, and where it's focused. Rather than, "Well, I want to be seen as a guy," saying, "I really feel like a guy and this body is wrong," those sorts of statements, as we have conversations, can really help us predict what we call the persistence of the gender identity.

Liz Goldwyn: Our ideas around our own sense of gender and sexual identity are beginning to be very strongly formulated around seven years old, is that right?

Dr. Amy Weimer: Probably even earlier. Most kids, by the time they're two or three, can identify their own gender and other people's gender. Usually, by the age of four or five, [they] can pretty strongly state, "I am a boy or girl." 

Liz Goldwyn: Then we'll see what happens as we allow kids more options, right? 

Dr. Amy Weimer: Yes, at a very young age. However, it's expecting a lot of kids to have the insight to recognize that what's not feeling right in their body is because of gender incongruence. Many people who are older tell us, "I knew through my childhood that something wasn't right. I didn't feel comfortable, but I never understood what it was until I heard about the transgender experience. Or until I heard a story that a transgender person told."

Then they start to have this aha moment where their whole history makes sense. There are some kids who, from a very early age, can very strongly express, "I'm not a boy,” or, “I'm not a girl." That's the minority. Most people will gain that awareness during adolescence or even early adulthood.

Liz Goldwyn: I suppose if parents are coming to you in the first place, they're already open-minded enough to want to see this through with their kids. What about if there's a kid reading this or a young adult reading this that just feels they have no hope, that their families are totally unsupportive? Where can you go online or in your community to find resources, information, medical assistance?

Dr. Amy Weimer: The first thing that I would really encourage is to work with family. There's not an urgency for medical interventions, at least until puberty starts. The most important thing for younger kids is to allow them to present themselves the way that's comfortable, to wear what they want to wear, do their hair the way they want to do their hair, or participate in the activities they want to participate in. If a kid is really struggling, then working with a therapist can help that child understand how to communicate better. There's lots of counselors at schools. A school-based counselor can be a really good place to start. There's definitely online communities and support groups. There's The Trevor Project, which is really dedicated to helping younger kids with support. 

There's also a line called the Trans Lifeline, which is a crisis hotline for people who identify as transgender. The biggest barrier that I've seen with, particularly the youth that I've worked with, is they don't feel worthy of taking up the time of the person who's on the other end of that line. There's a terrible self-worth problem in this population. The biggest thing that I can say is, "You're definitely worth it. That's why the person is waiting on the other end of that line. If you're feeling you're lost and you need to reach out somewhere, that's a great resource to have.

Liz Goldwyn: The stats around suicide and violence are really high in this community.

Dr. Amy Weimer: Yes. Rates of suicide attempts—there was a survey done in 2015, it was an online survey, and about 27,000 people responded. They reported a 40% rate of suicide attempt history. Those are the people that survived the suicide attempts. The suicide rates are tremendously high. We know that treating, that allowing people to express themselves in the way that feels authentic, has a huge impact on reducing suicide rates.

Liz Goldwyn: What about rates of sexual trauma?

Dr. Amy Weimer: They're higher than the general population, for sure. That's across all gender identities. It's not specific to trans girls or trans boys. Sexual trauma history is pretty prevalent. That's one of the things that can contribute to being difficult to tease out sexual dysfunction. There's genital dysphoria, there's potential for trauma history, then there's sometimes the impact of the interventions that we're using medically.

What Work is Still Being Done

Liz Goldwyn: Wow. I know you've spoken a bit about this before, but what advice would you give to other doctors in terms of intaking sexual history that might be different? 

Dr. Amy Weimer: The advice that I would give is actually applicable to everyone. It's probably a better way for us to approach sexual history for everybody. It's to focus on behaviors, rather than orientation, rather than a sexual identity, but just to say, "Tell me about the types of sex you have. What are the genders of your partners? What is the anatomy of your partners?" If you tell me that you're sexually active only with women, that may mean women who have penises and there might be sperm involved. Maybe we need to talk about pregnancy prevention. We really need to broaden the questions we’re asking to be about sexual behaviors. I think asking the questions, approaching it very neutrally. The more that we can say things in practice, saying things and become comfortable with them ourselves, that allows people to open up to us much more easily.

Liz Goldwyn: How much of that work did you have to do on yourself?

Dr. Amy Weimer: This is an area that I've always been pretty comfortable talking about. I had to retrain some of the questions that I have learned to ask. When I was in medical school, it was considered very proactive to ask, “Are you sexually active with men or women?” but this goes back to a binary concept. I had to relearn some of the questions that I asked, but my comfort level with it was pretty good. I do a lot of teaching for residents and medical students. This is one of the things that I really push them to do. It [varies] how comfortable people are talking about it.

Liz Goldwyn: What are you still learning about sex?

Dr. Amy Weimer: I think one of the most important things that I did when I started this work was really get in touch with my humility. That this is not my community. I knew that I had a lot to learn, not just about the medical care, but about what it's like to live as a trans person. I make no assumptions that I already know all of the answers and all of the information. I can recognize patterns when people are talking to me if they say they're having a certain experience. It can sound familiar to me. I can give them those reflections that I've learned from other people who might have shared this experience in the work we've done together. I can't make the assumption that that experience is true for them. I just don't know what I don't know yet.

Liz Goldwyn: But humility is part of it?

Dr. Amy Weimer: Humility, I think, is tremendously important. I have to assume that you, as a person coming to me, know more about your experience than I do. For so long, this care has been dictated and prescribed by physicians to patients. It really needs to be a much more collaborative endeavor.

Liz Goldwyn: I've heard that a lot—across the system of healthcare, if you're talking to people who don't fit into a cis-white framework, in particular—that a lot of times they have the experience of going to a physician where the physician does not validate their experience or their pain.

Dr. Amy Weimer: It requires the person to be steadfast in expressing themselves, but really what it requires is a lot of education throughout our whole medical curriculum.

Liz Goldwyn: Is that happening?

Dr. Amy Weimer: It is. It's happening. I think many medical schools are really looking at their curricula and trying to integrate this more. We have a big endeavor going on here at UCLA to actually integrate it at all levels, from medical school, through residency programs, and at the faculty level. We need to get that education also going out to the other staff that work in our offices, so that people are having a uniformly validating experience wherever they go. It's going to take some time. We've got some catch-up work to do for sure.

Liz Goldwyn: Is it gonna happen in our lifetime do you think?

Dr. Amy Weimer: Yes, I do.

Liz Goldwyn: I like your positivity.

Dr. Amy Weimer: There has to be hope.