So many name is Eric Meininger. I'm an internist and a pediatrician with a sub-speciality in adolescent medicine. I've been doing work in the trans community since the late 90's. I think my first patient was when I was a second or third year resident, whose mom brought him in, he was 12. And she knew of this doctor in Boston, an endocrinologist that would see him. She wanted to know if there was anybody closer, so she brought him to the Teen Clinic. I think I interviewed every endocrinologist in town. Four years later I was involved in starting a clinic for homeless youth. And homeless teens are living independently, they're on the streets. And they started to come to me and say, hey Dr. Eric, I'm about to start buying drugs on the street and injecting them into myself. And I said, gosh, I know nothing about this other than that one patient a couple years ago. And so I started doing my research and I said, if you had osteosarcoma, I would know what to do with you. But there was very little out there other than, at the time Harry Benjamin Standards, and the standards were very clear that he didn't see people under 18. And so we really took a harm reduction approach of, I'd rather that the medication came from a legal dispensary and we know what it is. First of all, being transgender isn't a diagnosis. The best take away from a recent conference I went to, you don't have to make a diagnosis. The patient will tell you I'm transgender, or I'm really a boy, or I'm really a girl, or I'm somewhere in between. And so gender affirming care is really supporting that and saying there's nothing wrong with you. The dysphoria that they have, that is a diagnosis, and it's something that we know how to do some things to manage. And it's really about supporting families and young people where they are in their process and not making assumptions about well you're going to want this surgery or you have to dress this way. It's really meeting young people where they're at. And in adolescent health we try to do that regardless of why they're coming to see you and I think it's really important. So in general, I know that from research not doing something has horrible outcomes. The minority stress theory if you don't address the dysphoria and all of the outside stressors that this young person is dealing with, that depression, chemical use, substance use, suicidality. In general bad outcomes, are very prevalent. By addressing the issues and helping young people fit their body better to reflect who they are they become healthy adults. And I've been doing this long enough that I've had some contact with some of the adults who stay in the community, and it's exciting to see them move from periods of some pretty unstable places in their life to long-term careers and advocates themselves and going to school. And also to see now new young people that are coming in, the family support that they have. When I started, it was homeless kids because LGBT youth in general are overrepresented in the homeless population. I was seeing about 40% LGBT kids. And now to be seeing young people who are coming in with Mom or Dad who are still struggling often times, but are supporting the young person. And to be able to help the parents understand what their child is going through and see those successful family outcomes is really exciting. There are times where parents aren't on the same page as the young person. And I often will sit with the young person and say, so, remember it took you how many years from when you first started considering the idea to when you told your parents and then how many years from that to when you saw me, how long that's taken you. When you were born, your parents had a plan for you. Whether or not it's reality, they said, this is my daughter, I want her to grow up and become a lawyer when she's an adult. And if you say, I want to be a musician, parents have to kind of shift to that. And they might try to talk you out of it, and hope that it's just a phase that you're going through, but eventually they come around. When you said, I'm actually not a girl, I'm a boy, that's a huge shift for them, and it takes them some time to reach that point. You've been working on this for four or five years, they've only been working on it for six months since you first told them, and so they will come around. Now, what can I do with the parents? I usually will have conversations with parents about this usually isn't a phase. Look at these things going all the way back until she was four, five, six. I will usually talk with parents about the not doing something is still has bad outcomes, and the importance of providing some level of intervention. And I'll just be that consistent voice to connect parents with reality, connect them with resources in the community to help them understand what their child is going through. So, in informed consent you, legally, I need parental consent, or I need a guardian. So occasionally it's been a social worker or a court assigned guardian. But there's the legal signature on a page thing, and then there's what is the reality of informed consent. And so informed consent involves a patient knowing what the options are and being able to make informed decisions between the options. And for a young person that requires the ability to think abstractly, which is one of the developmental tasks of adolescence, and it requires honest conversation with them and their parents, who are the legal decision makers, about what are the consequences, that it will have an impact on your ability to get pregnant or get somebody pregnant. So which has long term effect on your ability to have a family. It doesn't mean you can't, and many people have fought through that already. What are the long-term effects, to the best of our knowledge, on heart disease, on diabetes, on other morbid health conditions? So informed consent as a model is really the concept more than the actual legal definition. Insurance has been actually really interesting because I've been doing it so long. When I started, insurance would typically cover my visit. They would cover the lab work that I do because it's common screening lab work that we do in children for lots of reasons. But they'd get the prescription and they'd say what is this for? And sometimes they cover it, sometimes if they knew what it was for, they usually wouldn't. That was 15 years ago. The state of Minnesota passed a law that was explicitly saying, we won't cover gender confirming surgery. And it was a very conservative approach. It's one of the few places in Minnesota legislation that there's outright discrimination against a community. And the commissioner of health at the time interpreted that as, we won't cover surgery but we will cover other treatments. And so medical assistance then would cover cross-gender hormones. Now there was a lot of education with the different contracted insurance plans with medical assistance that yes this is a covered benefit. And a lot of back and forth with letters from the commissioner of health to the insurance companies. But eventually that became fairly standard. And then if medical assistance is covering it, why is our private health insurance plan not covering it? So we started to see some changes in private health insurance in the self insured employers. The big change came with the Affordable Care Act, which specifically identified that not providing gender-affirming surgery or other benefits was discrimination against the specific community. And so, the law on Minnesota books was essentially invalidated. The Commissioner or the Department of Commerce has interpreted that to mean that insurance plans that are sold in the state of Minnesota cannot discriminate in terms of medications. And the medical assistance plans are now covering surgery. So we've seen a lot of progress. It's not always been easy and yet there are still some insurance plans from other states or even self insured plans here that that's the weather plate language, we do not cover this. And it's a very slow tedious process to get it removed. Oftentimes, it's somebody on the inside. I remember a particular patient a number of years ago that worked for a non-profit. I knew the director of HR at the non-profit, very progressive non-profit, hired trans identifying people knowingly would never discriminate against them, and yet they have health insurance plan that specifically did not cover that. And so, we called up the HR person and she said, no, we didn't ask for that. I will fix that. And that was it, then it was done. In larger corporations obviously it takes an advocate at different levels to be able to make that change. There is an employee group at one of the big bio medical companies in town that's been working to change their boiler plate. And once that's changed, we hope that we can take that to other companies and say this is really what you should be using. I think the, certainly there's a lot online, there are books that you could read. But what's been most helpful for many parents is a parent support group. We have one of those here in the Twin Cities. That's where I make a lot of referrals. I actually get a lot of referrals from them as well. because they find their way to that group and then start asking, who are the providers in the community? But I think it's helpful for parents, less so for the young person. If they go they usually just want to get together and talk about themselves. But the parents usually want to know, so my child is here, what are the challenges or issues that I should be anticipating. And so parents who are at a different point along the line of exploration are able to provide that. And, I think in a much more convincing way than I, as a provider, can provide it.
