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Join Rosemary Eseh-Logue, an internal medicine physician, as we delve into the often-overlooked topic of intersex variations in sexual development. We explore the importance of understanding intersex identities, breaking down misconceptions, and improving health care experiences for intersex individuals. Discover how health care professionals can bridge the knowledge gap and advocate for the rights and well-being of this diverse patient population.

Rosemary Eseh-Logue is an internal medicine physician.

She discusses the KevinMD article, “What is intersex? What do you know about your patient’s sexual development?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Rosemary Eseh-Logue. She’s an internal medicine physician, and today’s KevinMD article is titled “What is intersex? What do you know about your patient’s sexual development?” Rosemary, welcome to the show.

Rosemary Eseh-Logue: Thank you for having me.

Kevin Pho: We’ll get into the article in a little bit. Just first off, briefly share your story and journey to where you are today.

Rosemary Eseh-Logue: I am an internal medicine physician. I am originally from Nigeria. I went to medical school at George Washington University in D.C., and I did my residency in Texas, at Baylor College of Medicine. I currently fully utilize my internal medicine degree: I teach, I do inpatient, I do outpatient and I have my own practice.

Kevin Pho: All right, so tell us about a typical day, because I’m an internal medicine physician myself. I do outpatient primary care, and as you know, a lot of physicians are specializing in either all inpatient or all outpatient, but you seem to have that traditional practice, doing it all. How’s that going?

Rosemary Eseh-Logue: Well, I’m doing it all, but each in its own section. On Mondays and Tuesdays, I teach residents in the clinic, and on Thursdays and Fridays I’m usually doing hospital work. Then, mixed in between, I’m doing my own practice work.

Kevin Pho: All right, and for medical students who may be listening now, what are some reasons they should consider internal medicine as a career?

Rosemary Eseh-Logue: Internal medicine is the place to be, because with internal medicine you really can expand your field of practice. Take me, for example. I’m able to practice in basically whatever setting, because I have a diverse enough knowledge base.

Kevin Pho: All right, so let’s talk about your KevinMD article. It’s titled “What is intersex? What do you know about your patient’s sexual development?” Tell us how your article came together.

Rosemary Eseh-Logue: One of the things I discovered is that a lot of residents are not even aware of the word “intersex.” Either they’ve never heard of it, or they don’t know what it means. This is important because, especially in our current culture, where we need to be culturally competent, you cannot provide culturally competent care if you don’t even know the person who is in front of you. So that is a really important gap in knowledge, and I really wanted to take the opportunity to educate residents and fellow physicians about intersex. And it’s not unusual, because I didn’t learn about this, and it’s just surprising that many years later, residents are not learning about it either.

Kevin Pho: Sure. So let’s start there. Can you please explain the concept of intersex?

Rosemary Eseh-Logue: Intersex people, almost 2 percent of the population, are born with genetics, anatomy, hormones or a phenotype that does not fit our stereotypical understanding of male or female, which we assign at birth.

Kevin Pho: All right, and what are some misconceptions or stereotypes associated with intersex individuals?

Rosemary Eseh-Logue: One is that if somebody is intersex, that means they identify as gay, which is not correct. There are people who are intersex who do not identify as gay, so that’s one. In the LGBTQI acronym, the I stands for intersex. The other thing people don’t understand is that basically all intersex people are transgender, transgender either to their biology or to society.

Kevin Pho: And can you give us a little demographic information about the intersex population?

Rosemary Eseh-Logue: In the U.S. population, or really the population as a whole, that’s 17 out of every thousand births. Most people are diagnosed in their teenage years or as adults, but some can be diagnosed when they’re born, or even before that. It is important to be aware that there are people who are intersex, and of what that means for our practice.

Kevin Pho: Now, from the perspective of intersex patients, tell us some of the psychological and emotional challenges they face when they seek care in our health care system.

Rosemary Eseh-Logue: This population feels stigmatized because of their gender identity, which can be in conflict with what either we as professionals or family members often expect it to be. So there is a lot of anxiety and depression, and just fear of getting biased care. A lot of them don’t even come in for medical visits, and when they do, it’s a stressful situation, which it shouldn’t be. It’s so important that we recognize this, because a recent study showed that in the intersex population, about 40 percent have attempted suicide, and one of the contributing triggers, if you will, is just the way the health care community treats them. I think that’s just not acceptable for a community of professionals who heal.

Kevin Pho: Now, teach my audience, like you teach your residents, about the intersex population. What are some things we should know in the exam room when we talk to our patients? Give us some advice, and walk us through a typical encounter.

Rosemary Eseh-Logue: One of the main things to understand is that there’s a lot of diversity in what we call intersex, in intersex people. Some have changes that we can’t see; in others, it’s clear that this person is intersex. So we have to go into it with curiosity, knowing that we don’t know what this patient’s particular anatomy is. One of the things to ask is what they identify as, in terms of gender: male, female, neither or both. The other thing you want to ask is, “What surgeries have you had?” In other words, you want to find out what organs are present and what organs are missing.

For example, you may have a patient who is female-presenting, who looks like what we typically call a female. But when you ask, “Hey, tell me about your surgical history,” which is a very neutral way to get more information about the intersex anatomy, if you will, you find out that they had their testicles taken out some years back. So now you’re going to say, “Whoa, what’s going on?” It clues you in that you might be dealing with an intersex person, so you need to dig, so you know what body parts they have. This is important for screening. There is certain screening we would need to do that you may miss if you’re not aware of certain organs a patient has.

Kevin Pho: What are some other surgical procedures the intersex population would typically undergo?

Rosemary Eseh-Logue: Some can have breast implants, and some can have mastectomies. Those who identify as male and have developed breasts, you may find, have had mastectomies, and that would be a reason to ask, “Hey, why did you have that surgery?” That’s one. And in terms of the genital organs, they can have implants put in, penile implants. So there are different surgeries they can have done to make the genitals more appropriate for what they feel they should be.

Kevin Pho: Talk about some of the resources available to our intersex patients.

Rosemary Eseh-Logue: In the medical profession, there isn’t a lot. There are not a lot of physicians who are either comfortable addressing intersex health or feel knowledgeable enough about it. But there are support groups, like InterConnect, that support people who are intersex and help them find resources, both for medical care and for mental and emotional well-being. For the physician, there are organizations like USPATH and WPATH that give some information on how to care for somebody who is intersex.

Kevin Pho: Now, you mentioned before that there isn’t a lot of training when it comes to treating our intersex patients in medical school and residency. How did you learn? What kinds of resources did you turn to, to better equip yourself to manage intersex patients?

Rosemary Eseh-Logue: I basically started reading different books on sexual development, and different articles and journals from the intersex community and from other organizations within the medical community. Urology is one of the specialties that tends to see a lot of intersex people. So basically a lot of books, articles and journals, then online research, and then connecting with the intersex community.

Kevin Pho: What is the perception of the intersex community as it relates to physicians? Are they generally suspicious of a lot of physicians because physicians don’t have a lot of exposure? How do you gain their trust?

Rosemary Eseh-Logue: There is a lot of mistrust, for sure. There’s a lot of fear as well, which is sad. So mistrust is there, and also a feeling of incompetence, because when they do go to a physician’s office, the physician has never even heard of their condition, let alone knows how to manage it. A lot of them voice that they end up having to teach their physician, which they’re willing to do, but that mutual understanding and trust is sometimes missing.

Kevin Pho: So in terms of the common issues that come up when you see intersex patients, what are some common scenarios that, as an internist, you would see in the exam room and have to address?

Rosemary Eseh-Logue: The main ones would be, first, hirsutism: patients who present and are hairier than they would like for their gender identity. Another is patients who are on hormone therapy and need to be managed. For example, a patient who’s taking hormone therapy so they can be more in the female body they feel is consistent with their gender identity is going to be on a higher dose of estrogen than you would typically give a usual postmenopausal patient who’s on estrogen. That’s one of the common ways you see it: It’s not a mistake that they’re on a very, very high dose of estrogen, and that’s actually appropriate.

Kevin Pho: Now, you’ve talked about some of the things we clinicians should do. Tell us about red flags. What are some things we shouldn’t do? What are some mistakes you see when it comes to clinicians interacting with the intersex community?

Rosemary Eseh-Logue: A big mistake, one that I still make and have to catch myself on, is that we have to basically let go of our biases, which is hard to do. A patient might present to you appearing to be a certain stereotypical sex, but they identify as the opposite, so we have to be mindful, again, of the pronouns they use. There’s one person I know, for example, who does not like to use any pronouns. I’m going to use “they,” just to protect their identity, but they would prefer that you use their name every time, rather than a pronoun. The reason is that they actually do not have any of the organs we typically associate with male or female. They don’t have testes, and they don’t have ovaries, because of their particular condition. In that case, you just use their proper name.

And it’s very hard, because I find myself saying “her,” because the default, biology-wise, is female: If the body does not get that testosterone input during development, the default is a female-looking body. So my tendency is to say “her” or “she,” and I have to catch myself and say, “Nope, use their name.” And it’s OK, because you’re learning. But that’s one big mistake we make, and it’s important that we try to learn.

Kevin Pho: We’re talking to Rosemary Eseh-Logue. She’s an internal medicine physician. Her KevinMD article is titled “What is intersex? What do you know about your patient’s sexual development?” Rosemary, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Rosemary Eseh-Logue: The main thing I want to leave is that it is important to know about intersex. We can learn about it; the data is out there, and we just have to engage with it. It’s not about a religious view or a political view; that’s not what this is. This is about understanding a patient’s body, the anatomy, so that we can take proper care of them.

Kevin Pho: Rosemary, thank you so much for sharing your perspective, time, and insight, and thanks again for coming on the show.

Rosemary Eseh-Logue: Thank you. Thank you very much.