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Infectious disease physician Tyler B. Evans discusses his article “Meeting transgender patients where they are: a health care imperative.” Tyler, an infectious disease specialist and author of Pandemics, Poverty, and Politics: Decoding the Social and Political Drivers of Pandemics from Plague to COVID-19, shares striking data on violence, mental health, and HIV disparities affecting transgender and nonbinary communities worldwide. He recalls formative patient experiences that reshaped his understanding of gender affirming care, emphasizing the need to move beyond outdated disease models and rigid medical training. Tyler explains why social determinants from housing to acceptance are critical to health outcomes, and why true reform begins with meeting patients where they are. Listeners will gain practical insights into building compassion driven systems that improve health equity and save lives.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Tyler B. Evans. He’s an infectious disease physician. Today’s KevinMD article is “Meeting transgender patients where they are a health care imperative.” Tyler, welcome to the show.

Tyler B. Evans: Thanks, Kevin. Good to be here.

Kevin Pho: Let’s start by briefly sharing your story and then jumping right into the KevinMD article that you shared with us today.

Tyler B. Evans: I am an adult infectious disease and addiction medicine doc. I’ve worked with trans folks for the last dozen years or so. I am deeply committed to the mission. I’ve worked for many years in the global south, in low- and middle-income countries, areas in sub-Saharan Africa, the Middle East, and Latin America. I’ve worked in war zones and complex humanitarian emergencies. I’ve worked on the Ebola response twice.

Throughout all those experiences, I connected that to my work in the U.S. and a lot of my work in the states, in the foxholes of chronic health inequities, places like the South Bronx and South LA. I have a theory on the “Souths,” connecting that to the South Sudan experience where I was the only doc for 29,000 refugees. I didn’t see that much difference in terms of the feeders that connected to the health care outcomes.

The magnitude of the burden of disease was considerably different, but in terms of the feeders, a lot of them were very similar. That universal thread is often socially and politically driven. I talk about that extensively in my book, *Pandemics, Poverty, and Politics*. When I focus on certain communities, particularly historically marginalized communities, trans communities are a key one.

The good news is we’ve had a lot of advances in understanding what trans health looks like in the United States and beyond. I’ve talked about this extensively across the country. We have good evidence to support primary care and surgical care for trans communities. Unfortunately, we’ve gone several steps back in the last few years as a result of the politics, focusing on the wrong messages and banning pediatric care for trans communities. It’s so important to get it right early on; the evidence is very strong for that case. If we are able to provide gender-affirming care at a very early age, the outcomes are very similar to cisgender communities from a mental health outcome perspective. It’s really important to get it right early on.

Kevin Pho: You talk more about these issues in your KevinMD article, “Meeting transgender patients where they are a health care imperative.” For those that didn’t get a chance to read your article, just tell us what it’s about.

Tyler B. Evans: It was summarizing the importance of understanding the trans experience and providing that gender-affirming care, essentially coming at it from a trauma-informed perspective as much as possible. Honestly, it’s not about treating trans communities any differently than you would any patient. You just meet them where they’re at and you understand where they are in their experience.

The simplest way that I explain it is there are three chapters to their path. The first is the realization, connecting to that identity. That’s a big one. I don’t think we often acknowledge that. When we have certain patients that might identify with different gender pronouns, and we might see a beard or some other physical manifestation while hearing a feminine name, sometimes as docs or providers, we see that and it disrupts us. It disconnects from everything that we’ve ever been trained to understand. It’s really important to just let go and understand where they’re at and meet them where they are, even though it deviates from our cultural norms or understandings.

The second is the primary care. The modalities are not significantly different from what we do in general practice. Yes, when it comes to certain prevention modalities, cancer prevention, etc., you’ve got to follow the guidelines in terms of their biological assignment at birth. You have to get used to that. Then there’s the hormone component, and you need to understand what’s important to them. Again, that doesn’t really deviate much from that physician or provider-patient relationship. It’s really important to understand what’s important to our patients and to get them there.

The third is the surgical, if they choose to accept that. There are a few other pieces in there. There are some behavioral health concerns sometimes that we do need to address. It’s hard to live in that space, particularly in today’s world when there are so many politics making these folks feel uncomfortable. Particularly as kids, even in my own community. I live in Santa Cruz, California, which is generally a pretty progressive community. I go back and forth between New York City and Santa Cruz, both very progressive places. Yet even in my own community, there was a school where my youngest son was at, a Montessori school. He was two years old at the time, and not trans or deviated from the biological course as far as we know. The school essentially started banning books that were talking about it, and that made us feel very uncomfortable. We’re seeing it all across the world, and I can only imagine what certain parents are experiencing. I think the important thing is for docs and providers to be champions for our communities and really help parents out as much as we possibly can.

Kevin Pho: As you know, a lot of physicians don’t get a lot of education when it comes to treating trans patients. In the exam room, I’m a primary care physician. Tell us the type of questions that we should be asking that can maintain that sensitivity and understand some of the lived experiences that trans patients are going through.

Tyler B. Evans: The most important ones are really just understanding where they’re at in their journey. Start off with gender pronouns. Sometimes that gets confusing for certain primary care providers. I see this happen often; they’re trying, but it’s a bit uncomfortable for them because it’s something different, and that’s OK. That cultural humility is really important to invoke in this space. Sometimes, particularly in the beginning, I would just say, “Listen, I don’t often do the gender pronouns. My name is Dr. Evans or Tyler. That’s how you can address me. Tell me about you. Tell me about your experience. Tell me about how you want me to talk to you. If I make some mistakes, I really apologize. I don’t mean to do it.” That really works if you’re just human about it.

It’s important to level-set, understanding where they are in the journey again. When did they first identify as a gender different from what they were assigned at birth? We are seeing a lot of gender fluidity nowadays, so it’s sometimes not just this bifurcation. Understand where they want to go. A lot of folks… I was in New York at the time where Medicaid was started. Most of my patients are Medicaid patients or uninsured, so when Medicaid started supporting the surgeries for my patients, they were queuing up to get there, but not everybody is. You have to see where they’re at.

The primary care piece is really important. Again, the primary care should not be that different, and I honestly think that as physician champions of these communities, sometimes we talk a little bit too much about treating these folks differently. Don’t treat them differently. They’re just humans, and their care is slightly different, but the primary care approach is very similar. Then there are the other pieces adjacent to it, which are the hormone modalities. A lot of my patients didn’t want hormones, so you ask them, “Is this the outcome that you want?” And if it is, then the primary care providers can easily look up what the guidelines are. There are tons of CMEs out there that they can receive. WPATH is the gold standard for trans professionals. It’s the World Professional Association for Transgender Health. Go to WPATH; there are guidelines out there. UCSF has great guidelines. They’re out there. Get your CMEs. Learn about it. It’s really important to your patients.

Kevin Pho: On the other end of the spectrum, are there any red flags or things physicians definitely should not do that you are seeing that they’re doing?

Tyler B. Evans: Obviously, you don’t want to disrespect your patients. If you do slip and say certain things that trigger them, you have to understand why it triggers them. They’re dealing with decades of trauma, so it’s not you; you just happened to trigger them. Getting back to that cultural humility, apologize. Just apologize and say, “I really apologize for triggering that. I can understand how…” Use that empathic language that we have been trained and experienced to invoke here. “I can understand how this triggered you. I’d like to get back on track,” etc.

Don’t go rogue. You have to get some training. It’s not that difficult, but don’t go rogue on this stuff. Phone a friend if there’s something that’s a little bit different. What we do often find is some of our patients may… back in the day, it’s changed considerably, but 15 years ago or so, a lot of my patients would get hormone meds on the streets because there weren’t a lot of providers out there that could provide them. Some of those meds were expired or not good or not real, and sometimes we’d see excess amounts of certain medications. Spironolactone is one of them, so you’re going to want to measure your potassium, for example. You have to keep on track on certain things.

Don’t go rogue. Understand that sometimes when they’re taking something, there’s this rush that folks are feeling. Imagine, right? It’s hormonal. When they’re feeling that rush, whether it’s the testosterone or the estrogen, they might use too much of it, and you have to track that. If they do deviate, and I’ve seen this quite a bit, you just have to level-set with them. Just say, “This isn’t working. I understand that it’s really important to you and you want to accelerate it.” Imagine these folks now have access, and they’re feeling the rush, and they just want to move on that journey. You have to pump the brakes. You have to slow it down and say, “We have to do this together because there are serious consequences if you go too fast.”

Kevin Pho: You mentioned politics a few times. Just give us a sense of some of the lived experiences that your trans patients are currently feeling or living through under this political climate.

Tyler B. Evans: It’s rough. In California, New York, your core blue states, it’s a little bit easier for our patients, but even there, it’s hard. I hear a lot of narratives from our patients, particularly in other states, where they’re thrown every type of verbal assault. They’ve been beaten. There was one particular situation where I had one patient who switched to us because that person was provided the incorrect name at the front office. Somebody knew that person and followed that person home and beat them because they understood that they had transitioned, and that was not OK. This is in the Bronx. They are going through a lot in terms of social environments that certain communities don’t understand.

In terms of the politics, we are not in a politically supportive environment right now, unfortunately. A lot of folks don’t understand the science. Almost every academy or institution—the American Academy of Pediatrics, the American Academy of Family Physicians, certainly WPATH and the WHO, and the American College of Obstetricians and Gynecologists—that I know of supports gender-affirming care. The science is there. It’s real.

This is a pathological element to it, and that’s tough sometimes. When we are communicating this to patients, sometimes this comes up: “Why are you treating me like this is a disease? This is not a disease.” Here’s the problem: as docs, we have to. We have to code it that way. We have to put in an ICD code to get our care reimbursed. That’s the reality of medicine. I think it’s important to frame it that it’s not a disease per se; it’s just a state of health. They might see that on their paperwork, and we have to explain that to them. I and others have worked for the Centers for Medicare & Medicaid Services to change some of these ICD codes. It’s an uphill battle. There are a lot of politics against this.

I’m an optimist. I do think we will get past a lot of these challenges, and in the future, I think we will get to a better place. At the same time, I am a member of communities. I’m a dad of four. I understand how communities can react to this, and they’re scared about their kids as well. They’re scared because they don’t have the information. That’s it, bottom line. A lot of these folks just don’t have the information beyond their politics. We can’t change that, but I think that as docs, as champions of these communities, if we can explain this in a way that gets to the core elements of people’s moral compass or ethical base… Even a lot of religious communities, particularly Christian communities, I have certain good friends who have experienced this themselves or have fathered or mothered children that are going through this experience and who are religious, and it’s been transformative for them. If we can really explain this to people to understand what these folks are going through, I think we can get to a better place. But we can’t push these folks either. I think that was some of the problem with our space in the last ten years or so; I think we pushed a little too fast. From a political spectrum, in terms of the 2020 election, I think we were just pushing too much. I think we need to go at a pace that is commensurate with what people are comfortable with, and I think we just have to read the room there.

Kevin Pho: What does that mean, like when you say that you have to go at a pace that is commensurate with people’s comfort levels? What does that mean to you?

Tyler B. Evans: You have to read the room. If you are in a California coastal community, you have to see where folks are at. If you are a local leader, you have to talk to folks and just ask them questions and see where they’re at. You have to talk to community leaders, interfaith leaders, and other CBOs and see where those folks are at. Then you need to go at a pace where you feel they’re going to be comfortable. I’m generalizing here, but if you’re looking at a very conservative state, perhaps a Mississippi or Kentucky or an Indiana, that’s going to be a very different pace from California. I think they’ll get there, perhaps, or certain micro-communities will, but you have to explain it and you have to get the right stakeholders in the room to get them there as well, and interfaith leaders are a big one.

Kevin Pho: So we’re going to look at a situation perhaps where different states are going to have different levels and different comfort levels with gender-affirming care.

Tyler B. Evans: As a doc, I always use metaphors for what we are doing. You have to triage. You have to see where folks are at and how you can get them to where you want them to go. You have to use your population health scalpel to do that. You might not be able to do everything, but you could probably move the needle to get somewhere, so that’s important to acknowledge.

Kevin Pho: Before we summarize, just tell us, in your ideal world, what would your ideal vision be like for gender-affirming care? If you were in charge of everything, what would you like to see happen?

Tyler B. Evans: Great question. I would love to see a place where all providers had some training on this, and there were general grand rounds or conferences around this where there was dialogue, interdisciplinary rounds, and dialogues to help address certain patients. We could look at certain case studies. I think if all medical communities needed to come together to understand the intersectionality of these humans and how everything comes together, and we all learned from that and looked at the science, I think we could have considerable advancements in biomedicine.

I do think there has been considerable research. If you go to the last WPATH conference I went to, it was about nine years ago. I actually piggybacked my wedding on that. It was in Buenos Aires, Argentina, and I ended up getting married in Argentina. But at that time, there was one session where they were looking at the increase in studies on transgender and gender-affirming care, and it was almost a parabolic curve. It was really considerable. I’d love to look at where that’s at now. Unfortunately, I think it’s been a bit stagnant in the last few years, again, because of the politics. But I think we’ll get back there. If we use the science and the evidence to support this care, I feel like most docs, not all, but most docs and health care professionals would support it.

Kevin Pho: We’re talking to Tyler Evans. He’s an infectious disease physician. Today’s KevinMD article is “Meeting transgender patients where they are a health care imperative.” Tyler, let’s end with some take-home messages for the KevinMD audience, and certainly you could mention your new book in that as well.

Tyler B. Evans: Great. Thanks, Kevin. The take-home messages are, my practice in health care is both on the individual level as well as the systems level. Lately, I run an organization called Wellness Equity Alliance, so we are working in the streets through street medicine, HIV street medicine mostly. We are working with at-risk youth and carceral health communities. We’re really focused on historically marginalized communities because we’re looking to close the gap on those inequities. I often now treat the system as opposed to the individual, but I still do see patients, and the system’s very sick.

The reality is I think we need to understand that more. As our students come out of their training, it’s really important to understand how the systems connect to the individual level, and I don’t think that we get enough of that in medical school. When we can marry med school with the MPH, for example, or public policy, you start to understand the more macro level. I think that’s really important to understand the systems that you are working in before you just apply your technical skills to that. A good, concrete example of that is in my world, we address a lot of our issues through the syndemic lens. Those are epidemics that are working together synergistically to amplify the outcome. HIV, for example, never really acts alone. In the individual exam room or on a systems level, we cannot look at HIV in a vacuum. We need to understand how it intersects with behavioral health, with addiction and substance use, with other infectious diseases, and particularly with the social determinants.

That is the main takeaway message: to really understand how health is all connected. Particularly when we’re looking at historically marginalized communities, we need to understand that all of these pieces connect, and if we are not addressing all of that, you’re going to lose. It’s super important to do that. I talk a lot about that in my book, *Pandemics, Poverty, and Politics*. It’s on Amazon and Barnes & Noble, published by Johns Hopkins University Press.

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

Tyler B. Evans: Great to be here. Thanks.