I recently participated in a conference where clinicians asked some absolutely phenomenal questions — the kind of thoughtful, vulnerable, nuanced questions that make me genuinely hopeful about the future of gender affirming care.

Questions about uncertainty.
Questions about fear.
Questions about mistakes.
Questions about systems.
Questions about how to practice ethically in a field where the evidence is evolving and the stakes are deeply human.

I found myself wanting more space for longer-form answers, nuance, and the ability to hyperlink directly to resources and references.

So I am working on answering questions here:

Q: Any difference in timing for osteoporosis screening for TGD patients?

For osteoporosis screening, I appreciate that both WPATH SOC8 and UCSF leave room for clinical judgment rather than pretending we have robust evidence here. SOC8 emphasizes detailed history taking around hormone exposure, gonadal surgeries, and traditional osteoporosis risk factors before deciding on screening timing. (Available in Chapter 15:12-13)

UCSF’s guidance feels practical to me:

• routine screening at 65

• consider 50-64 if additional risk factors

• and earlier screening if someone has had gonadectomy + prolonged time without hormone replacement.

I also appreciated the nuance in the 2019 ISCD Official Position paper on bone densitometry in TGD individuals (which was the document I mentioned). Their position essentially argues that if someone is on adequate gender affirming hormone therapy, BMD is generally stable to improving, and TGD status alone is not an indication for more aggressive osteoporosis screening. They specifically note that concern rises more with prolonged hypogonadism, significant lapses in hormone therapy, puberty suppression without adequate replacement, or other traditional osteoporosis risks.

What I struggle with sometimes is that many recommendations for TGD populations trend toward more aggressive screening despite limited outcome data. And I want to be careful not to recreate the pattern of overmedicalizing trans bodies simply because they are trans bodies.

At the same time, it’s impossible to separate these conversations from structural realities:

• many TGD people have interruptions in hormone access due to insurance, discrimination, poverty, geography, or safety

• many avoid healthcare settings entirely because of trauma

• many have eating disorder histories, HIV, smoking exposure, disability, steroid exposure, or chronic stress burdens that independently affect bone density

• and many clinicians still undertreat or inconsistently manage hormones because of discomfort or lack of training.

So for me, the question becomes less “Should trans people be screened earlier?” and more:

“Which TGD patients are experiencing cumulative structural and physiologic risk that actually changes pretest probability enough to justify screening?”

I probably lean a bit less aggressive than some guidelines because I worry about false positives, unnecessary medicalization, cost barriers, and the emotional burden of navigating more healthcare systems that often already feel unsafe to our communities.

But I also think a trauma-informed, individualized approach is evidence-based care in a field where evidence is still evolving.

Would love to hear other’s thoughts, opinions, and practices!

Q: How do you handle transgender patients asking you to do/prescribe off label meds/treatments that you haven't learned about using or feel uncomfortable doing? Recently had a patient get really upset with me for not doing something they wanted.

This is such a powerful and vulnerable question to ask. Thank you for your courage in doing so. I think almost all of us have had a similar experience and it feels terrible.

I have a sort of dual approach to this:
I start from a place of “yes” and from a place of transparency about my own limits.

During intake at our practice, one of the pre-visit questions asks:

“Are there any specific gender affirming medications or treatments you are interested in?”

That allows me some preparation ahead of time and honestly creates a much more trauma-informed experience for everyone. A lot of trans and gender diverse people are used to either:

• being immediately shut down

• needing to defend themselves

• or feeling like they have to hide what they are actually hoping for.

So instead of beginning from suspicion, I try to begin from collaboration.

I’ll often say something like:

“I saw you were interested in medication XYZ. If after we spend some time learning together this still feels like the right fit for your goals, I will prescribe it. In order to help you make the best choice for you, can you help me understand what you are hoping each of these medicine will do for you?”

I also have patients identify their desired changes/goals ahead of time in paperwork, which helps frame the conversation around outcomes rather than around whether a request feels “reasonable” to me personally. Sometimes what someone is asking for is actually a proxy for a different unmet goal or counter to their desired goal.

If it’s something I have limited or no experience with, I’m very transparent about that. I’ll say:

“I have limited knowledge/experience with this medication and I want to make sure I’m giving you accurate information. Can we schedule another visit in 1-2 weeks so I can spend some dedicated time researching and learning more? Then we can make a more informed decision together.”

Starting from a place of “yes” or “let me learn” has dramatically reduced conflict in my practice.

Ultimately, there have been rare occasions where I prescribed something against my recommendation after extensive informed consent discussions. In those cases, I documented:

• the risks discussed

• the limited evidence base

• my recommendation

• the patient’s understanding of risks/uncertainties

• and the rationale for shared decision making.

Because here’s the thing:

FDA-regulated prescriptions are often safer than forcing people into DIY care in isolation.

And therapeutic relationships require trust and safety.

I think many of us were trained in systems rooted in paternalism:

“I decide what is acceptable care.”

But honestly, I think it goes even deeper than that. We were all trained inside systems shaped by white supremacy and misogyny — systems that historically and currently controlled, experimented on, pathologized, and harmed BIPOC bodies, intersex bodies, disabled bodies, fat bodies, and trans bodies. The roots of modern medicine include paternalism and the belief that clinicians should determine what kinds of bodies, identities, risks, and futures are acceptable.

Even as medicine has shifted toward “shared decision making,” many of us still carry:

• fear of litigation

• fear of causing harm

• fear of uncertainty

• and fear of stepping outside institutional norms.

And to be fair, the desire to not harm someone is deeply real and human.

But I also think it is important to recognize that healthcare systems have often caused more harm to trans people through their “no’s” than through their “yes’s.”

Refusing care, delaying care, gatekeeping care, forcing DIY pathways, demanding perfection, demanding certainty, demanding conformity — those harms are not theoretical. They are measurable and lived.

That doesn’t mean we abandon clinical judgment. But it does mean many of us need to actively decolonize the ways we were taught to think about authority, expertise, risk, and autonomy.

And importantly: clinicians should not have to do that work alone.

Part of practicing ethically in evolving areas of medicine is building networks for ongoing learning and support. We need:

• trusted colleagues we can call

• mentors and experts willing to consult

• communities of practice

• harm reduction frameworks

• and accessible educational resources.

Some resources I’ve found incredibly valuable include:

• TransLine free e-consults

• the GAHC listserv

• colleagues doing thoughtful community-centered gender affirming care

• and CME spaces that allow for nuance and uncertainty, learnign together

And honestly, we also need ways to care for ourselves when these encounters happen.

Because when a patient is upset, many of us feel shame, fear, grief, defensiveness, inadequacy, or panic. Those feelings deserve care too. We need spaces where we can tend the hurt and tenderness in ourselves, let others help tend it, and continue the lifelong work of decolonizing our minds and practices without collapsing into fragility or avoidance.

This work asks us to stay teachable.
It asks us to tolerate uncertainty.
It asks us to be accountable without becoming punitive toward ourselves or others.
And it asks us to keep showing up anyway.

It is beautiful and messy and hope-giving. I have to believe that doing this work helps me to become the version of myself that can co-create a liberatory future.

Q: Please explain the link with transgender and colonialism? To my knowledge colonialism usually deals with race/ethnicity, not gender.

Ooo yes. This is SUCH an important question because a lot of us were taught to think about colonialism primarily through race and ethnicity, but colonialism absolutely also shaped modern Western ideas about gender, bodies, sexuality, and whose humanity is considered “civilized.”

Transness and gender diversity are not new.

Across history and across the world, there have always been people whose identities, roles, bodies, or ways of living existed outside rigid Western male/female categories. Human Rights Campaign notes that anthropologists have documented more than 150 pre-colonial Indigenous cultures that recognized third genders or gender diverse social roles. Some Indigenous North American communities today use the umbrella term “Two-Spirit,” though the meanings and traditions vary widely between Nations.

Many cultures historically had gender systems that were far more expansive than the rigid Western binary of “man/woman.” There were people who held spiritual or ceremonial gender roles, people whose labor and dress crossed categories, people who lived socially outside binary expectations, and people whose communities understood gender as fluid, relational, or expansive rather than fixed and biological.

Colonialism often violently disrupted those systems.

European colonial powers — deeply rooted in Christianity, white supremacy, patriarchy, and rigid gender roles — exported the belief that:

• there are only two genders

• those genders are biologically fixed

• men should dominate women

• reproductive sex is the “purpose” of bodies

• and deviation from these norms is immoral, uncivilized, criminal, or pathological.

Colonization didn’t just take land.

It imposed social structures and cultural control.

Just as colonial systems attempted to erase Indigenous languages, dress, spirituality, kinship structures, and cultural practices, they also targeted gender and sexual diversity as something to suppress or eliminate.

That included:

• criminalizing queer and trans identities

• forcing European gender roles onto Indigenous cultures

• erasing ceremonial/spiritual gender roles

• imposing binary dress and labor systems

• policing bodies and sexuality

• and later medicalizing people who existed outside those norms.

A lot of anti-LGBTQ+ laws globally are actually colonial imports. Many countries that currently criminalize homosexuality or gender diversity inherited those laws from British colonial rule rather than from their own pre-colonial cultural traditions.

And medicine participated in this too.

Modern Western medicine has a long history of deciding which bodies are “normal,” “healthy,” “moral,” “productive,” or “acceptable.” Intersex infants had surgeries forced on them to preserve binary norms. Black bodies were experimented on without consent. Disabled people were institutionalized and sterilized. Fat people were pathologized. Women were denied autonomy and excluded from research. Trans people were forced to prove themselves “trans enough” to access care and were often institutionalized. You can learn more about this history in an excellent article in the NEJM.

These systems are interconnected.

So when people talk about decolonizing gender affirming care, I don’t think they mean:

“Everything Western is bad.”

I think they mean:

• Can we critically examine the inherited assumptions underneath our systems?

• Who benefits from rigid binaries?

• Who gets harmed?

• Who gets erased?

• Who gets authority over other people’s bodies?

And importantly:

Can we move away from models rooted in control and toward models rooted in autonomy, informed consent, humility, and relationship?

So the connection between colonialism and transness is not that gender diversity is “new” or caused by colonialism.

It’s that colonial systems worked to erase and criminalize longstanding forms of gender diversity while enforcing rigid binary norms as part of broader systems of domination and cultural assimilation.

And medicine inherited many of those assumptions whether we realize it or not.