Dr. Crystal Beal (they/themme): All right, everyone. Welcome back to the queer See Me podcast. I'm super stoked to have Mitchell Hunter on and I'm gonna let Mitchell introduce yourself.
Mitchell Hunter: hi. My name is Mitchell Hunter. I go by Mitch. Is I'm a transgender man of I would call an activist an advocate for at least the last 30 years, but that would be before transition. So I would be considered somewhat the OG so the Old Guard prior to and around the year 2000 was my transition. So a lot of my information has been
Mitchell Hunter: and the work I've done has been in kind of catching people up to who we are and also in kind of in maintaining at least the protections and the things we have in this state of Washington and city of Seattle. So we've continued to work on things from the very beginning and that's part of my work. I've done not only education for Clinicians and Hospital situations and UW Medical Center, we created a course but also for getting the rules and the insurance coverage that we really need and that we need to continue. So the legislative kind of boring part of that too. So
Dr. Crystal Beal (they/themme):
Dr. Crystal Beal (they/themme): I don't know that I would call that boring as someone who also does quite a bit of legislative work. Maybe we'll agree to disagree on that part. But I would love.
Mitchell Hunter: Yeah, maybe slow going.
Dr. Crystal Beal (they/themme): It's yeah,…
Dr. Crystal Beal (they/themme): that is a very good way to describe it.
Mitchell Hunter: okay in that form of boring like we're way ahead,…
Dr. Crystal Beal (they/themme): That Yes. Yeah,…
Mitchell Hunter: so where it is? Yeah.
Dr. Crystal Beal (they/themme): I would say slow grains a very good way to describe it also time consuming and frustrating.
Mitchell Hunter: Yeah.
Dr. Crystal Beal (they/themme): Yeah, I would love to actually talk a little bit about both aspects of that work both the teaching and training educating and the advocacy. we'll start with the teaching training advocacy and we are mostly talking to our listeners as prescribing clinicians. So what are some of the major gaps you've seen in healthcare knowledge in the prescribing clinicians knowledge when you go in an educate, these are my top five pearls for something like
Mitchell Hunter: Okay top five. that's great and challenge. I would say.
Mitchell Hunter: and I may not get that order of importance to these down but in that I am an older guy and someone who transitioned later in life, one of the most important things that I want to do, especially for prescribing folks is to try and get across the idea that our bodies transgender masculine. I'm just going to talk from my own point of view all this time, but our bodies are identical or in many ways at least our genitals and the things that we need to talk about in terms of
Mitchell Hunter: internal stuff is identical to postmenopausal women and yet I've never heard of that before or we don't really treat that and it's like, excuse me, but you do these are things that you all know about and
Dr. Crystal Beal (they/themme): It's funny. I was actually talking to a group of residents. And yes yesterday and I actually think I'm front hole or vaginal estradiol is highly underutilized and under prescribed for gender diverse people with vulvas who are on testosterone and I also think that is true of personal CIS women it's not a population I work with anymore, but I think that's still true and it was really funny because one of the faculty spoke up and was like, I don't have a lot of experience with trans patients, but I do with Postman Apostles this women and yes, it was great.
Mitchell Hunter: yeah. Yes, yes.
Dr. Crystal Beal (they/themme): I was saying venue, right? So, the atrophic changes that occur to the vulva in the vagina with prolonged testosterone exposure are not dissimilar to the atrophic changes. We see and post mental puzzles this woman. I'm throwing a lot of medical words out right now but being
Mitchell Hunter: No, I like that. you're saying it more correctly. I'm doing the kind of vernacular. But yeah,
00:05:00
Dr. Crystal Beal (they/themme): I think both are great because we listeners are going to have all different levels of experience and training.
Mitchell Hunter: And it's especially the problem comes in. when I've asked for estradiol or some sort of estrogen. Substitute because I need both right and all of a sudden Insurance gets surprised. They're like, we just got you figured out as a guy what the hell why are you asking for two kinds of pronouns?
Dr. Crystal Beal (they/themme): Thank you.
Mitchell Hunter: I mean a pronounce that two kinds of hormones. what is this? And I'm like No, this is absolutely required. And the other thing is I educate my friends who happen to be in the postmenopausal women State because I'm said guess what doctors aren't gonna tell you either. So, when you're having these?
Mitchell Hunter: trouble with dryness and itchiness inflamed pain, who wants to as in anyone with that particular part of the anatomy who wants to use it or lose? I don't want to use it when it's Hurts like hell, right. Who wants to do the things that you need to do to stay healthy and…
Dr. Crystal Beal (they/themme): right
Mitchell Hunter: it's in to maintain your health, especially Sexual Health, right? And I'm those guys and…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: they're like you're kidding me. And I said no this is something important.
Dr. Crystal Beal (they/themme): It's so funny where I'm slightly derailing the question. I asked you because this really did come up just the other day and I was saying how underutilized I think vaginal front hole Astra dial is for people taking testosterone with vulvas that honestly, I would actually love to start the prescription for testosterone and estrogen at the same time for most of my patients and that I have not found the right way to script that to patients for them to actually buy into which is totally understandable. These are people who are coming to me who are over astrogen. I want nothing to do with it anymore right in our super excited to start testosterone, but I really think I need to work on how I'm toxications about it. So that the educational Point comes across right that Lake and
Mitchell Hunter: right
Dr. Crystal Beal (they/themme): You know that this won't have huge effects on the results you see from your transition, but it will help protect the vulver and vaginal tissues and to keep them healthier as you age inary tract infections less risk of recurrent urinary symptoms, right? Because we have a lot of urethral irritation and urinary symptoms when we have atrophic vaginitis involveitis, and then just the elasticity of all of those tissues, right their ability to stretch and…
Mitchell Hunter: No completely.
Dr. Crystal Beal (they/themme): be resilient when we have any kind of receptive sexual practices decreases significantly under the influence of testosterone.
Mitchell Hunter: I actually had in working on an advocacy team for transhealth at one of our area hospitals, Virginia Mason. I had an argument with I'm gonna forget it the word for people that deal with only with hormones and things like that.
Dr. Crystal Beal (they/themme): endocrinologist Yeah.
Mitchell Hunter: Thank Yeah, I had an argument and I said, look what happens is the minute that will not them in it. But if we've been on full dose of testosterone for more than a year even between years one and three We start to see these symptoms and I said, so you need to understand you're prescribing this for.
Mitchell Hunter: Guys that are maybe up through their first puberty and they're going to be in their 20s when their sex drive is the very highest and they're gonna start saying, my God, what is the Hat? I don't understand. Why is this hurt? why is everything kind of closing down on me? I don't get this, Especially for me men who have sex with men in particular it comes up because we want to be available and it's like no, maybe not now, and how do we
Mitchell Hunter: I agree that there's this kind of question about…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: how do we educate each other? my guys I'm like, look, here's the deal. You need to know this is coming up and it won't come up right now. you're still counting your chest hairs. You're trying to see where hair's gonna come up and my God, But it's gonna happen and it's gonna happen about the same time. This is my second piece is about the same time that you start getting.
00:10:00
Mitchell Hunter: cramps during orgasm so your pelvic floor
Mitchell Hunter: Guess what we're getting strong everywhere and it's not about whether or not you're doing your kegels, That's what every doctor told me. In fact, I started using that question I said, what is the deal when I'm having about to have orgasm and all of a sudden everything tenses up I go into a charlie horse and…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: it's like, my God, I can't even finish and I don't want to do this and it's just really hard because you're all revved up. So how do you relax that those muscles when you're about to come and I said, we discovered that because we talk together and you young guys you can see or people early in their transition. I should say also, they're like, what is this thing? I've never had that before so I used to ask the
Mitchell Hunter: doctors that and if they answered with you need to do your kegels I would say goodbye.
Dr. Crystal Beal (they/themme): the opposite Yeah, it's the opposite right?
Mitchell Hunter: Thank you very much. You don't know enough about me. So no, we're not working together. And yeah.
Dr. Crystal Beal (they/themme): And that's where a really great pelvic floor physical therapist can help as well and who has good training and working with transgender diverse folks and we were lucky enough to have a few in Seattle. We actually have a pelvic floor physical therapist who is trans themselves, which is phenomenal and…
Mitchell Hunter: cool.
Dr. Crystal Beal (they/themme): they do home visits. So Dr. Ken McGee who's contributed a lot of content. So my work in the past phenomenal human and has great lived experience that they can build on as well as a lot of amazing training they're Wicked smart every time I talk to them. I'm learn so many things but yeah that hypertonicity of that pelvic floor can cause quite a bit of discomfort and yeah, it can be very much the opposite of a Kegel. It's like you actually need to learn how to loosen and soften all of those muscles.
Mitchell Hunter: Yeah, And that's another one of those things. So these things that I have that are my big issues. I'm not just telling doctors about it. I'm also telling other guys about it…
Dr. Crystal Beal (they/themme): up
Mitchell Hunter: because it's a look here's the deal, we get strong everywhere. the only muscles that don't strengthen with testosterone are your anal sphincter muscles right? Because they don't get stronger, or that would have been a really bad design,
Dr. Crystal Beal (they/themme): Yeah, there's mood muscle fibers the other slightly different muscles issues. Yeah,…
Mitchell Hunter: Yeah, yeah, but I just explained.
Dr. Crystal Beal (they/themme): but you do lose the last Tiffany right like that back to kind of that first point.
Mitchell Hunter: mmm
Dr. Crystal Beal (they/themme): I find that And this is interesting this came up on my list. I'm like derailing I think and you were like keep me on topic and I'm like, you're gonna have to keep me on topic So it's a journey.
Mitchell Hunter: it's okay because it's a nice year I can go with you.
Dr. Crystal Beal (they/themme): And people were talking in our list serve today about is there a higher incidence of a condition-related to hypermobility among trans and gender diverse people. It seems like there might be some correlation between having more mobile joints in stretch your skin. Possibly with being transgender diverse. We're not really sure the data is early and we don't have a lot of the research, but it seems to be maybe that's a thing.
Mitchell Hunter: More stretch or less stretchy. okay.
Dr. Crystal Beal (they/themme): More stretchy and so often I don't know if you ever heard of earlier Stan Lewis EDS and so it is a thing where hypermobile joints and a lot of people who are gender diverse Who start testosterone report Improvement in their hypermobility. After starting testosterone and so there's some kind of tonesty change happening in that tissue, it's getting less elastic and less stretchy definitely like muscular strength can help support joints, but really kind of the physical therapy we ask people to do to help support hypermobile joints is very specific and the way we have them strength training is very specific. So, I don't know that just general strength will do the same thing. So I do think there is some component of connective tissue. That gets less stretchy when we expose it to testosterone.
Mitchell Hunter: mmm
Dr. Crystal Beal (they/themme): And so that all of those kind of again vulver and rectal tissues. Especially if you are a side Queen and you want them to stay stretchy,…
00:15:00
Mitchell Hunter: Yes. Yes, exactly.
Dr. Crystal Beal (they/themme): right and resilient and so that's circling back to that lake front hall or vaginal estradiol being a very important component of this care.
Mitchell Hunter: right so To two things are popping into my head one is that I wanted to kind of get in there that there are many more different forms of estradiol than the cream.
Dr. Crystal Beal (they/themme): So I did get to your point.
Mitchell Hunter: I personally hate the cream, …
Dr. Crystal Beal (they/themme): .
Mitchell Hunter: you have to put it in it is messy it's drippy. It drips out all night. That means that I don't have access to a sexual partner who's interested, at that point and so that's the first thing that gets Prescribed right and it's hella expensive even for the insurance to cover I asked for the suppositories or…
Dr. Crystal Beal (they/themme): of you Inserter,…
Mitchell Hunter: that's what they call it, but it's the stuff that you can put in with the little fake one.
Dr. Crystal Beal (they/themme): yeah. Boop
Mitchell Hunter: And I like that because it does dissolve but it dissolves slowly. There's no drippiness for the most part, it's and it just sorted does it on its own and I mean, I have a couple of really strange little stories about that, but that's for a stand-up comedy routine,
Dr. Crystal Beal (they/themme): Already, I always weren't right. I always wore my patients because then the brand name for that is vagifim, which is not a great name for Trans folks a lot of times. So I always let people know that that might be on the package and make sure that's okay with them and…
Mitchell Hunter: It's also super pink.
Dr. Crystal Beal (they/themme): prescriber. always you…
Mitchell Hunter: Everything is Pink.
Dr. Crystal Beal (they/themme): so the other thing I sometimes do prescribers. Let me remind you you were responsible for your own practices. it does not alleviate you of liability to say I heard it on Dr. Bill's podcast, but I have occasionally for effectiveness and actually just ordered oral estradiol tablets. So actually what we typically give trans and gender reverse folks who want to get boobs. And to order the 0.5 milligrams, which is 50 micrograms. So it's still way more than 10 micrograms. That is the badge of him tablets but have someone
Dr. Crystal Beal (they/themme): Cut those in halves or quarters, they're real tiny. So it halves is sometimes hard and do it and just place that if they're happy or comfortable placing it digitally and instead of the badge of him tell it's in their cheapest dirt. And so that's a really accessible way as well.
Mitchell Hunter: They're not taking them orally but using them to digitally place. Okay, because I was like God I want to put it orally,…
Dr. Crystal Beal (they/themme): Mmm Yeah No,…
Mitchell Hunter: once they make
Dr. Crystal Beal (they/themme): no because almost all of the astrodiol tablets in the United States are micronized so they will absorb into the mucosal tissue over time. If you just pop them somewhere. That's right, most trans folks taking estrogen they don't swallow it. They let it dissolve in their mouth, right they do it sublingually and…
Mitchell Hunter: .
Dr. Crystal Beal (they/themme): so you can just do that in other holes.
Mitchell Hunter: Yeah, yeah surprising. that's all about that tissue being the same kind of tissue, right? Yeah,…
Dr. Crystal Beal (they/themme): Right similar. Yeah.
Mitchell Hunter: the other thing that popped up besides that was I'm just the importance of asking about, requesting because doctors won't suggested but just saying that you need the pelvic floor physical therapy and the name for that is really gross and it's about this long. So I don't know it starts with a d I think maybe did The name for the condition when you need pelvic floor.
Dr. Crystal Beal (they/themme): this Perry urania.
Mitchell Hunter: it sounds gross. I won't say it.
Dr. Crystal Beal (they/themme): I Probably got to go school. So
Dr. Crystal Beal (they/themme): listening to this podcast
Mitchell Hunter: Okay, so my experience was I went in to the desk at physical therapy because I did mine at Virginia Mason. I had an incredible physical therapist. there and I explained how she was really good with me and that she should take this on the road for the rest of us, because we did it but I went in to the front desk and the most ridiculous thing was I said this advocacy team was working on how we could get better with all kinds of Health. So I went to the front desk and they had two colored papers pink and blue when you walked in.
00:20:00
Dr. Crystal Beal (they/themme): God.
Mitchell Hunter: the first of all which kind are you basically and…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: then they had the thing you got a circle where your issues are and so The wrong body symbol there wasn't a way for me to do that on the blue and…
Dr. Crystal Beal (they/themme): wrong bits and Bob
Dr. Crystal Beal (they/themme): You're like, excuse me.
Mitchell Hunter: there what? Yes.
Dr. Crystal Beal (they/themme): Can I have scissors and some tape and glue so I can arts and craft this s* for you right now.
Mitchell Hunter: Yeah, and then they asked okay, it's an open. you just come in for physical therapy. So it's big open, Room everybody sitting side by side and then they're like and what are you here for? and I'm this dude with a beard and…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: and I said can I just write that down for you? And then they're like no real, just tell me what kind of stuff I'm like. I'm not gonna say it out loud. I'm not gonna say this, right? …
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: it is the front desk admin clinicians that are a part of this too. It's not just and so it was all that first of all I'm not going to say that d word and they said didn't Let alone like no don't don't. Yeah, no, no. so there's that
Dr. Crystal Beal (they/themme): I try to always remind all of my patients and also my community the power of no and I also always try to educate clinicians about how important it is to empower.
Dr. Crystal Beal (they/themme): Disenfranchised and marginalized people to say no in a healthcare setting right? And so it's so important prescribing clinicians for us to make it a safe space for people to say no because This is the one thing in the world we get to control right and…
Mitchell Hunter: Yes, yes.
Dr. Crystal Beal (they/themme): as a fem person as a queer and gender diverse person so many of my rights and privileges are outside of my control and so much of my experiences outside of my control, I walk down the street and I'm Gonna Get comments questions concerns, ask to smile all the things that happen where and you wear lipsticks and skirts and it's just outside of my control and it's part of how I'm gonna have to interface with the world unless I want to change how I present which I don't
Dr. Crystal Beal (they/themme): It's** exhausting and then top it off. I'm gonna get misgendered 42 times at my goddamn job most the time, I go to present and teach and educate about trans health care and get misgendered why I'm there but the one thing I do get to control is what actually happens to my body. This is my body and my Healthcare I get to have autonomy and control over this and so please clinicians, please Empower your patients to say no and so specifically when I'm working with adolescents we talk about this a lot. I say you're trans at some point while you were getting Health Care. Someone is going to ask you something inappropriate about your body because they're curious not because it actually is relevant to your health care and I want you to have practicing no with me where it's gonna be safe in my response is gonna be like, I'm so glad you said a boundary. That is awesome. Let's move on. and before you actually have to use that no in a situation where you feel scared. and so it's
Mitchell Hunter: Look, yeah, the female tells you that you're not going to get the treatment you want or need if I know to you you're the gatekeeper…
Dr. Crystal Beal (they/themme): yeah.
Mitchell Hunter: what happens even if you're at a desk and you're not even doing the work, right you're an admin, but you have the power of being a gatekeeper to me and…
Dr. Crystal Beal (they/themme): right
Mitchell Hunter: all it takes is me saying no.
Dr. Crystal Beal (they/themme): Yeah, it feels that way into one of the other things. I always say and to my adolescence and then I say this to my adults too. when they're getting to know me I say I think consent is essential. So if I ever ask you any questions, you don't want to answer feel free to say that. it is almost never gonna affect my ability to prescribe for you and if it were absolutely essential for prescription purposes, I would let you know that So I automatically and…
Mitchell Hunter: Yeah.
Dr. Crystal Beal (they/themme): taking off the table the fact that I will keep the thing that they need if they say no to me and…
Mitchell Hunter: That even just hearing that.
Dr. Crystal Beal (they/themme): so Clinton.
Mitchell Hunter: My God it just
Mitchell Hunter: yeah, so everybody listened to this s*** that we're saying because I'm sorry the stuff that we're saying because This is real this and…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: I am really old. I just had a birthday last week. I just turned 63. Yes, thank you.
Dr. Crystal Beal (they/themme): Happy birthday.
Mitchell Hunter: And Even now just hearing that, almost my God, my shoulders dropped. It's like okay, I can say this, right? and…
00:25:00
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: It's important. We're used to gatekeeping at everything. And in the old days when I did this there were many Hoops that we had a jump through and…
Dr. Crystal Beal (they/themme): Yes.
Dr. Crystal Beal (they/themme): Yeah. Yeah.
Mitchell Hunter: that we had to say and in fact, I still live with having a mental illness.
Mitchell Hunter: On my records because in order for me to even start my journey with hormones. I had to have a mental health diagnosis gender dysphoria, and that meant that one disease that I was classified as Meant that I could start the journey to have the life that I deserve to live, and I'm like at the time. I was selling insurance. And I was a financial advisor in selling insurance.
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: And do you know that for me to buy my own life insurance? I had to pay extra premiums and…
Dr. Crystal Beal (they/themme): Yep.
Mitchell Hunter: they went into my medical records because I had a mental health diagnosis.
Dr. Crystal Beal (they/themme): Yep.
Dr. Crystal Beal (they/themme): Yep.
Mitchell Hunter: And they dug in and I don't even want to tell you how I had to work out of that. And I was a professional in the field. Right. And so I knew…
Dr. Crystal Beal (they/themme): Yes.
Mitchell Hunter: what I had to do and I said, okay, I went to my doctor I said look here's the deal. This is what you need to write. It does not affect That's a whole other thing we can talk to you about life expectancy.
Dr. Crystal Beal (they/themme): Life insurance premiums.
Mitchell Hunter: Okay. Yeah.
Dr. Crystal Beal (they/themme): I actually talk about this concept as well and whenever I'm lecturing somewhere, I start off my lectures by taking a moment to reflect on social justice values that I hold. and I talk about the concept that Giving gender diversity a diagnosis allows access to care in our current system. It can be very pathologizing to people to say this
Dr. Crystal Beal (they/themme): This everyday part of being human is we're gonna call it a disease, And so for some people it's really freeing right sometimes when we have people get a name that is really freeing for them. But for a lot of people it's like you this isn't perfectly awesome part of who I am and now you're calling it a disease and so I like to always talk about that concept and remembering how important that is and I use an endocrine diagnosis. For 97% of my work. The only time I pull a gender diagnosis is when I have to for insurance and so it's to get surgery covered and it's to get puberty blockers covered. That is when I diagnose gender. Otherwise, they call it endocrine disorder NOS.
Mitchell Hunter: Yeah, right.
Dr. Crystal Beal (they/themme): E34.9 clinicians you can use that.
Mitchell Hunter: Yeah.
Mitchell Hunter: That's just so important and it's not the social justice part is the part that you and I were talking about that we work on. The other side of is that it has still in society.
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: There are other effects like the insurance company was worried. my God. Now this is gonna affect, if it's mental health and it's the same as being possibly taking, antidepressants like what eighty nine ninety percent of our whole population does now,
Dr. Crystal Beal (they/themme): the Seattle
Mitchell Hunter: But because of that you have a mental, so therefore it could affect our statistical, and of life, right? And…
Dr. Crystal Beal (they/themme): Yep.
Mitchell Hunter: what is that death day and all that other kind of stuff. and then it becomes this systemic just like racism like all the others it becomes a systemic and institutionalized form of Injustice, And so then I had to get up and talk about these. They're the only studies at the time. We're from Switzerland that were more than 10 years, and I had to go into that and talk to the statisticians and you can still use a female, I mean, it just went on and…
Dr. Crystal Beal (they/themme): Right actually very well data was like a man.
Mitchell Hunter: on and on I mean Yes, yeah, yeah.
Dr. Crystal Beal (they/themme): And I think it's so important like we're talking about I just want to call it out because we're talking about social justice and we're talking about systemic forces of Oppression. Right? And I know listeners, this but intersectional identities are going to amplify all of those systemic forces of Oppression, So if you're trans and black or if you are trans and disabled or you are your black fat disabled and trans, every time you add another intersectional Identity or more. I always call it being multiple marginalized right? You're gonna have worsening systemic oppression making it even more challenging to access care and so it's so amazing Mitch
00:30:00
Dr. Crystal Beal (they/themme): Actually had the knowledge ability and skills to advocate for himself but he just happened to be in that industry right think about all the people who weren't and didn't know how and couldn't access those things. and it's always important for each of us as individual clinicians to continue to work on.
Dr. Crystal Beal (they/themme): Anti-racism and other forms of anti oppressive training even and so we have to do that on an individual level, but then it's also so essential for us to take those skills into our workplaces and to bring them to Virginia Mason or Swedish or Providence or University of Washington or Kaiser or Sutter wherever it is you are in the country because Healthcare is a system and systems across people and so it's so essential that we continue that anti oppression work. at the level of our Healthcare Systems not just as individuals
Mitchell Hunter: Yeah, and I think there's a couple of instances in the talking about transition. In general that we have to work together in order to do this. I remember even as simple as having the letter, it's like And I don't know if we should call it a scarlet tea instead of I don't know.
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: the Scarlet, whatever, but do you know that when I did not apply for
Mitchell Hunter: to go out of the country you need I did not apply for a passport…
Dr. Crystal Beal (they/themme): your passport.
Mitchell Hunter: until I sing with the Seattle Men's Chorus and we were gonna go to Germany. And so it was 2014.
Dr. Crystal Beal (they/themme):
Mitchell Hunter: And so let's see. I think I was about 12 years cooked by the time so I was pretty easy, but I never had a passport. so I started working six months ahead of time because I knew there was going to be Michigan
Dr. Crystal Beal (they/themme): poop poop
Mitchell Hunter: Yes. Oops as a Yiddish word for those of you that may not have recognized it so
Mitchell Hunter: I worked with the doctor and I said look, I went to the official passport site because I started polling everybody. What do I do? Because we ask each other we don't do anything else,…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: And how do we do this? I went to the official site and looked at what they were acquired. I copied it. And I took it to my doctor and I said I want you to reproduce this on your own word And I said the spots that you put your name and your designation or whatever great. I want you to sign it in ink and give me two copies. One has to go somewhere and one I will have because that could get lost right.
Mitchell Hunter: And do you know when I set up my appointment? And because I'd never had one I had to go show up in person. And do you know the person at that window? Put the doctor's letter right here and pulled up the letter there and they went word you think I was not fully sweated underneath all my clothes.
Dr. Crystal Beal (they/themme): Jesus Christ
Mitchell Hunter: I was like, okay, please God and they were other people in line, and I'm like what the hell don't they have a special person? Who does this for you call the trans person to come and call the person that handles this right,…
Dr. Crystal Beal (they/themme):
Mitchell Hunter: but don't put it up on the window and go with your, Monitor and It was the most embarrassed.
Dr. Crystal Beal (they/themme): And thank goodness. They have removed the requirement for letters from federal documentation. No longer needed for passport or Social Security. Right? And there is Yes,…
Mitchell Hunter: We thought hard for that and this is why.
00:35:00
Dr. Crystal Beal (they/themme): that is those experiences. essential and I would say other since we're on it. The other thing I often hear come up questions from Community clinicians is how do we counsel patients about the X option on and passwords? And I just always tell them so much is unknown currently because it's such a Option and that if you get an X option in some ways it does automatically out you when you travel and so the importance of doing your research should make sure you're only traveling to countries that are safe or going to be like that much more essential which is something I counsel all my patients to do anyways, but it just becomes that much more important when you're automatically outed but self attestation. So no one has to sweat in the passport office like Mitch. Did I hope your trip to Germany was good, though.
Mitchell Hunter: Always incredible and in fact the whole way that I view my comfort level and my self-acceptance in my sexuality and my sexual choices and identity. I can thank Germany in the European model for that. So that yeah,…
Dr. Crystal Beal (they/themme): Okay, yeah.
Mitchell Hunter: that's a whole other one too. And that's an exciting one. So, it's
Dr. Crystal Beal (they/themme): Berlin's on my list of places to go. I am a very kinky human and so Berlin is on my list. I'm like, I'm gonna get there one day.
Mitchell Hunter: Okay, we that's a whole other cap thing right,…
Dr. Crystal Beal (they/themme): Yeah, and I actually was just doing a talk for a bunch of attorneys and…
Mitchell Hunter: but I can go there with you too.
Dr. Crystal Beal (they/themme): Who were very specifically wanting to hear about telemedicine and trans Healthcare bans and banned States? And so we were talking about that, but I was talking about how Right first Western medicine trans Health Clinic was in 1919. It's been over a hundred years. This is not new health care anymore. FYI. This is old Healthcare. and…
Mitchell Hunter: exactly
Dr. Crystal Beal (they/themme): Ray and trans people have existed as long as humans have existed, but we have Western medicine gender firming care. 1919 and that was in Germany, right? That was the hirschfield clinic and…
Mitchell Hunter: Cursive, yeah.
Dr. Crystal Beal (they/themme): so I'm super important to remind everyone that this is not This is not untested. This is not a fad and this is not a phase. And so trying to keep that in perspective for people and I think that little fact can be helpful to remind people that we've had trans health clinics for over a hundred years in Western medicine.
Dr. Crystal Beal (they/themme): You can also remind them that you…
Mitchell Hunter: Yeah.
Dr. Crystal Beal (they/themme): the herschfield clinic went to function when the Nazis showed up and that half of all Physicians joined the Nazi party in Germany. So FYI, if you are not doing advocacy around bands and you're not speaking up to support your trans patients. I'm concerned that you might become part of the Nazi party that is establishing itself in the United States. And so I'm just going to shake that shame finger out all of you clinicians. Sorry, we're done.
Mitchell Hunter: I like to consider myself an change agent from within so I work within the systems and…
Dr. Crystal Beal (they/themme): There you go.
Mitchell Hunter: I remind them if they're not speaking up for someone then it may be them when it's
Dr. Crystal Beal (they/themme): So yeah.
Mitchell Hunter: And we're seeing that across the country. So we see all these anti-trans bills all the youth and whether it's using the restrooms or you getting their pronouns or being in sports, whatever it is, right? We see it start. In all these country and states and we can look at the map right,…
Dr. Crystal Beal (they/themme): Right you.
Mitchell Hunter: Aaron in the morning, right?
Dr. Crystal Beal (they/themme): I love Aaron in the morning.
Mitchell Hunter: okay, so the map you can go straight by that and…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: then I've been bitching about how these are the very same states that are going to be starting to have issues in terms of wanting to follow women out of the state because they might have an abortion in another state right and I said this is gonna follow and once you start with one, then the other stuff is that's why I'm a feminist. I stopped at wearing the p**** hat, but I was in the March. And it for me just do that.
Dr. Crystal Beal (they/themme): nice elsewhere the Hat. No one has to wear the hat.
Mitchell Hunter: Okay, but I was there. Yeah, even that. Yeah, so
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: But we have to take up each other's issues. Because if we don't none of us are gonna be here, it's like we just find one thing after another and I was listening to Rachel maddowell and she said, okay look. they came for the transfers and now we're going for women and now we're gonna follow them out of the state because we want people from other states that are giving and Healthcare appropriate health care and human rights Services, right? We want your names too, and we want to follow our people out and she Looks like she tied at state to state and…
00:40:00
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: it was like, my God, I was like reach it.
Dr. Crystal Beal (they/themme): Yeah, I completely agree solidarity and everything and it is really interesting. One of my talks in Portland and the room was primarily this female Physicians and one of the things I always challenge my colleagues on is how does it feel when a patient uses your first name? Because I give all of my patients the option to call me, Dr. Christler Crystal and
Dr. Crystal Beal (they/themme): And because you never know who's traumatized too, right and more importantly there is a power differential that exists in that room and…
Mitchell Hunter: three
Dr. Crystal Beal (they/themme): I am on top of that power differential and it is my job to try to flatten it. and I don't need the title to have the power. I have it like I did it right like I went to the school. I got the degree. I have the prescription pad and…
Mitchell Hunter: a piece of paper. It's on the wall. Yeah.
Dr. Crystal Beal (they/themme): so, what gives me the power is this whole system that we've built that says I have it and so it's so essential to allow space for that. To not exist to try to flatten that power Dynamic. So people feel like they have the right to say no to me right because it's so important for people to be able to say no to me because this is their body and so I think. That's a super important thing for this female Physicians. It is a very hard concept to sit with because they have spent so much of their career. Not being addressed as the doctor. right
Mitchell Hunter: I get that. yeah.
Dr. Crystal Beal (they/themme): They're always the nurse which hello shout out to all my nurses who are doing amazing work. Thank you, rate and then they're like the male presenting our Mass presentation colleagues are always the doctor and so it's been a hard thought like identity to be recognized and so to let go of and so it's always an interesting conversation to have about the Nuance of it. And I think one of the women in the audience when this woman in the audience presumably says, I didn't ask her identity but she said I want to be welcoming to everyone but I feel like I'm losing my identity I am a mother I am breastfeeding. and I was like that is a Lie the patriarchy has told you that there is a limited amount of power. Are you giving up some of your
Dr. Crystal Beal (they/themme): Recognition, you're giving up some of your power like that is not how this system works. inclusion is not a pie. If I give up some of my pie, right? That's not…
Mitchell Hunter: It's like he's near City versus abundance,…
Dr. Crystal Beal (they/themme): how it works.
Mitchell Hunter: theories.
Dr. Crystal Beal (they/themme): Yeah, it's So there's not a limited amount of power and there's not a limited amount of love in this world. And so it's really really important to keep that solidarity and everything and when you start thinking If I recognize someone else I lose some of my recognition just remember that that is a lie that the people in power have used to keep us disenfranchised and we can learn that from our history lessons from feminism. We know that the first feminist kind of f***** up because they were like, we're just gonna focus on white ladies rights. Said that's all we're gonna do right?
Mitchell Hunter: they all were white ladies at the team.
Dr. Crystal Beal (they/themme): I know greatly because they didn't allow space in their movement.
Mitchell Hunter: So yes, yeah. Yeah or yeah.
Dr. Crystal Beal (they/themme): For other people and so it's so essential. I do want to shout out though. You called out Aaron in the morning. I'm gonna screen share for people who are watching the video.
Mitchell Hunter: Please do.
Dr. Crystal Beal (they/themme): Aaron in the Mormons an independent journalist that Mitch just mentioned who tracks anti-trans legislation does a phenomenal job. And if you have ever used Aaron's resources or refer to them frequently, I do encourage you to contribute and I think you have a patreon. Anyways, you can subscribe somehow and As an independent journalist, all of their funding comes from their subscribers. And so this is how we get news besides the New York Times which we all know were unhappy with now, and another if you're ever looking for another good map project and I do love the movement advancement project as well they do
Mitchell Hunter: Yeah MIT. That's what I use in all The two ones.
Dr. Crystal Beal (they/themme): Yeah, they do amazing mapping and…
Mitchell Hunter: There we go.
Dr. Crystal Beal (they/themme): of all kinds of different issues around Health Care trans rights, and so really really great for any of you clinicians who are working and advocacy or just want some more broad Strokes understanding of the current situation.
00:45:00
Mitchell Hunter: Thank you for doing that. Yeah, those are my sources when I do training. So yeah, it's really really important. I was going to bring up we kind of have danced around a little bit about the size question and I will be super honest. I had to look up the letters that you said how to prep for this. health and every size Maybe look it up.
Dr. Crystal Beal (they/themme): Health at every size. Yes. why?
Mitchell Hunter: I didn't know what that was. So I will admit that. I did have to look it up. The thing I wanted to say about that and what I do another one of the main things that I tell my folks I work with. And frankly, I have educated every doctor and every nurse and every clinician I've worked with and I consider it.
Mitchell Hunter: I don't think it's a burden. I started in the early days when we did no more. And I don't think it's a burden. It's something that I feel like I have the privilege to be out and my life out. I don't live stealth and I have a privilege and so I use my privilege for people that don't that or can't And because it's unsafe for them, right so I consider it to be this great privilege that I get to tell you something that you may not know. and I know there's no, education in the medical field because
Mitchell Hunter: I was on a very small team who created curriculum. and taught a transgender Health Care course the very first one at a major medical and school at the UW Medical School medicine. So we taught it we were given to start with we created a whole course and then they said no, we're only giving you an optional course that they can take and so we had to cut it down in half for the number of weeks. Right so we only got it. but
Dr. Crystal Beal (they/themme): Yeah. Yeah, I love when people ask me to teach gender affirming Karen an hour and I'm like it takes me 90 minutes to talk about prescribing estrogen for adults.
Dr. Crystal Beal (they/themme): What you want me to do with this one hour for my entire field?
Mitchell Hunter: It's the same when I'm asked to do that for they call it cultural competency. it's difficult to be competent in anything you're not so I call it,…
Dr. Crystal Beal (they/themme): Yes cultural humility. Yes.
Mitchell Hunter: cultural awareness. Maybe that kind of skirts I call it cultural enment, engage with my community and…
Dr. Crystal Beal (they/themme): Love it.
Mitchell Hunter: me, we're happy right to engage with you.
Dr. Crystal Beal (they/themme): Love it.
Mitchell Hunter: But yeah, can you do that? by the way, we have a lunch and learn. Can you do that? I'm 40 minutes because We have to tell them to get their whatever her 20 minutes we have to do something. I'm like no no.
Dr. Crystal Beal (they/themme): I actually can't yeah that was like when my employer started asking me to do less with more or…
Mitchell Hunter: Yeah.
Dr. Crystal Beal (they/themme): wait more with less as a physician, we're gonna give you less time with patients and we need you to accomplish more and I was like, I actually just do less with less. Thank you. I'm gonna go start my own practice now. so yeah, I doesn't fit.
Mitchell Hunter: it's crazy. But the point that I wanted to make that I'm circular Point person. is that Before I started transition before I started hormones. I did not live in my body. I was 248 pounds and I'm five foot two. I had just been diagnosed a year prior with type 2 diabetes. And a fatty liver.
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: I had no idea what that meant. but I did know what diabetes was about and so I started medication and when I started transition it took me 10 months to find a physician who would work with me first. No one in those days. Wanted to be the tranny doctor. They didn't want to be labeled and if we start these particular number codes, we're gonna be the tranny doctor and that means once that everybody's gonna be at your door and blah blah. Okay, that wasn't The second thing was you have a fatty liver. I don't think treat I'm like, excuse me. You have fat people you treat. I mean, I don't understand.
00:50:00
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: I'm the only one I didn't realize that because I've been walking around and I don't even live in Texas anymore where everybody is 300 pounds. So it's like I didn't get it and then they said look you have type 2 diabetes. So I don't think I can help you with this transition thing and I said wait a minute. I don't have the people that are diabetic at least half aren't they men?
Dr. Crystal Beal (they/themme): And they do yeah.
Mitchell Hunter: These don't make sense to me and the only person who would work with me in the first doctor that worked with me was an endocrinologist and she said look here. I'm going to tell you why people's keep saying that. She said look you're diabetes is already a system going up and down your blood sugar and she said I didn't want for you your hormones to be going up and down at the same time, right? and…
Dr. Crystal Beal (they/themme): Do you know…
Mitchell Hunter: I'm like
Dr. Crystal Beal (they/themme): what they do in our bodies? every day Go up and down. It's not like your hormones aren't cycling ways.
Mitchell Hunter: And they're already in there.
Dr. Crystal Beal (they/themme): That's what
Mitchell Hunter: We already all have hormones,…
Dr. Crystal Beal (they/themme): I know.
Mitchell Hunter: right? okay,…
Dr. Crystal Beal (they/themme): My God. Sorry.
Mitchell Hunter: so I was the only person in my litter That a transitioned at the same time. in Seattle on AndroGel my whole transition started on Andrew.
Dr. Crystal Beal (they/themme): mmm
Mitchell Hunter: Gel and I was that way for the first three years because I had really good insurance. And they would cover it.
Dr. Crystal Beal (they/themme): awesome
Mitchell Hunter: Then I lost my job and became a contractor which meant, I paid for it out of pocket. I didn't want it to show up anywhere, and so I went to injectable and…
Dr. Crystal Beal (they/themme): expensive Yeah.
Mitchell Hunter: and so I did also.
Mitchell Hunter: They say that I've been told by doctors that there will be no more changes. No matter I used compounding ha in Oregon, which many of us used
Dr. Crystal Beal (they/themme): New Era
Mitchell Hunter: Yeah straw hackers. So, all of us were like, do this and when I went to the actual vials and the other testosterone, I also experienced changes both times I had because I sing I know this I got a little bit more. Lower notes, I got two or…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: three lower notes. I got a little bit. Difference in feet size Mitchell height maybe but I did get growth in my you…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: my digits and the good things and they were like none of that will happen. They're not and I'm like look you try to live in this body and all of a sudden and be like, no, there's world.
Dr. Crystal Beal (they/themme): Doctors I always tell people we really like to make s* up all the time and it's so true and I think there's an episode of this podcast and it's like a two-part series it's called dosing Deep dive. I think the first one I actually sit and talk with one of my practice Partners about testosterone dosing for singers. And so you might be interested in that. It's a particular area that I've done a fair bit of work in and so I talk about my Approach and all the resources I bring to the table and we do that but Yeah.
Mitchell Hunter: I would like that because I'm often a to guy. They'll tell…
Dr. Crystal Beal (they/themme): yeah, and…
Mitchell Hunter: how did you start and…
Dr. Crystal Beal (they/themme): There's a Blog up I think on queer CME,…
Mitchell Hunter: how did it work?
Dr. Crystal Beal (they/themme): that's like maybe my top resources for testosterone and singers. I don't know. I'll find it for you. and then I think you said something else. but we were really just talking about again that multiple marginalizations right that identity as a fat person and a trans person and how that made accessing care even more challenging and we continue to see that and more specifically around surgery these days. Last commonly around hormones and I want to be very clear for my listening prescribers. There are no absolute contraindications to prescribing hormones there is and I think this is one of the things which guideline was I reading the other day.
00:55:00
Dr. Crystal Beal (they/themme): It was the one I did for Jude that aging so there's a geriatric trans.
Mitchell Hunter: Would you?
Dr. Crystal Beal (they/themme): Guidelines paper that came out and they do say that there's some reasons not to prescribe hormones. I hard and fast disagree. There is no absolute contradiction and intercations to hormone prescribing. There is an informed consent conversation that happens and it's a shared decision-making process. And so what that means is if my patient has an estrogen fed best breast cancer, and she still wants to take her estrogen knowing that it is going to end her life sooner because her cancer is going to continue to progress. And that is her choice in her, And as the Physicians do not get to say I'm not going to prescribe for you because you have different values than me.
Mitchell Hunter: mmm
Dr. Crystal Beal (they/themme): and so I want to be really really clear fatty liver diabetes not contraindications to gender reforming hormone therapy. it changes the informed consent conversation. It says, testosterone is sometimes stressful for people's liver and your livers already a little stressed out. So we might want to start at a lower dose in Thai tree that more slowly and watch your Labs more closely and I want you to let me know if you start having pain in the upper right side of your belly or if you start notice swelling and your hands or feet or in your belly or you start getting foggy or And rate, that's the conversation. It's just a different conversation in some patients.
Dr. Crystal Beal (they/themme): Some patients have values that are very centered around safety and lower risk tolerance. And so they are actually going to be like, is there something else we could do? Is there something else we could try it's actually really my chest that bothers me the most and maybe just Top surgery is gonna be the solution for me. Some patients are actually gonna opt to do different things when the inform consent conversation changes, but not all patients are because for some patients it is so essential for their hormones to line up with how they see themselves that risk is totally tolerable to them and it's each individual's patient's choice not mine and I think that is just really important to emphasize and we're running into that barrier now, With surgery all the time, right people struggle to access gender affirming surgeries around size.
Mitchell Hunter: right
Mitchell Hunter: Yeah, I just think the biggest part is that. I didn't live in my body my body didn't look like what I thought I was and so many of us, are more than a hundred pounds overweight, but as soon as things started happening in my body, I was like, wait a minute.
Mitchell Hunter: my God, I could do something about this. I This is my body now because I'm looking in the mirror and things are starting to look. my God that's what I thought. I should have something there. And all of us have a way of looking at ourselves in the mirror and not seeing the parts that we don't want to see I don't care if it's your nose. You don't like or whatever right? So I tell my guys when I talk to them I said look at what you do want to see look at this stuff and let's see if we can find ways to do better now that we're coming back in and gonna live in this space again Is it gonna feel good to take a walk or maybe eat an apple instead of whatever it is,
Mitchell Hunter: And I think that allowing. Us as patients the grace. To come into that on our own and just celebrate that with us as I change rather than the shaming of how couldn't you already? I wore sizes clothing that were three sizes too big. So I worked three lay Years. I walked around in front around. yeah. wasn't me and yeah.
Dr. Crystal Beal (they/themme): We've been talking about gender diversity and how it is this absolutely 100% natural occurring part of the human experience. And I think size diversity is part of that as well humans come and all shapes and sizes. Right and we have a lot of data and research that shows that sustain weight loss over time is actually not successful for most people always don't get me wrong. There's always exceptions to that. But what is the point in trying to shame someone into a treatment that we know is actually not successful most of the time like that just seems like such a way to damage a therapeutic relationship right when I am working with a patient my goal is to create a therapeutic relationship. That's what we call it sounds silly but whatever right and that has to feel full of welcome and
01:00:00
Dr. Crystal Beal (they/themme): safety and positive regard and…
Mitchell Hunter: And celebration. Yes.
Dr. Crystal Beal (they/themme): so if I'm bringing Shame about anything about you to the table, especially something as core to how you experience this world as your size. what the f*** am I doing? and this is really hard clinicians some of y'all are gonna hear me talk about this and be not happy with me, especially because there is such a big contention in our field about health at every size versus obesity medicine and weight loss medicine and now there's glp ones right? So there's big things happening in that field right now, but I want to invite all the clinicians to just think about reframing your practice recognize that body diversity is just a natural part of human experience and not
Dr. Crystal Beal (they/themme): weight loss is not something that we should necessarily be recommending for any of our patients. It's something that we can talk to patients about if they bring it up to us, rate and definitely there are certain conditions, when we're talking about joint pain, I have I broken ankle rock climbing years ago and when I put on weight my chronic pain get significantly worse, And so there's definitely things where we can talk about the fact that caring more weight over a joints is potentially going to exacerbate any pain conditions more. but again, I'm not saying hey, why aren't you losing weight? You should lose weight. Your pain is caused by your size. I'm saying this is just the physiology of how this works. Would you like to talk about that more? Would you like to talk about other interventions? And so I just think it's like we really Really?
Dr. Crystal Beal (they/themme): Have done a horrible job as a field of creating a safe space for people to be different sizes. and the fat phobia and fat shaming that people experience in healthcare settings is similar to the transphobia that transmission's experience right and maybe in some ways even worse not that there's a marginalization Olympic then we're gonna say someone wins, but I think
Dr. Crystal Beal (they/themme): Currently in our culture transness is becoming despite the right wing. People going wild with legislation over there. Overall in our population transness is becoming more accepted right? We have some polls saying we think this is getting a little more acceptance and more awareness and it is still considered very acceptable to shame fat people in our culture and our society. and then I again layering the two together being a fat trans person just f****** sucks going to try to get Healthcare. Is everybody's gonna turn you away? Like they did to Mitch like that's still happening.
Mitchell Hunter: And it's been being the BMI thing and I've been against that since I was young because Even as a really strong young Dyke in my early days, I did bodybuilding and I have always been I'm gonna say actimore is that the right shorts stocky body? I've always.
Dr. Crystal Beal (they/themme): You're using words. I don't know…
Dr. Crystal Beal (they/themme): but sure.
Mitchell Hunter: yeah, and…
Mitchell Hunter: There's types and a more Spectrum or something. I don't know what I mean. Anyway, I've always been it's easy for me to put on muscle.
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: I can do it very I don't even have to do much lifting at all. That's just how I've always been but I also had extra, weight around but this whole difference of coming into myself and I told you I started at 2:48 and over the first 10 to 15 years of my transition. I lost 85 pounds now. I didn't drop it all at once right but over time and getting used to my body and doing different things that felt good and figuring out what that was and what it was and I did but Even for my hysterectomy, which I had I think when I say six years ago.
01:05:00
Mitchell Hunter: It turned out that I had not been as well regulating on my blood sugar as I thought. and so My DOT, we had to put off my hysterectomy by six months to give me time to get my blood sugar under control. And I totally understand that. they were like look this is a really bloody surgery and we're already gonna have trouble and we don't want anything extra so you got to get it under That 180, requirement and I'm like, Okay, so I did go into a pretty Looking forward to getting that surgery and it took a while to do that. So a while I had about nine months or so to prep for that and I didn't know gluten no sugar no Dairy and…
Dr. Crystal Beal (they/themme): My gosh,…
Dr. Crystal Beal (they/themme): these are all the things I live on.
Mitchell Hunter: It was a crazy.
Mitchell Hunter: right but I did lose about 40 pounds and I don't know how but before that surgery. I registered not Full on the BMI scale for the very first time in my whole entire life.
Dr. Crystal Beal (they/themme): Yeah, and…
Mitchell Hunter: And I was 50 58 for that surgery.
Dr. Crystal Beal (they/themme): we know.
Mitchell Hunter: So that's a long time.
Dr. Crystal Beal (they/themme): right Right, and we know BMI is a racist measure, right? It was created not by Anyone in the healthcare field. It was created by a statistician an insurance person like you right and it was created in Europe using primarily white people. And so it is just like we know it was
Dr. Crystal Beal (they/themme): Never meant to be a measure of Health. It was meant to be a population measure. And so it's really unfortunate how it's been adopted for health purposes because it's not actually a good measure of that. clinicians. I do not include BMI in my letter. So for those letters we were talking about in our Scarlett teeth right for surgery referral letters. if you ever see any of the templates that are out floating around in the world unless it's mine. they have BMI because surgeons have BMI restrictions and insurance coverage has BMI restrictions, and so everyone wants it.
Dr. Crystal Beal (they/themme): I do not put BMI in my letters. Like I said, it's racist. I'm not going to support systemic racism. I am here to dismantle this system. And so I will put height and weight and I will make a comment. I opened a star by that and I will just say, we do not include right BMI in our letters because it's a racist measure if you would like to calculate the BMI yourself that is Here's the reason why we think you should not do that. and there are a few surgeons who are starting to remove BMI restrictions Dr. Stater white in San Francisco does gender affirming mastectomies with no BMI restriction. So any size body can get a gender farming mastectomy there and then he also does and vulva vagoplasting.
Dr. Crystal Beal (they/themme): Remember if he does Fallows off the top of my head right now and I do think he still has some BMI restrictions around some of his genital gender-affirming surgeries, but he's definitely more open to conversations and working with people and then also doctor Moser in San Francisco as well at the gender confirmation. Clinic removed Top surgery BMI requirements as well for mastectomy.
Mitchell Hunter: Yeah.
Dr. Crystal Beal (they/themme): And so there is some movement in the field away from the measure and I just want to also for anyone who's listening. and talk about the fact that
Dr. Crystal Beal (they/themme): one I am like a thin person and I have thin privilege when I move through this world. So if you can't see me, I'll just call that out and my stance on things around and site has changed a lot and that is been because I was called outer and I don't know how you want to frame it by colleagues. so, and I think
Dr. Crystal Beal (they/themme): definitely size can affect risk with surgeries that can be an important thing to consider but not in the ways that we often think about it doing that as Physicians and so it's really really important the system isn't supporting the research and the data to really understand. What is the effective size and what is the effect of someone's other complicating health conditions when they're going into the surgery. right because sometimes when we look at data about sizes affecting surgical outcomes, it's in patients with metastatic cancer, and I'm like, that's a very different person than a trans person who is maybe otherwise fairly healthy getting a surgery, right? That's a totally different risk profile. And so I just think that's really really important that
01:10:00
Dr. Crystal Beal (they/themme): As prescribing clinicians, I'm sorry should not be a barrier for hormone therapy and it is currently systemically a barrier for accessing surgeries. But continuing to try to dismantle the system to improve access is really important and then transparency with our patients when we're referring them is really important. So if you have not vetted your surgeon and you are referring a fat person to a surgeon and there is a chance that surgeon might decline them that surgery because of their size and you have not worn them of that as the referring provider. You have not done your job very well because your patient has just been incredibly traumatized. They were super* excited. They were going to talk to their bottom surgeon. It's like something they've wanted. I don't know how long two years 10 years 22 years and this was the day and they were gonna have the conversation and then that conversation went you're too fat. I'm not gonna do this surgery for you. I just imagine how that feels for someone and so if you don't have time clinicians to call
Dr. Crystal Beal (they/themme): Your surgeons and get that information before you refer someone be transparent with them that it might happen. Or potentially if you have social workers or support staff who can call those surgeons that you refer to most often and ask those questions and then you just know not to refer to them with larger patients do that. And we also keep a provider database on our website where we try to keep that information available and as much as possible. It's really hard to keep up to date like we've had. Projects that we've had a couple of the University of Washington Public Health students work on and…
Mitchell Hunter: living
Dr. Crystal Beal (they/themme): but yeah just a reminder and if you know about your referrals be transparents with your patients that you haven't vetted them. So they're prepared for the experience.
Mitchell Hunter: The size thing comes in also for surgeons when we look at in the early days, we had a few surgeons that did, Top surgery and we used to line up as guys at a conference for show and tell so that it was just for us. So that we would know kind of what to expect and what to think about and all that stuff.
Mitchell Hunter: But we would line up all the different ones and it did not have pop surgery. I have not had Top surgery. And so I would line up on the side of the no surgery. Right? So we had us all but we could pick out the surgeons but the chest surgeon by the chests so we would say that's a so-and-so chest that's so into and we could go right now the line and it got to the point where and I used to teach with a surgeon who's really well known. Who got their ideas of beauty or thing from studying, wait.
Mitchell Hunter: lifters and bodybuilders and people who more than likely did take testosterone And some other things, and I'm like you do realize those are b**** tits. So yeah, I'm like but anyway, they used to Early days odds, okay, but they would put a dime on your chest and actually draw a circle around a dime for your areola. Come on, it's if I lined up and…
Dr. Crystal Beal (they/themme): yeah every
Mitchell Hunter: I've been on some nude beaches now, if I line up there is no everybody's a dime. And if I'm a big-ass guy,…
Dr. Crystal Beal (they/themme): yeah.
Mitchell Hunter: I'm six foot and I'm 200 and something pounds.
Mitchell Hunter: And my family maybe I would be the only dime in my family compared everybody else. minor at least a quarter, or whatever and It's just this whole thing like that. There is.
Mitchell Hunter: A standard and it's like, That's what diversity is about. That's what this whole world is about.
Dr. Crystal Beal (they/themme): right
Mitchell Hunter: That's why we're biodiverse is a reason why we have persevered as a species that's part of it, right?
01:15:00
Dr. Crystal Beal (they/themme): And that's actually one of the things I always talk to my patients when I'm referring them for surgery. I always talk about when you talk to your surgeon. It's super important that you talk to them about both Form and Function. So what you want things to look like and how you want them to work for you and ideally And if you can bring pictures of what you want things to look like that is even better because we all use words a little bit differently. right and if you have a surgeon who can't have both those conversations with you and then help you understand what your options are an individualize the approach to your desires and goals. You might want to try to talk to a different surgeon. If you have the option to do that with your time money energy resources and insurance coverage, and it is 2023 and there are a lot of Surgeons who still apply.
Dr. Crystal Beal (they/themme): Their Ideal concepts of beauty to everybody that comes through their office right as opposed to listening to their patient. who has individualized goals, and I was talking to a surgeon and he was like, someone only wanted one nipple I wouldn't do that, because that would be weird and I was like why atypical numbers of nipples are one of the most common diversity things that happen in human bodies and in someone's like someone want a heart-shaped nipples, I wouldn't do that. I'm just like why you're never gonna f****** see those hearts again. Why do you f****** care? coming for food because of times and then they're gonna leave your office and they're never gonna come back. Why do you care? and I think
Dr. Crystal Beal (they/themme): Sometimes surgeons are worried.
Mitchell Hunter: And it's what it's them thinking.
Dr. Crystal Beal (they/themme): Someone will come back, with regret but I think again, we're not talking about health care. We are talking about bodily autonomy, and we were talking about human rights. And so that's that's for me. My question when surgeons are like I wouldn't do that. I'm like f****** why because I'm talking about bodily autonomy and human rights and they're talking about paternalistic Healthcare.
Mitchell Hunter: And they're talking about the reputation. They think that if someone sees that someone's going to make a judgment about them. Excuse The whole thing is not about you. I mean I came to you maybe…
Dr. Crystal Beal (they/themme): Not about you at all.
Mitchell Hunter: because of your skill. Maybe I chose you…
Dr. Crystal Beal (they/themme): Yeah.
Mitchell Hunter: because of a certain skill, but the rest of it is not up to you. and…
Dr. Crystal Beal (they/themme): It is.
Mitchell Hunter: that's that whole thing. It's like yeah.
Dr. Crystal Beal (they/themme): I feel like we could talk forever. But I have to let you go because I have someone coming over to my house. I have had a blast though and where can people find you if they're interested in seeing more of your work or having you come to their institution or anything like that.
Mitchell Hunter: Starting to hang out my shingle again. I don't have my setup website as Mitchell at Mitchell C Hunter Comm, but Right now you can give out my Hotmail address that I did Mitchell see Hunter at hotmail.com. And my cell number is a personal number and I do a lot of conferences and…
Dr. Crystal Beal (they/themme): Okay.
Mitchell Hunter: speaking and you can see that I'm very personable and I'll talk about any level of it. that is one of my superpowers is the people do trust me and they feel really comfortable. in talking with me, no matter…
Dr. Crystal Beal (they/themme): amazing
Mitchell Hunter: if I'm teaching them pronouns or what right, so
Dr. Crystal Beal (they/themme): So if your institutional organization needs some more Feel free to reach out to me. If you can't figure out Mitchell's contact information and remember that maybe Mitchell's a really good soft Landing for people who are having more complex feelings about this. sometimes I think I actually am oftentimes a soft Landing. I hear that despite the fact that I think some of my colleagues think I can be a little intense, but I think I'm actually oftentimes more intense with my colleagues who are already on board because I want you to be further and whereas when people are really new to it. I tend to be a little bit softer, but Mitchell's like He's gonna be soft all around, which is great. So, thank you so much for your time today and…
Mitchell Hunter: Yeah. I thank you.
