Empowering Transgender and Gender Diverse Youth: Q&A with Linda Hawkins, PhD, MSEd, LPC; and Nadia Dowshen, MD, MSHP

The Gender and Sexuality Development Clinic at CHOP is committed to research to improve health for transgender and gender diverse youth.

Editor’s note: We celebrate LGBTQ Pride Month each June as a tribute to those involved in the Stonewall Uprising, a catalyst for the gay rights movement in the United States. This year not only marks the 50th anniversary of this annual LGBTQ celebration, but also the recent landmark Supreme Court ruling that the civil rights law protects gay and transgender workers from workplace discrimination.

In recognition of these LGBTQ milestones, we sat down with Linda Hawkins, PhD, MSEd, LPC; and Nadia Dowshen, MD, MSHP; co-founders and co-directors of the Gender and Sexuality Development Clinic, and faculty in the Perelman School of Medicine at the University of Pennsylvania, to discuss CHOP’s commitment to research and clinical support for transgender and gender diverse children and youth and their families.

Dr. Hawkins, would you please give us an overview of the Gender and Sexuality Development Program at CHOP?

A: In thinking about Pride Month, especially in context of where we are in 2020, we need to look at where we started. Nadia and I have worked together for about 15 years, and we work from a strong social justice framework and health equity framework. What we were able to do in the start of our work together, around youth living with HIV, was look at the populations and the patients who weren’t getting the level of care and service that was really warranted and needed. In particular, that was our transgender, gender expansive, and gender nonbinary children, youth, and their families at CHOP.

Linda Hawkins, PhD, MSEd, LPC, co-director of the Gender and Sexuality Development Clinic.

We developed a framework and a one-stop shop for support, including medical, behavioral, nutritional, psychological, legal, and educational support, for transgender and gender nonbinary children, youth, and their families through the Gender and Sexuality Development Clinic. When our doors opened in January 2014, we had what we call ‘our first 40’ — 40 families who were a combination of families from my therapy practice, youth who Nadia and I were already caring for within the HIV Adolescent Initiative program, and youth who were receiving care from various places throughout the CHOP network. Those families helped by giving wonderful feedback into the clinic structure that we were creating with them and for them.

Just six and a half years later, we’re caring for about 1,500 families throughout the tristate area and as far beyond as places like Germany and Saudi Arabia. Families will come to us specifically because of the multidisciplinary comprehensive care that we can offer to transgender and gender expansive children and their families.

Q: Congratulations on your recent recognition, the “2020 LGBTQ+ Leadership Award” from the Pennsylvania National Diversity Council! Would you please tell us about the award and what it means to you?

A: I’m incredibly humbled. I like being a leader from behind, which is more my style, so having this level of acknowledgment is exciting, but also very humbling. I think the great work that the entire Gender and Sexuality Development Program has been doing throughout the state of Pennsylvania is probably why I was selected for this.

In the last two years, we’ve been working with Pennsylvania Secretary of Health, Dr. Rachel Levine, to provide trainings throughout the state of Pennsylvania for mental health providers to increase the competency as a therapist in more rural locations in the state to support transgender and gender expansive and gender nonbinary patients and clients of all ages. Through those trainings, in-person and virtual, we’ve been able to reach nearly 2,000 therapists across the state.

That’s a partnership of all of the people who are part of the Gender and Sexuality Development Program — from our physicians who have been providing some of the webinars, as well as our leaders in education over this last year. At CHOP, we’re creating strong policies and practices for care for patients, their families, as well as guidelines for supporting transgender staff and protecting the rights of LGBTQ staff. We’ve been setting the precedent throughout the state of Pennsylvania on how LGBTQ staff and patients should be best cared for at a hospital level throughout Pennsylvania and even nationally.

The last piece that created some momentum for this award was just the great work that’s been done through our program in education and in school. When Nadia and I started this work in 2014, over half of the young people we were seeing were not attending school because of bullying. That motivated Nadia and I to get a grant to fund a school educator and advocate to go out to schools where we knew kids were being bullied and create trainings and policies and accountability streams to reduce all of this. What we’re seeing now is about 20 percent of our kids are being homeschooled because they don’t feel safe in school. That’s a huge change just from education. The bulk of that education has been happening in the state of Pennsylvania. I do believe those are some of the reasons why they looked to me for this award.

The Gender Clinic is working on a number of groundbreaking research and quality improvement projects for this population that has been determined to be a priority by the National Institutes of Health, the Institute of Medicine, and the leadership at CHOP. Dr. Dowshen, as co-director of the Clinic responsible for research, please tell us about some of these projects.

Nadia Dowshen, MD, MSHP, co-director of the Gender and Sexuality Development Clinic.

A: Since starting the Gender and Sexuality Development Program, Linda and I have made research a priority because we think it is critical to improving quality and access to care and helping patients and families make decisions that are sometimes challenging, given all that young transgender children and adolescents and other gender-diverse youth experience. From early on, we developed a registry where we’re tracking psychosocial and biomedical outcomes for all the young people who are seen in our clinic. We’re constantly working on that ongoing project.

Also, we’ve conducted a number of qualitative studies to try to empower the voices of the young people in our clinic to talk about the different aspects of care and of their identity that are important for clinicians, policymakers, and others to know. We’ve also done work to understand better the policy environment in terms of insurance coverage for care for youth.

Dr. Dowshen, as a Stoneleigh Fellow at PolicyLab, we understand you are leading an action-oriented research project to improve healthcare quality and access — particularly related to HIV prevention services — for transgender youth. Would you please tell us more about this work?

A: The Stoneleigh Foundation is focused on improving systems and policies for our vulnerable youth in Philadelphia. My project reflects something that Linda and I have been committed to from the beginning. As she mentioned, we started our work with young people who are living with HIV, who identified as transgender, most of whom are young transgender women of color and specifically Black, young transgender women. Transgender women, in general, are 50 times more likely to become infected with HIV than the average person. Almost one in four transgender women of color will have HIV by the time they’re in their 20s. This is due to a variety of factors, including racism and discrimination because of gender identity. It’s important that we’ve centered on this in our work.

Specifically, the project is trying to empower young transgender women in Philadelphia to improve the quality of care that they receive for HIV prevention and gender affirming care. We’re getting together a group of young women who will be doing a variety of things, including mystery shopping visits at places that offer HIV testing, and they will evaluate the services they receive.

In addition to the mystery shopping, the young people will do a facility audit where they will meet with the manager of the clinical sites and go through their policies, practices, and the flow of a visit. They will go through a checklist as to whether all the services that are necessary for support of gender affirming care are in place and as to whether their policies and practices are gender affirming.

Then, different clinical sites throughout Philadelphia will receive reports from us about the areas in which they are doing well, and in the areas in which then need to improve. And together, partnering with the health departments, the youths and I will provide training to the organizations across Philadelphia to try to improve the quality of care that they’re providing for young trans women who are seeking HIV prevention services.

Q: Would you please explain how the CHOP research program in this field has grown over the years?

A: The growth in research in our program has been directed by our clinical experiences; the needs of our patients and families; and questions identified by our state, local, and community partners. For example, gender-affirming medications may impact biological fertility for trans youth, so this can be an important decision point for youth, parents, and providers. We conducted a survey of youth and parents to understand their attitudes toward fertility preservation and their preferences for how to discuss this topic in the context of clinical care. This paper published in the Journal for Adolescent Health provides important developing educational information and interventions for shared decision-making.

This year, the Center for Diseases Control and Prevention (CDC) completed its first National HIV Behavioral Surveillance Survey for transgender women, and Philadelphia was one of seven participating cities. We partnered with the Philadelphia Department of Public Health to complete 50 qualitative interviews of trans women in Philadelphia. These interviews helped to achieve high participation rates in the national survey, and as a result, we formed a community advisory board that will continue beyond this project to drive the research agenda for trans women’s health more generally in Philadelphia.

What motivated each of you to make this your life’s work?

Dr. Dowshen: I have a strong interest in health equity and social justice for young people that stems from my own personal history of growing up in Philadelphia and attending public school in Philadelphia from kindergarten to 12th grade. I witnessed firsthand many health inequalities especially experienced by LGBT youth and youth of color.

Also, I have always believed that adolescence is a wonderful and exciting time, and it’s an absolute joy working with this population. Adolescence is a time of creativity and learning and a point where we can really intervene and support young people in their lives to be their healthiest selves. I was lucky to have the opportunity to begin to provide care for transgender youth, in the context of HIV care, at a time when society was generally unaware of what it even meant to be transgender.

As a cisgender person committed to social justice and health equity, supporting a young person to be who they are is incredibly rewarding. Ultimately, that was my motivation for working together with Linda to try to create safe spaces and opportunities to improve health for trans and gender diverse youth.

Dr. Hawkins: I’ve focused my life on raising the voices of folks who are not being listened to or heard well by professionals. When I first got out of undergrad, I was a sign language interpreter for deaf children. In graduate school, my work focused on inner city African-American children and youth and mental health systems. Later, I was working with Nadia in HIV work, supporting our young people who are living with HIV. Now my career focus is with transgender, gender expansive, and gender binary children, youth, and families. I think I have a theme within the work I do that makes me feel whole and like I’m doing good in the world.

About the work focusing on LGBTQ youth, which I’ve been doing in Philadelphia for the last 20 years, I started realizing that people were getting better at the LGB part of the LGBT, and in many cases in the past; we were pretending to do well by trans folks. But once that light bulb went off for me, it made it very clear where my next layer of career and focus was going to shift to.

Many people ask me if I am trans or my partner’s trans or my kids are trans or my family is trans. That isn’t the case. I feel it’s important for me to be able to utilize my white cisgender privilege and place in the world to create the needed listening and the needed space to support this wonderful and important part of our population.

What do you enjoy most about your work/research?

Dr. Dowshen: Most exciting for me is to be able to empower the voices of young people who often have been discriminated against and whose voices haven’t been heard in our society, and to use research as a way to both empower their voices and work toward health equity for them.

Dr. Hawkins: Recently, I had the pleasure of witnessing parents, a mom and dad, find their way back to their child. As they said, “We’re so happy to get to see our child again. We can see a kid who is no longer overwhelmed by depression and anxiety because we now realize that we don’t have a daughter — we have a son.” Once they started leaning into accepting that they have a transgender son, that’s when the depression and the anxiety finally started to come away from this kid. Seeing their happiness — that’s the joy.