Science
'We've created medical refugees.' LGBTQ+ healthcare workers fight for gender-affirming care amid rise in anti-trans laws
Nico Olalia had just finished her initial nurse training in the Philippines when she realized her aspirations were growing bigger than her home archipelago.
“There are a lot of trans Filipinos, but they’re always known in the beauty industry, and they’re very seldom found in the professional side,” Olalia said.
So she moved back to the United States, where she was born, for better career prospects. Today, she is a clinical nurse at Cedars-Sinai, one of the largest hospitals in Southern California, where she assists new hires and cares for patients in the neurology division.
Olalia feels like it’s a dream come true; her peers and patients respect her and welcome her contributions. It’s a hope shared by a small but growing number of trans and nonbinary healthcare workers in the U.S.
Yearly surveys of first-year medical students by the Assn. of American Medical Colleges show that the percentage identifying as transgender and gender nonconforming doubled from 0.7% in 2020 to 1.4% in 2023.
These numbers align with the growing LGBTQ+ population in the United States. Today, younger generations are more likely to identify as LGBTQ+ than generations before. A national survey this year found that 28% of Gen Z respondents identified as lesbian, gay, bisexual, transgender or queer.
But that rise in LGBTQ+-identified youths and trans healthcare workers has coincided with escalating restrictions on gender-affirming care.
Between 2022 and 2023, anti-trans legislation proposed across statehouses tripled, with a majority of the bills proposing restrictions on gender-affirming care. According to the Movement Advancement Project, at least half of the states exclude transgender-related healthcare for youths from their Medicaid programs, while only 22 explicitly cover it.
“We’ve created medical refugees who have to leave their state to get that care,” said U.S. Assistant Secretary for Health Rachel Levine, the first transgender person confirmed by the Senate to a high government post.
“Transgender medicine can be suicide prevention care. It’s been shown in many studies that it improves the quality of life and can save lives for youth and adults,” said Levine, a pediatrician specializing in adolescent care.
When Levine was doing her medical residency at Mount Sinai Hospital in New York City during the 1980s AIDS crisis, she saw friends and co-workers succumb to the epidemic — an experience that rings eerily familiar to the discrimination she sees transgender people facing today, she said.
One study from 2023 showed that 70% of transgender and gender nonconforming patients faced at least one negative interaction with a healthcare provider, ranging from an “unsolicited harmful opinion about gender identity to physical attacks and abuse.” It was only in 2019 that the World Health Organization removed gender dysphoria from its list of mental health illnesses.
Alex Keuroghlian, a clinical psychologist at Harvard Medical School, directs training programs through the National LGBTQIA+ Health Education Center that educate healthcare providers across the country on gender-affirming care. They’ve noticed a double standard when it comes to the doubts that people raise against transgender healthcare.
“Given how well resourced anti-trans political groups are, it can really distort the public discourse and make it harder to advance evidence-based, clinically sound practices,” Keuroghlian said of the rampant misinformation they’ve seen online.
An uptick in the number of transgender-identifying youths seeking gender-affirming care sparked a theory that “social contagion” was influencing teens to experience “rapid-onset gender dysphoria.” Some practitioners oppose this framing, and research published by the American Academy of Pediatrics has disproved it. Both the American Psychiatric Assn. and the American Pediatric Assn. support gender-affirming care for adolescents.
The news on the legal front hasn’t been all bad for trans healthcare providers; last month, a federal court judge struck down Florida’s law restricting gender-affirming care for minors and adults. However, the practice of categorizing gender in a binary medical system continues.
That’s problematic, said Mauricio Dankers, the intensive care unit director at HCA Florida Aventura Hospital, because the medical erasure of trans people can prevent a proper diagnoses. When doctors have to make split-second decisions in the ICU, he said, failing to recognize a transgender person could prevent them from receiving lifesaving care.
“If I don’t know that a transgender woman may have gone through laryngoplasty to change the tone of her voice, I’m going to go and put the breathing tube [and] I may run into trouble,” Dankers offered as an example. Chest binding used by some transgender people to appear more masculine can also lead to pneumonia if done improperly, he said.
Dankers, a gay immigrant who left Peru for the more tolerant New York City, worries that the politicization of transgender healthcare will put a target on LGBTQ+ healthcare providers.
These restrictions “are going to change how the LGBTQ+ trainee thinks about their career,” Dankers said. He said they might think, “I’m not going to a place where they don’t want me by law.”
After Texas banned gender-affirming care for teens, a pediatric endocrinologist closed her practice and moved out of the state because she feared violence from armed protesters. And this year, a Texas man was sentenced to three months in prison for threatening a Boston physician serving transgender patients.
Fear and violence have had a ripple effect even on states that have enshrined transgender healthcare into law.
Baltimore Safe Haven, a nonprofit that provides transitional housing service focused especially on Black trans women, received an increase of 7,000 calls last year after Gov. Wes Moore signed an executive order protecting gender-affirming medical care in Maryland, according to the Baltimore Sun. Most of the callers lived out of state.
“I can’t even see my own doctor,” said Jules Gill-Peterson, a transgender woman and associate professor at Johns Hopkins University in Baltimore who studies the history of transgender medicine. Anecdotally, she’s heard of doctors’ caseloads tripling with the slew of requests they receive from new transgender patients.
“It’s only going to put greater pressure on [the] system as people migrate from states where it’s illegal to transition medically to states where it’s not,” Gill-Peterson said.
LGBTQ+ healthcare workers are on the defensive, said Kate Steinle, a queer nurse and chief clinical officer at Folx, a nationwide healthcare provider that serves transgender and queer patients.
“Our general counsel wakes up in the morning and is looking at every single possible legislation that could affect our care,” Steinle said. Folx lobbies the government to ensure that its patients have access to gender-affirming care, but Steinle said fighting anti-trans legislation can sometimes feel like “a game of whack-a-mole” — as one goes down, another takes its place.
Anti-trans legislation is largely symbolic because most of these bills fail, said D Dangaran, a lawyer and director of gender justice at Rights Behind Bars. According to the Trans Legislation Tracker, of the 617 bills introduced, 44 have passed, 348 failed and the rest are pending.
But the fate of transgender healthcare could shift dramatically depending on the outcome of the presidential election in November.
“A Trump presidency will signal to the states another possibility to move forward on all fronts with anti-trans legislation,” Dangaran said. Former President Trump has promised to end gender-affirming care for minors if he wins, and Dangaran anticipates that he would sign “executive orders that are antithetical to protecting trans rights.”
Keuroghlian worries that many career government employees in the Department of Health and Human Services could be ousted by political appointees as part of Trump’s ambition to reshape the federal workforce. “There is a lot of important healthcare and research funded by the federal government,” he said.
All of this could reverse the progress that the Biden administration has done to advance gender-affirming care across the country.
“There hasn’t been any president that has more explicitly supported access to gender-affirming care,” said Elana Redfield, the federal policy director at the Williams Institute at UCLA School of Law.
Last week, the Supreme Court agreed to consider the Biden administration’s challenge to Tennessee’s ban on gender-affirming care for teens. The administration argues that the ban violates the 14th amendment’s equal protection clause. A ruling is expected next year that could cement or further erode transgender rights.
Redfield warns that “people who are multiply marginalized are also most affected by these laws,” particularly people of color who live in the Deep South. Beyond the legal restrictions to care, they face problems affording the cost of procedures such as gender-affirming surgery and traveling to where care is available, she said.
Nor can lower-income transgender people afford Folx, a private subscription service that charges $39.99 a month on top of any out-of-pocket costs and co-pays levied by an insurer.
“Trans people have a lot to tell us about just how bad U.S. healthcare can get,” Gill-Peterson said. “Trans healthcare is not really that different than the rest of healthcare.”
Increasing the representation of transgender people in a healthcare system where “profit is placed over people” won’t solve those fundamental inequities, she said. Even if doctors support their transgender patients, Gill-Peterson said, they are still bound by law to follow state regulations and insurers’ dictates.
On the other hand, studies have linked positive health outcomes in LGBTQ+ patients and patients of color to having a healthcare provider who shares their background. That’s one reason University of Michigan medical student Gaines Blasdel, a trans man, wants to become a urologist who can provide gender-affirming surgery to transgender patients such as himself.
Blasdel said gender-affirming care can be an abstract social justice issue to his cisgender classmates, but it isn’t to him. “I’ve been embedded [in medicine] and I’m going to be, no matter how hard it is.”
Jona Tanguay, a physician assistant and medical lead in the medical substance use disorder programs at Whitman-Walker Health in Washington, D.C., said it’s important not to discredit the incremental but meaningful progress in the representation and quality of care offered to transgender people.
“Progress isn’t always linear,” they said. Tanguay, who is nonbinary, is also the president of GLMA, formerly known as the Gay and Lesbian Medical Assn. They already see the curriculum expanding and the number of out transgender healthcare providers growing steadily. “Every generation after is going to be more self-aware than they used to be about health disparities.”
Olalia said her story demonstrates that trans people can practice medicine just as well as their cisgender colleagues. Because she’s also enrolled full time in a nursing doctoral program, her days start at 4:30 a.m., when she wakes up to prepare for her 10- to 12-hour shifts. Her efforts at Cedars-Sinai earned her a prestigious $10,000 no-strings-attached grant from the Simms/Mann Institute & Foundation.
“I do hope that I can have more power to inspire transgender women,” Olalia said. “I want those who are walking behind me to … have that opportunity to go beyond what they’re told to do or what society deems them to be.”
Science
How to protect yourself from the smoke caused by L.A. wildfires
You don’t have to live close to a wildfire to be affected by its smoke. With severe winds fanning the fires in and around Pacific Palisades, the Pasadena foothills and Simi Valley, huge swaths of the Southland are contending with dangerous air quality.
Wildfire smoke can irritate your eyes, nose, throat and lungs. The soot may contain all kinds of dangerous pollutants, including some that may cause cancer. The tiniest particles in smoke can travel deep into your lungs or even enter your bloodstream.
Conditions like these aren’t good for anyone, but they’re particularly bad for people in vulnerable groups, including children, those with asthma or other respiratory conditions, people with heart disease and those who are pregnant.
Here’s what you should know to keep yourself safe.
Stay indoors
Minimize your exposure to unhealthy air by staying inside and keeping your doors and windows shut.
If you have a central heating and air conditioning system, you can keep your indoor air clean by turning it on and keeping it running. Make sure the fresh-air intake is closed so that you’re not drawing in outdoor air.
Keep your pets inside
They shouldn’t breathe the unhealthy air either.
Check your air filters
Clean filters work better than dirty ones, and high-efficiency filters work better than regular ones. The California Air Resources Board and the South Coast Air Quality Management District recommend filters with a MERV rating of 13 or higher.
You might consider using portable high-efficiency air cleaner in a room where you spend the most time. The U.S. Environmental Protection Agency has information about them here, and CARB has a list of certified cleaning devices here.
Don’t pollute your indoor air
That means no burning candles or incense. If your power is out and you need to see in the dark, you’re much better off with a flashlight or headlamp.
If you’re cold, bundle up. This is not the time to start a cozy fire in the fireplace. Don’t use a gas stove or wood-fired appliances, since these will make your indoor air quality worse, not better, the AQMD says.
The CDC also advises against vacuuming, since it can stir up dust and release fine particles into the air.
Take care when cleaning up
You don’t want your skin to come into contact with wildfire ash. That means you should wear long sleeves, pants, gloves, socks and shoes. The AQMD even wants you to wear goggles.
If you’re sweeping up ash outdoors, get a hose and mist it with water first. That will keep it from flying up in the air as you move it around. Once the ash is wet, sweep it up gently with a broom or mop. Bag it up in a plastic bag and throw it away.
It’s a good idea to wash your vehicles and outdoor toys if they’re covered in ash. Try not to send ashy water into storm drains. Direct the dirty water into ground areas instead, the AQMD advises.
Those with lung or heart problems should avoid clean-up activities.
Discard spoiled food…
If you lost power for a significant length of time, the food in your refrigerator or freezer may be spoiled.
Food kept in a fridge should stay safe for up to four hours if you’ve kept the door closed. If you’ve been without power for longer than that, you’ll need to toss all perishable items, including meat, poultry, fish, eggs, milk and cut fruits and vegetables. Anything with “an unusual smell, color, or texture” should be thrown out as well, according to the U.S. Centers for Disease and Control Prevention.
Refrigerated medicines should be OK unless the power was out for more than a day. Check the label to make sure.
…even if it was in the freezer
Your freezer may be in better shape, especially if it’s well-stocked. Items in a full freezer may be safe for up to 48 hours if it’s been kept shut, and a half-full freezer may be OK for up to 24 hours. (The frozen items help keep each other cold, so the more the better.)
If items have remained below 40 degrees Fahrenheit (4 degrees Celsius) or you can still see ice crystals in them, they may be OK to use or refreeze, according to the federal government’s food safety website.
Ice cream and frozen yogurt should be thrown out if the power goes out for any amount of time. Meat, poultry, seafood, eggs, milk and most other dairy products need to go if they were exposed to temperatures above 40 degrees F for two hours or longer. The same goes for frozen meals, casseroles, soups, stews and cakes, pies and pastries with custard or cheese fillings.
Fruit and fruit juices that have started to thaw can be refrozen unless they’ve started to get moldy, slimy or smell like yeast. Vegetables and vegetable juices should be discarded if they’ve been above 40 degrees F for six hours or more, even if they look and smell fine.
Breakfast items like waffles and bagels can be refrozen, as can breads, rolls, muffins and other baked goods without custard fillings.
Consider alternative shelter
If you’ve done everything you can but your eyes are still watering, you can’t stop coughing, or you just don’t feel well, seek alternative shelter where the air quality is better.
Hold off on vigorous exercise
Doing anything that would cause you to breathe in more deeply is a bad idea right now.
Mask up outdoors
If you need to be outside for an extended time, be sure to wear a high-quality mask. A surgical mask or cloth mask won’t cut it — health authorities agree that you should reach for an N95 or P-100 respirator with a tight seal.
Are young children at greater risk of wildfire smoke?
Very young children are especially vulnerable to the effects of wildfire smoke because their lungs are still rapidly developing. And because they breathe much faster than adults, they are taking in more toxic particulate matter relative to their tiny bodies, which can trigger inflammation, coughing and wheezing.
Any kind of air pollution can be dangerous to young children, but wildfire smoke is about 10 times as toxic for children compared to air pollution from burning fossil fuels, said Dr. Lisa Patel, clinical associate professor of pediatrics at Stanford Children’s Health. Young children with preexisting respiratory problems like asthma are at even greater risk.
Patel advises parents to keep their young children indoors as much as possible, create a safe room in their home with an air purifier, and try to avoid using gas stoves to avoid polluting the indoor air.
Children over the age of 2 should also wear a well-fitting KN95 mask if they will be outdoors for a long period of time. Infants and toddlers younger than that don’t need to mask up because it can be a suffocation risk, Patel said.
What are the risks for pregnant people?
Pregnant people should also take extra precautions around wildfire smoke, which can cross the placenta and affect a developing fetus. Studies have found that exposure to wildfire smoke during pregnancy can increase the risk of premature birth and low birth weight. Researchers have also linked the toxic chemicals in smoke with maternal health complications including hypertension and preeclampsia.
What about other high-risk populations?
Certain chronic diseases including asthma, chronic obstructive pulmonary disease or other respiratory conditions can also make you particularly vulnerable to wildfire smoke. People with heart disease, diabetes and chronic kidney disease should take extra care to breathe clean air, the CDC says. The tiny particles in wildfire smoke can aggravate existing health problems, and may make heart attacks or strokes more likely, CARB warns.
Get ready for the next emergency
Living in Southern California means another wildfire is coming sooner or later. To prepare for the bad air, you can:
- Stock up on disposable respirators, like N95 or P-100s.
- Have clean filters ready for your A/C system and change them out when things get smoky.
- Know how to check the air quality where you live and work. The AQMD has an interactive map that’s updated hourly. Just type in an address and it will zoom in on the location. You can also sign up to get air quality alerts by email or on your smartphone.
- Know where your fire extinguisher is and keep it handy.
- If you have a heart or lung condition, keep at least five days’ worth of medication on hand.
Times staff writer Karen Garcia contributed to this report.
Science
Punk and Emo Fossils Are a Hot Topic in Paleontology
Mark Sutton, an Imperial College London paleontologist, is not a punk.
“I’m more of a folk and country person,” he said.
But when Dr. Sutton pieced together 3-D renderings of a tiny fossil mollusk, he was struck by the spikes that covered its wormlike body. “This is like a classic punk hairstyle, the way it’s sticking up,” he thought. He called the fossil “Punk.” Then he found a similar fossil with downward-tipped spines reminiscent of long, side-swept “emo” bangs. He nicknamed that specimen after the emotional alt-rock genre.
On Wednesday, Dr. Sutton and his colleagues published a paper in the journal Nature formally naming the creatures as the species Punk ferox and Emo vorticaudum. True to their names, these worm-mollusks are behind something of an upset (if not quite “anarchy in the U.K.”) over scientists’ understanding of the origins of one of the biggest groups of animals on Earth.
In terms of sheer number of species, mollusks are second only to arthropods (the group that contains insects, spiders and crustaceans). The better-known half of the mollusk family tree, conchiferans, contains animals like snails, clams and octopuses. “The other half is this weird and wacky group of spiny things,” Dr. Sutton said. Some animals in this branch, the aculiferans, resemble armored marine slugs, while others are “obscure, weird molluscan worms,” he said.
Punk and Emo, the forerunners of today’s worm-mollusks, lived on the dark seafloor amid gardens of sponges, nearly 200 million years before the first dinosaurs emerged on land. Today, their ancient seafloor is a fossil site at the border between England and Wales.
The site is littered with rounded rocky nodules that “look a bit like potatoes,” Dr. Sutton said. “And then you crack them open, and some of them have got these fossils inside. But the thing is, they don’t really look like much at first.”
While the nodules can preserve an entire animal’s body in 3-D, the cross-section that becomes visible when a nodule is cracked open can be difficult to interpret “because you’re not seeing the full anatomy,” Dr. Sutton said.
Paleontologists can use CT scans to see parts of fossils still hidden in rock, essentially taking thousands of X-rays of the fossil and then stitching those X-ray slices together into one digital 3-D image. But in these nodules, the fossilized creatures and the rock surrounding them are too similar in density to be easily differentiated by X-rays. Instead, Dr. Sutton essentially recreated this process of slicing and imaging by hand.
“We grind away a slice at a time, take a photo, repeat at 20-micron intervals or so, and basically destroy but digitize the fossil as we go,” Dr. Sutton said. At the end of the process, the original fossil nodule is “a sad-looking pile of dust,” but the thousands of images, when painstakingly digitally combined, provide a remarkable picture of the fossil animal.
Punk and Emo’s Hot Topic-worthy spikes set them apart from other fossils from the aculiferan branch of the mollusk family. “We don’t know much about aculiferans, and it’s unusual to find out we’ve suddenly got two,” Dr. Sutton said.
Stewart Edie, the curator of fossil bivalves at the Smithsonian National Museum of Natural History, said that Punk and Emo’s bizarre appearances shook up a long-held understanding of how mollusks evolved. Traditionally, scientists thought that the group of mollusks containing snails, clams and cephalopods “saw all of the evolutionary action,” said Dr. Edie, who was not involved with the new discovery. “And the other major group, the aculiferans, were considerably less adventurous.” But Punk and Emo “buck that trend,” he said.
The new alt-rock aculiferans reveal the hidden diversity of their group in the distant past and raise questions about why their descendants make up such a small part of the mollusk class today. “This is really giving us an almost unprecedented window into the sorts of things that were actually around when mollusks were getting going,” Dr. Sutton said. “It’s just this little weird, unexpected, really clear view of what was going on in the early history of one of the most important groups of animals.”
Science
FDA sets limits for lead in many baby foods as California disclosure law takes effect
The U.S. Food and Drug Administration this week set maximum levels for lead in baby foods such as jarred fruits and vegetables, yogurts and dry cereal, part of an effort to cut young kids’ exposure to the toxic metal that causes developmental and neurological problems.
The agency issued final guidance that it estimated could reduce lead exposure from processed baby foods by about 20% to 30%. The limits are voluntary, not mandatory, for food manufacturers, but they allow the FDA to take enforcement action if foods exceed the levels.
It’s part of the FDA’s ongoing effort to “reduce dietary exposure to contaminants, including lead, in foods to as low as possible over time, while maintaining access to nutritious foods,” the agency said in a statement.
Consumer advocates, who have long sought limits on lead in children’s foods, welcomed the guidance first proposed two years ago, but said it didn’t go far enough.
“FDA’s actions today are a step forward and will help protect children,” said Thomas Galligan, a scientist with the Center for Science in the Public Interest. “However, the agency took too long to act and ignored important public input that could have strengthened these standards.”
The new limits on lead for children younger than 2 don’t cover grain-based snacks such as puffs and teething biscuits, which some research has shown contain higher levels of lead. And they don’t limit other metals such as cadmium that have been detected in baby foods.
The FDA’s announcement comes just one week after a new California law took effect that requires baby food makers selling products in California to provide a QR code on their packaging to take consumers to monthly test results for the presence in their product of four heavy metals: lead, mercury, arsenic and cadmium.
The change, required under a law passed by the California Legislature in 2023, will affect consumers nationwide. Because companies are unlikely to create separate packaging for the California market, QR codes are likely to appear on products sold across the country, and consumers everywhere will be able to view the heavy metal concentrations.
Although companies are required to start printing new packaging and publishing test results of products manufactured beginning in January, it may take time for the products to hit grocery shelves.
The law was inspired by a 2021 congressional investigation that found dangerously high levels of heavy metals in packaged foods marketed for babies and toddlers. Baby foods and their ingredients had up to 91 times the arsenic level, up to 177 times the lead level, up to 69 times the cadmium level, and up to five times the mercury level that the U.S. allows to be present in bottled or drinking water, the investigation found.
There’s no safe level of lead exposure for children, according to the U.S. Centers for Disease Control and Prevention. The metal causes “well-documented health effects,” including brain and nervous system damage and slowed growth and development. However, lead occurs naturally in some foods and comes from pollutants in air, water and soil, which can make it impossible to eliminate entirely.
The FDA guidance sets a lead limit of 10 parts per billion for fruits, most vegetables, grain and meat mixtures, yogurts, custards and puddings and single-ingredient meats. It sets a limit of 20 parts per billion for single-ingredient root vegetables and for dry infant cereals. The guidance covers packaged processed foods sold in jars, pouches, tubs or boxes.
Jaclyn Bowen, executive director of the Clean Label Project, an organization that certifies baby foods as having low levels of toxic substances, said consumers can use the new FDA guidance in tandem with the new California law: The FDA, she said, has provided parents a “hard and fast number” to consider a benchmark when looking at the new monthly test results.
But Brian Ronholm, director of food policy for Consumer Reports, called the FDA limits “virtually meaningless because they’re based more on industry feasibility and not on what would best protect public health.” A product with a lead level of 10 parts per billion is “still too high for baby food. What we’ve heard from a lot of these manufacturers is they are testing well below that number.”
The new FDA guidance comes more than a year after lead-tainted pouches of apple cinnamon puree sickened more than 560 children in the U.S. between October 2023 and April 2024, according to the CDC.
The levels of lead detected in those products were more than 2,000 times higher than the FDA’s maximum. Officials stressed that the agency doesn’t need guidance to take action on foods that violate the law.
Aleccia writes for the Associated Press. Gold reports for The Times’ early childhood education initiative, focusing on the learning and development of California children from birth to age 5. For more information about the initiative and its philanthropic funders, go to latimes.com/earlyed.
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