Pride and Joy
Julia Chang’s Work with Transgender Health Seeks to Improve Lives and Gather Data
Finding your vocation is never an exact science, but maybe Julia Chang got lucky. Because on day one of medical school, she found hers.
She’d always wanted to be a doctor — “since I was a kid,” Chang, MD, clinical assistant professor of endocrinology, explains. But her specialty wasn’t settled. And then, on that very first day of medical school in 2012 at Case Western Reserve University in Cleveland, the very first speaker they had was a physician who directed the city’s Pride clinic, a man named Henry Ng, MD. And Julia found her vocation.
“As a first-year med student, I didn’t even really know what a Pride clinic was,” Chang remembers. “But I could sense the compassion Dr. Ng had toward the queer community, which has traditionally been very marginalized in health care. He spoke passionately about diversity, equity, and inclusion at a time when it wasn’t at all an emphasis in medicine. He was very inspiring. I remember thinking, As soon as I finish clerkships, I want to work in that clinic.”
And she did. Many more medical school classes and rotations followed, and Chang developed an interest in endocrinology, which dovetailed neatly with her interest in the PRIDE clinic and other issues of LGBTQIA+ health. She developed research interests in hormone health, diabetes, and other chronic medical conditions as well, and after medical school she matched at Stanford for residency. She’s been here ever since, for her fellowship and now in her first year as an attending.
Answers to Urgent Questions
There are many research questions about transgender health, Chang describes, that have not been fully explored, particularly regarding hormone therapies. For example: “Is there an ideal hormone regimen for trans feminine and trans masculine individuals in terms of safety and efficacy? Do injections work better than patches? What are safe and effective regimens for a nonbinary individual? And what’s safe for older adults? It’s not one-size-fits-all.”
Chang and her team want to know, and they’re specifically interested in progesterone, a hormone often used by transfeminine individuals to help aid their transitions. “We found that more than 25% of transfeminine individuals coming to Stanford were receiving some type of
Julia Chang, MD, discusses her research with a patient.
progesterone or progestin prescription, but there’s very little mentioned about progesterone in guidelines from the Endocrine Society or the World Professional Association for Transgender Health (WPATH),” she says. “So many trans women are asking for progesterone, but we don’t yet have large studies looking at its safety or its effectiveness for breast development or feminization. It’s a huge gap in our current knowledge.”
To alleviate this, Chang and her faculty mentor Danit Ariel, MD, clinical assistant professor of endocrinology, studied how progesterone was being used at Stanford and presented their findings at the Endocrine Society and USPATH (the United States chapter of WPATH) conferences. One thing Chang discovered was that only about a third of patients on progesterone had documentation in their files regarding why progesterone was started and whether it was helping to achieve the patient’s goals. Many times, progesterone was continued indefinitely.
Fortunately, Chang also found that none of the reviewed patients on progesterone had major cardiovascular or blood clot adverse events, which is a substantial risk of progesterone use as seen in studies with cisgender women. As Chang acknowledges, this result on a small scale means there’s a need for longer-term, larger-scale studies, but it’s a start. Even simply documenting a patient’s reasons for taking progesterone and noting what they’re experiencing can be a step in the right direction, Chang states. She hopes to take her study of progesterone to the next level by launching a nationwide survey in the coming year aimed at transfeminine adults and surveying their use of and experiences with progesterone.
“We need to do a better job as a medical community in trans health care to have those conversations with patients about risks and benefits,” Chang says. “Sometimes, patients will experiment with hormones on their own to try to address clinical questions that we don’t always have the answers to. The online chatter among transgender people is robust and fast-paced, and there are hundreds of threads about hormone regimens on subreddits, on Twitter; people are talking to each other. And we just don’t have a lot of data yet to fully answer some of the questions about long-term risks of gender-affirming hormones. But these are questions that the patients are coming to us with every day, and we owe it to them to conduct the studies and continue the research, so that they can make the most informed decision and take their hormones safely.”
...we owe it to [our patients] to conduct the studies and continue the research, so that they can make the most informed decision and take their hormones safely. – Julia Chang, MD
It Takes a Clinic
Getting those informed answers, however, is not an easy task. Chang, like many Stanford faculty, splits her time among various clinics and projects: She spends one day a week at the Los Altos LGBTQ+ Clinic and two days a week at the endocrinology clinic at Hoover on the main campus. (The rest of her time is split between medical education, quality improvement, and research efforts.) It makes for a busy schedule, but Chang clearly finds these efforts rewarding.
Particularly in the work she does with gender-affirming hormone care, she really gets to know patients, seeing them often for months or even years and developing “long-term, even lifelong relationships.” She sees patients through various stages of their lives as well, from the young 18- and 19-year-olds just starting hormone therapy to a 50- or 60-year-old patient “who’s grappled with their gender identity for decades and now finally feels comfortable coming out.” She also sees patients who’ve started hormones elsewhere and require follow-up care, and her work involves guiding them through the process and other health issues that may arise.
“I really enjoy ambulatory medicine,” Chang enthuses. “When patients come back for their follow-up visits, and you see the progress that they’ve made, not just in their physical health but in their emotional health, and they can see and feel it too — that’s the best part of my job. You get to establish a relationship with these patients over time and see how you’re making an impact on their lives.” She calls working with the trans community “particularly gratifying in that way, because it’s a community that’s been very stigmatized but is starting to really come into its own publicly on the national stage with a strong voice.”
Chang adds that in the past (and even in the present), “so many of them were afraid of seeing a doctor who really doesn’t understand the challenges they face. And so having that relationship and working with these patients and really being able to make a difference to their physical and emotional health has been extremely rewarding.”
At the Stanford LGBTQ+ Program and Endocrinology Clinic at Hoover, Chang works with a whole team of dedicated providers who are passionate and committed to helping this community, including primary care doctors, psychiatrists and psychologists, OB-GYNs, urologists, nurses, patient care coordinators, medical assistants, and front- and back-office staff.
"One misconception is that providers should only see these patients through one particular trans lens." – Julia Chang, MD
Correcting the Record
Chang’s other major efforts involve medical education. She wants medical students to have the experience she did, where transgender and LGBTQ+ health training is included early in the curriculum. Benjamin Laniakea, MD, clinical assistant professor of primary care and population health, and Neil Gesundheit, MD, Senior Associate Dean for Medical Education and the George Deforest Barnett Professor of Medicine, have been instrumental in spearheading and collaborating on educational efforts in LGBTQIA+ health.
“As medical professionals, we really owe it to all patients to treat them with respect, regardless of background and gender identity,” Chang says. “And we need to make sure we’re including this training early on in medical education and continuing it at every level.” The number of transgender-identifying youth in the United States has
risen, and as Chang points out, transgender youth will become transgender adults in the decades to come, making it “even more important that we have people who are trained to take care of our patients with respect.”
Chang has been collaborating with Laniakea on a two-hour session for medical students on working with LGBTQ+ patients. This session is currently required for all first-years. It focuses on big-picture things as well as smaller details, like preclinical issues that may arise when an LGBTQ+ patient walks into an office (including language used by front office staff and pronoun use, among other things). Chang, Gesundheit, Ariel, and Laniakea are also working on a new clinical case module for second-year students to delve deeper into various clinical care scenarios, including hormone suppression and hormone replacement for trans and gender diverse-patients.
All of this is flowing from a basic goal of equality and respect. “One big misconception about transgender health care,” Chang says, “is that transgender people just aren’t like ‘normal’ people who need good-quality health care. They deserve the same quality and same dedication, for all their health concerns, whether they’re coming to you for hormone health or something that may be completely unrelated. One misconception is that providers should only see these patients through one particular trans lens.”
Along with that comes the need for basic sensitivity. Chang says she’s gotten pushback sometimes when she wants to offer training but points out that even small things (like avoiding honorifics, such as using Mr. or Ms, in patient messages) can make a big difference. People can misgender trans patients without realizing it or by not paying attention to flags in a patient’s chart.
“That’s why it’s important to have training at all levels and for all departments, not just in endocrinology or primary care,” Chang says. “Trans patients are going to seek care for a cold or a cut on their arm or for surgical procedures that may not be strictly related to their hormone health, and they deserve to be addressed correctly and have their gender affirmed. By starting that training early in medical school, we are acknowledging that gender identity is an important part of people’s overall health, and health care professionals can start to feel comfortable with this very early on.”