Dr. Selena Dagnino: So a lot of times when somebody finds out that they're positive, there can be depression. There can be a lot going on in that person's life. And so I'm like, "Do you really want to withhold the hormones as well?"
Malachi Stewart: Welcome back to Positive Voices. And listen, we're continuing a conversation that we had earlier just about what it meant to be trans and the trans experience, and giving voice to that. We have Dr. Selena with us again, a medical pharmacist. Listen, working in the field of HIV where I come from, and you work at an HIV clinic currently, we used to have a joke that there's a lot of folklore. We used to actually call it the trans folklore, like people of trans experience having different ideas about things they heard on the street.
And some of the things you talked about in the episode that you filmed with us was that when you don't have a seat at the table, you are left to your own devices. And hearing from your homegirls and hearing from your elders, what kind of myths and folklore and information would you like to clear up for people in the trans community living with HIV and beyond?
Dr. Selena Dagnino: I actually love that you started with that because one thing... So, just a little bit of background. I am an HIV pharmacist. I wear a lot of different hats. One of those hats is training providers and pharmacists. So I train nurse practitioners, I train PAs, I train physicians on how to prescribe and treat trans people. So one of the things that I always tell those providers is that your patient a lot of times probably knows a little bit more than you. Not a little bit, a lot a bit a more than you. And so essentially what happens whenever you're, let's say, bringing a drug to market, in one of those trials you're wanting to know all the side effects. And you're documenting them and you're putting them into a study and you're putting it out there, and that's how you read all that. But with trans folks, that doesn't happen.So a lot of what people say on the streets, they have a lot of truth to that. So whenever your homegirls or your homeboys are telling you how you can transition, many times there is truth. And I'll give you an example. I gave a lecture at Translatinx in New York City, and they were saying, "I really like birth control," because now it was on the first hormones that came out, "because my breasts grew a lot faster." That's valid. That's true. There's a conversion with estrogen that happens, where that happens. What happens is, with birth control, there are a lot more side effects, and so, in these times, I don't necessarily say that they're myths because they're not. I let people know the pros and cons of what they're doing, and I give people also options. Are you looking to improve what your breasts look like? Okay. Have you ever thought about this dose of progesterone?And there's no studies on progesterone on that, but from our homegirls we hear, it helps with sex drive, it helps with my breast development, and there's science behind that too. So whenever we have trans patients that come in, I want to learn about where they learned about hormones. Sometimes they'll come in and be like, "I don't know anything." And I'm like, "Perfect. Clean slate. I can tell you a little bit more." And then there's other times where, like, "Well, my homegirls are saying that if I inject this and do that and do this," I validate that. I don't say that that's wrong. This is how the girls have been doing it for years. But I give them pros and cons. And I'll give you one example, is I had a trans woman come in and we were giving hormones and their liver enzymes were insane.That can either mean drinking or drugs or whatever, and so this patient's like, "I don't do any of those." And sometimes they're telling the truth and sometimes they're not. And I pulled her aside and I was like, "Sis, what else are you on?" And she was like, "Nothing, nothing, nothing." I said, "Sis, what else are you on?" And I gave her the femme queen just like... And she's like, "I'm on this and this and this and this." And I'm like, "You're overdosing yourself." So in those cases, I want to build enough trust with the patients so that they're able to tell me what else they're taking as well. So as far as folklore, I try to validate where that comes from or try to research how that came about. And sometimes it is dangerous, and sometimes they're doing a pretty good job.
Malachi Stewart: Because they're the subject matter experts, right?
Dr. Selena Dagnino: Yeah, they're the subject matter experts.
Malachi Stewart: That makes a lot of sense. So question I have. I know back when I was doing the work, it's been a little while since I've been frontlined, but when I was doing it, access for people who have trans experience depended upon, if they were HIV positive, it depended upon whether or not you were undetectable. Viral suppression is what undetectable means. Viral suppression determine whether you were going to get care. If you wanted top surgery, bottom surgery, hormones, everything depended upon you being virally suppressed. Is that still the case? And what can you say to that?
Dr. Selena Dagnino: I actually got that question a few weeks ago from a nurse practitioner and they said, "Somebody just tested positive. They want to also start their hormones, and can I start that at the same day?" And I said, "Why would you not?" And I try to ask these questions back to them. "Why would you not start them out?" "Well, dah, dah, dah, dah." So a lot of times when somebody finds out that they're positive before they realize their options, before they realize what undetectable is, there can be depression. There can be a lot going on in that person's life. And so I'm like, "Do you really want to withhold the hormones as well?" But they're like, "Well, what if they have a mood swing on hormones?"
And if somebody is asking you for hormones, there's really no reason why you need to deny them those hormones. I think back in the day when HIV medications were pretty rough on kidneys and pretty rough on the liver, a lot of times people were like, "I just want labs to come back." But what providers need to understand is, they will go to the streets and dose themselves. So you can either dose them appropriately, or they're going to dose themselves somehow else and then maybe not come back. And so we find that when trans women and trans men are given hormones, they're more adherent to their regimens. They're going to come back. They're going to come back for that.
Malachi Stewart: Right. And that's important that you say that. I've actually heard providers on teams I've been on say that they literally use hormones or surgery referrals and think that, because you know need them. You need the referral for the behavioral health specialist if you want to have surgery and have a diagnosis of gender dysphoria. You have to have all that. So they say, "I use it as a carrot to dangle in front of them."
Which never felt right to me. It felt like... I mean, you talked about having mood swings. Here on the show we've had a lot of people come on the show and talk about their experiences with depression and how it affected adherence. None of those people, to my knowledge, were of trans experience. What's the difference between them? So it is another way people are treated differently based on their identifiers.
Dr. Selena Dagnino: So I really love that you said that because as we talk about mood swings, people, you have hormones whether you're injecting yourself with estrogen or testosterone. And so the way that you're dealing... You can even think about cis women when they're...
Malachi Stewart: Menopausal, or...
Dr. Selena Dagnino: Menopausal or just once a month, and people deal with hormones differently. Hormones are going to surge up and down depending on cycles, but we learn how to deal with that, if that makes sense. In cis women, for example, a lot of times in sex ed you're learning, "Okay, this is what my cycle is going to look like. This is what I can expect," if you had a good sex ed program. But for trans people, we never really learn about those cycles. So whenever we're injecting ourselves, we never really learn that, "Okay, in two days from now, my hormones are going to be pretty high. I might have a mood swing."
But a lot of times when you're going to a provider's office, they're kind of blaming everything on that. Your depression is from your hormones. You're not adherent because of your hormones. Or they're blaming a lot on the hormones when you can actually really use that as a tool to help people heal. And so, whenever we think about surgery, for example, it was pretty custom to take people off of hormones while they're healing, and then people kind of fall into this post-surgical depression. And you're like, "Well, we don't do that to cis people. We don't clip their ovaries or clip their testicles until they're done with surgery. So then why do we do that for trans people?"
Malachi Stewart: Absolutely.
Tei Pearson-Hal...: Can I ask you a question about that?
Dr. Selena Dagnino: Sure.
Tei Pearson-Hal...: So what would be the point of stopping the hormones for recovery, right? Because, like you just said it, it causes all of these adverse things. So what would be the point, if any?
Dr. Selena Dagnino: That's a really great question. It goes back to studies. So because studies were never done on trans people, it was mostly... What people were using in the beginning was birth control for transfeminine people, and the high dose of the birth control can lead to thrombosis. So whenever we were having people go through surgery, we're like, "Well, we don't want thrombosis, so we don't want you to be on these hormones."
So then as more studies are coming out and we're realizing that estradiol doesn't have those same side effects, the same doses, there was not really a reason to. And if there is, for example, then we treat that. There's medications that we can give post-surgery to make sure that that doesn't happen. And that goes back to what we were talking about for cis women, for example, or cis men. We're not pausing their hormones due to side effects. We're treating what could happen based off of levels and science.
Malachi Stewart: Yeah. As a pharmacist, talk to me about those levels when it comes to what your provider's prescribing versus what you are taking from a friend, or what you got on the black market.
Dr. Selena Dagnino: Sure.
Malachi Stewart: Yeah, because I just have had experiences with trans women where you're looking at their labs and you're like, "Have you been crying randomly?" And you're like, "Because what the labs show me, is that," and then that's when they'll admit it when you say something to them.
Dr. Selena Dagnino: Yeah. What is really difficult about prescribing hormones is there's not really any guidelines or medical board that oversees this. And then there are a few and they all disagree with each other as far as levels. So when I have a patient, I'm more asking them what are their goals. How will they feel? And I'll just give you a quick example. Myself. Sometimes I can't get out of bed and I'm just like, "What is going on? Something's going on." And luckily I work in a clinic, so I get to go next door and I'm like, "Can you draw my blood and see what my testosterone is?" And if my testosterone is way too low, that makes sense. I'm like, "Oh, my gosh, that makes sense," because whether you're transfeminine or transmasculine, you need both.
Malachi Stewart: You need both.
Dr. Selena Dagnino: So I would say that the importance of getting your hormones from a provider or somebody that is able to monitor your labs is, we're seeing what type of hormone it is because some hormones have more side effects than others. And then we're also able to track those labs and then ask you, "How do you feel? What are you feeling?" And so I, personally, I got my labs a few days ago and I've been feeling great lately, and my testosterone finally went up. And that's something that I wanted, and it was one of my personal goals because even though you're trans, you can't have a testosterone at zero or close to zero. You go insane.
Malachi Stewart: Hey, you don't want to.
Dr. Selena Dagnino: You can't think properly. You can't wake up in the morning. Or when we talk about sex work, you can't work. So I talk about, "Do you do sex work?" And we talk about their testosterone levels and where we want that. And, yeah.
Tei Pearson-Hal...: That's a really new thought that I didn't know. So I learned something today. So a question about that. I heard you say, when you're in your trans journey, you have both, right? You'll have estrogen and TE. And so, as a parent for a trans boy, he's going to be starting with TE, right? But we know that his feminine things irritate him. When he has his monthly, we call it a T-shirt.
When he needs pads, he needs more tank tops. And so it's all of these code words that we've had to learn, because he just like, "Yeah, I need T-shirts." And I'm like, "I just bought you a pack. I just bought you... We just was at the store and got you a whole pack." And he's like, "Not that kind." "Got you." So, could you tell us and me of what happens? Like now, he has estrogen. When he starts to TE, the TE will start to do what it does. So what happens with the estrogen that he has?
Dr. Selena Dagnino: They oppose each other. As testosterone's going up, estrogen will level itself and start going down. During that time, you're kind of at a loss for energy. Your body hasn't really learned how to process the other one as energy yet. Migraines, for example, are another side effect of not really monitoring your estrogen. So I think when we're starting our journey, we were like, "I need this other hormone at zero, and you're not really understanding that everything's a process."
So in these guidelines, we do start patients out with an initial dose, which is a low dose. And I explain to people that this is a process, that you're not wanting to necessarily eliminate one hormone very quickly, and then we move on to the next dose and we move on to the next dose. I guess what I'm trying to say is, there is function for both, and there are some trans people that are on both for different reasons.
Tei Pearson-Hal...: Oh, okay.
Dr. Selena Dagnino: Whether that's vaginal dryness or atrophy. So then at that time, maybe they can start a topical estrogen instead.
Tei Pearson-Hal...: Oh, okay.
Dr. Selena Dagnino: So then we get to those conversations as well, because there's still people that want... They don't want vaginal atrophy, and they still are very functional as bottoms.
Malachi Stewart: Yeah. No, that makes a lot of sense.
Tei Pearson-Hal...: Thank you for that.
Malachi Stewart: Listen, you have the knowledge. And I want to say to you, Tei, great parenting.
Dr. Selena Dagnino: Great parenting. Yeah.
Malachi Stewart: Great parenting for creating that space. I think that if there's anybody who's watching and wondering how to make space for their trans child, you just gave some gem. So shout out to you.
Tei Pearson-Hal...: I mean, because... Thank you for that. But I think just it's accepting people for who they are. And so I have to see, and my wife have to see that our son was born a son, and then the outward appearance just didn't match with how he felt. But to see the daily struggle of him being in this feminine body with these feminine attributes and all of these feminine expectations, it was like, "No, this is not it." And so, like, "Who are you? How can we empower you to be more of you?" And so, that was conversation. That was, "I like male clothes. I like suits. I like to smell good." And so, we do field trips.
We go to Macy's. We go to Nordstrom. He wants to smell colognes. He wants to know what's going to smell good with him, and then he's going to be like, "Okay, all of this smells good, so now I like this, and I want to wear suits to school because I'm a gentleman." And you are, and you wear it, and we're going to go get you the most expensive suits. So when you click-clack with your Chelsea boots, because he likes Chelsea boots, when you click-clack through the school in your Chelsea boots, you let them know that you are a man coming through. And so this, the empower, for me as a parent, it's empowering... I don't even want to say his decision because I don't feel like he was given the decision, right? He was born as a boy. And so for us-
Malachi Stewart: It's definitely his truth.
Tei Pearson-Hal...: Right. His truth, right? And so for us as his moms, it's like, "How do we empower that truth?" And so, let's get you to where you want to be and figure out everything else, like speaking to wonderful doctors now with questions about TE and hormones.
Dr. Selena Dagnino: How old is he?
Tei Pearson-Hal...: He's 16 now.
Dr. Selena Dagnino: So one thought that crosses my mind is that empowerment is illegal in many states, so we're not allowed to use chosen names in Florida, for example. They just outlawed that. You have to have parents' permission for that. So in a lot of places... The Endocrine Society says at 16 you can start hormones. That's when it says. I don't think you need to start hormones sooner than that unless you're wanting to freeze puberty, which is a different approach. And [inaudible 00:16:23]-
Malachi Stewart: That's a whole different conversation.
Dr. Selena Dagnino: It's a whole different conversation. But as far as starting hormones, that's illegal in many states, which is crazy.
Tei Pearson-Hal...: You say illegal?
Dr. Selena Dagnino: Illegal.
Tei Pearson-Hal...: Oh, wow.
Dr. Selena Dagnino: Because I think it's Texas. A few others off the top of my head, I can't remember them. But, yeah, so I think what you're doing is really wonderful. And I think that asking these questions, it's not really talked about and it can't be talked about in a lot of places. But, yeah.
Malachi Stewart: Before you go though, I definitely want you to... What about STIs? I mean, because we're all having sex. One thing we talk about here is having sex.
Dr. Selena Dagnino: Hello.
Malachi Stewart: And so, I just want to hear how does STIs fit into transitioning, taking hormones, things like doxy-PEP? What does that look like?
Dr. Selena Dagnino: I really like that you brought up doxy-PEP. So doxycycline is an antibiotic, and it's pretty broad-spectrum in the sense that it treats all kinds of things. So we started prescribing it as doxy-PEP pretty recently, but doxycycline's been used for years. So when PrEP came out, which is for an HIV, they put in the guidelines, every three months you have to do STI tests. And people started getting STI tests every three months. But what happens in those three months is, you can become positive with a different STI. So then the conversation was, do we get tested more? Well, insurance a lot of times doesn't pay for more than that, so you have to find a free clinic, and the free clinics are not everywhere, and they got really long lines.
Malachi Stewart: Yeah. [inaudible 00:17:53].
Dr. Selena Dagnino: And you see all your friends there and you're like, "Oh, my God." So doxy-PEP, essentially how it works is, you dose yourself after you have unprotected sex. And so it should prevent against chlamydia, gonorrhea, syphilis, but you also have to realize that there's a lot of resistance. So, gonorrhea is forever evolving. For example, chlamydia, we just changed the guidelines on that, so we're treating it differently than we did two years ago.
So doxy-PEP is going to eliminate that replication of those bacteria, and people just need to know it's not 100%. But if you're doing sex work or if you are not wanting to test positive for anything for your own reasons, it's up to you. So I got it prescribed for myself. I do sex work sometimes. Do I take it all the time? No. I prefer a lot of times I get tested, that's my choice, but I want the choice to be yours.
Malachi Stewart: And does it interact with... Like if someone is trans and maybe they're on testosterone or they're trans and they're taking estrogen, is there any interaction?
Dr. Selena Dagnino: There's not.
Malachi Stewart: Awesome.
Tei Pearson-Hal...: Thank you.
Dr. Selena Dagnino: There's not.
Malachi Stewart: Thank you for sharing that.
Tei Pearson-Hal...: Just a follow-up question, and I think you may have answered it, but I'm not sure. So, does the hormones, does it leave you more susceptible to be able to contract HIV or STIs? Because the immune system-
Dr. Selena Dagnino: Oh, I know what you're talking about.
Tei Pearson-Hal...: ... is altering?
Dr. Selena Dagnino: Yeah. No, but a lot of times that gets brought up because of needle sharing. So back in the days, before the girls could get, or the boys could get access to hormones, people were needle sharing. So that got brought up, like, "Oh, it can lead to HIV." And that's not from the hormones. That's from needle sharing.
Tei Pearson-Hal...: That's from needle sharing. Right. Okay. So a folklore, like another folklore that was brought up [inaudible 00:19:45]-
Dr. Selena Dagnino: [inaudible 00:19:45]-
Malachi Stewart: And the folklore, I think what we're hearing is that the folklore is rooted in truth.
Dr. Selena Dagnino: Yes, in truth.
Malachi Stewart: But we just need more big docs at the table who have the experience, who can speak to that. Thank you so much for being here.
Dr. Selena Dagnino: Of course.
Tei Pearson-Hal...: Yes. So if I could ask you one more question. So, as a parent, because sitting here as a parent, so as a parent, what tips, if you could, give us maybe three tips for a parent who has a child? And in our earlier interview, our other guest, Dasia, says, "Moms know pretty early on." So what could you say in this magical world of wishlists to parents? Like three tips, if you recognize that your child is due for their transition to be able to live in their truth, what tips could you give?
Dr. Selena Dagnino: Oh, my gosh, this is so difficult. Tips for parents. Well, I'm not a parent, but so I'm trying to think of-
Tei Pearson-Hal...: Speak from your parents' perspective to you. Yeah.
Dr. Selena Dagnino: I know. I'm trying to think of... And then I get emotional about it too, because still my family calls me my dead name, and he/him. So I guess, we talk about pronouns and chosen names a lot, and sometimes you might feel like we're beating a dead horse, but we're not. So, asking them. And also everyone that presents as either feminine or further, who they're supposed to be and "supposed to be," and too masculine. Not everybody wants a transition. Some people love being androgynous. So I think also holding androgyny to be valid as well. And so I think a lot of times when somebody is young and might look like they want to transition, just listening to them and being like, "Do you like to be androgynous? Are you non-binary?"
And then not necessarily needing to rush hormones. I think sometimes people can be too supportive and like, "All right, let's get to the doctor right now. Let's start hormones." You can transition at any age. You can de-transition as well. So I think having the choice, letting them lead the way, but also trying to find groups with people that look like them, I think is also valid. The main reason why I moved to New York City was to be around other trans women. And that to me was empowering. So I think also supporting them, having a friends group, friend circle, whatever that looks like, is [inaudible 00:22:10]-
Tei Pearson-Hal...: Community.
Dr. Selena Dagnino: Community, that's what it is. Community.
Tei Pearson-Hal...: Community. Yes.
Malachi Stewart: Yeah. Community, community.
Tei Pearson-Hal...: Wonderful. Wonderful. Oh, I'm so... I feel full.
Dr. Selena Dagnino: Oh, do you?
Tei Pearson-Hal...: And I hope you guys feel full too with just the deeper conversation. To have a pharmacist, right, and that's doing the work that lives your truth is impactful and very powerful.
Dr. Selena Dagnino: Thank you. I appreciate that. And there's a lot of providers out there that are doing their work. A lot of doctors, a lot of PAs, a lot of nurse practitioners that are doing their work as well. So I think healthcare in our lifetime is going to look a lot different. But right now it's a little rough.
Malachi Stewart: It's transitioning.
Dr. Selena Dagnino: It's transitioning.
Malachi Stewart: It's transitioning.
Tei Pearson-Hal...: Yeah. That far.
Dr. Selena Dagn...: That's a good word.
Malachi Stewart: Where can people go if they're looking for resources?
Tei Pearson-Hal...: Listen, we have a wonderful site set up for you. If you want more resources, if you want to find out more about your options, head on over to linkUdmv.org. L-I-N-K, big U, dmv.org, and put your zip code in. It'll populate all of the resources in your area for you from testing spots to rent, okay? To, you might need a little voucher for something. Go there, put your zip code in. It'll populate the list for you. Also, if you want to just check us out more, you want to see what last season was talking about, what we're doing this season, we have a spot for you.
Head on over to DCEndsHIV.org/podcast. That's the line that go like that. And you'll be able to click up top, watch more episodes, fill out a survey, as well as connect to us and all of the spots that this podcast will be available on. Speaking of, when you view it, listen. Y'all know what it is. Like, share, subscribe, tell a friend to tell a friend, because we want to get the word out, that Positive Voices is here and we have you, just like you have us. We'll see you guys on the next episode. Positive Voices, season two, baby. We up out of here.
Malachi Stewart: Bye y'all.