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Dr. Rob Garofalo
00:00:00
I woke up one morning and there was a voicemail on my phone, on my cell phone, and I listened to the voicemail. And suddenly there was a man who said that I was a piece of shit and was going to rot in hell, and that he hoped that someone would run me down with a truck and kill me.
What happens when your job, the thing you’ve been getting up and doing every day for 20 years, becomes a flashpoint in the culture wars? And then you realize this job leaves you uniquely unprepared for what’s coming.
Dr. Angela Goepferd
00:00:40
My goodness. You’re talking to a pediatrician among a group of pediatricians. You know, we’re the, we’re the gentle, silly doctors of the world.
We’re going to hear from some pediatricians who work with transgender youth providing what is now known as gender affirming care. They’re following standards set by the American Academy of Pediatrics, and their work is widely accepted in the medical field. They are doing their jobs. And now they’re targets for people who believe that their work is morally wrong and willing to do almost anything to make that point.
Morgan Radford archival
00:01:16
The FBI has arrested a woman for making bomb threats to the Boston Children’s Hospital.
Dave Wade archival
00:01:21
The hospital says it’s being inundated with threats because of what they call misinformation about their treatment of transgender patients.
Aaron Gilchrist archival
00:01:29
A growing number of doctors say they are under threat from far right activists because they care for transgender patients.
What these doctors describe is a constant stream of online threats, menacing letters and phone calls and street protests. And it wouldn’t be the first time that U.S. doctors faced personal threats for providing a certain kind of medical care.
George Tiller archival
00:01:52
We’ve been picketed since 1975. My office had been blown up. We have had 4000 people arrested outside my office in 1991… 1993, I survived an assassination attempt.
I don’t know about you, but for me, there’s a bit of déja vu here. Today, we take for granted abortion clinics built like fortresses with protesters behind barricades and chaperones for the patients to the front door. And that’s because between the 70’s and 80’s, there were more than 100 cases of arson and bombings against clinics across 28 states. There were murders and attempted murders of doctors and medical staff. And that’s not the future that gender affirming care doctors want for their field.
Dr. Rob Garofalo
00:02:42
What we need are more people doing this work and brighter people doing this work. And I’m concerned that, like, if you’re a medical student or, you know, a young pediatrician who would choose to go into a field when this is what they may face.
So I wanted to talk to doctors about this very issue. What happens to medical care when it’s politicized? What does it feel like when doing your job is seen as a political act? I’m Audie Cornish. And this is The Assignment. Okay first, what actually happens in the offices and clinics that are drawing so much attention? I mean, there’s no shortage of misconceptions surrounding the field.
Dr. Angela Goepferd
00:03:34
Oh, there are so many. Here’s your hand sanitizer. Here’s your puberty blockers on your way in. Yes. That’s not how we operate.
That’s pediatrician Dr. Angela Goepferd, who identifies as queer and non-binary. In 2019, they founded the Gender Health Program at Children’s Minnesota. They’re the medical director of that program. And since its opening, Goepferd estimates that the program has served nearly 600 trans youth in the region. And it’s got a year long waiting list. Probably because it’s the only program of its kind in the state. Parents and patients find it a lot of ways recommendations from pediatricians, from family therapists just searching around online. So a parent comes in, maybe their child is ten or 11, and they’re hearing all kinds of aspects of gender affirming care, probably through the media. What are the first conversations like?
Dr. Angela Goepferd
00:04:35
Well, at our program, and I can’t speak for all programs, but in our program it’s an integrated model. So they’re going to have an intake with a mental health clinician first.
So it’s the whole family sits down in a room with a person who starts asking what kinds of questions?
Dr. Angela Goepferd
00:04:48
Asking about the family, the family system, the child’s health history, their mental health history, what’s happening at school and then getting into, you know, why are you here today? What do you want to talk about about gender identity? Tell us what the journey’s been so far and what questions you have and what struggles you’re having.
What kind of answers do you get?
Dr. Angela Goepferd
00:05:08
Really varies. You know, sometimes families have been supporting their transgender child from the time they were very young, three, four or five years old. They’ve socially transitioned, meaning they’re now wearing clothes and outwardly expressing through name pronouns and other things the gender expression that’s aligned with their identity. Sometimes that’s been happening from a young age. They’re now coming in because their child is starting puberty and they’re wanting to ask more questions about that. Sometimes their child has just started asking questions about their gender identity for the first time, and parents aren’t sure what to do. Sometimes they’ve just been in the emergency room because of a first suicide attempt for a patient, and they’re scared and they’re hearing about their child’s gender identity. They worry this might be distress related to that and they want to get help.
The care part includes a range of things therapy, support groups, referrals to vocal coaches, or hair removal. It could even include letters for legal name and gender marker changes and, if warranted, hormones. And this is what the major medical associations the American Psychiatric Association, the American Academy of Pediatrics, this is what they have agreed on when it comes to what’s clinically appropriate for adults and children.
Dr. Angela Goepferd
00:06:24
There’s a big misinformation campaign to position gender affirming care as surgeries on kids bodies. And that’s just not the case. Surgeries on any transgender person who’s under the age of 18 are pretty rare and certainly nothing that would ever happen for a child. And for many kids, it’s no medications at all. That’s the other misperception. A lot of what we’re doing is talking to families, answering questions, helping them navigate school and grandparents and clothing. Not all kids are going to be receiving medications for their care. There’s no kind of factory cookie cutter approach to this care. We’re working with each kid, each adolescent, each family on an individual basis and tailoring their care to what works for them.
But Goepferd says these days, parents are likely to wade through a lot of anti-trans material. Articles questioning this work, questioning the science.
Dr. Angela Goepferd
00:07:29
I would actually say most parents come in hesitant, and I don’t know that that’s because of the recent negative attention or just because it’s a big deal.
Yeah, it’s high stakes, right? It’s your kid.
Dr. Angela Goepferd
00:07:39
It’s your kid. And in some cases, you as a parent are being asked to help participate in decisions with them and with a health care team that may have long term implications for their future. And it’s hard. So I would say most parents come in a little weary, I mean, grateful for the information and grateful for the help, but they’re not sure when they come in and what comes next or where this is going to go.
What is something you want people to understand about what it’s like to be doing this work right now?
Dr. Angela Goepferd
00:08:14
I think what I want people to know is that it shouldn’t be this hard. At times, what it feels like is wanting to say, hold on, hold on a second. You need more accurate information. You need to understand more about these kids and teenagers that we’re providing care for. You need to listen to their stories. You need to know what their lives are like because you’re making a big mistake.
So the program launches in 2019. Is it controversial out the gate or like what’s the vibe?
Dr. Angela Goepferd
00:08:54
Unexpectedly no, actually… We launched pretty publicly. We were on the front page of the local newspaper here, the Star Tribune, and really didn’t hear much.
But a few years later, the messages started. Dr. Goepferd says they more or less sound the same. Still, I asked them to read one.
Dr. Angela Goepferd
00:09:14
Do you want me to read it verbatim?
Dr. Angela Goepferd
00:09:16
It has foul language in it.
Dr. Angela Goepferd
00:09:20
It says you need to have your license stripped and groomer. Children are not trans. They think they are because people like you tell them they are. When I was a child, I like to wear my mom’s heels and dresses. You would have told me I should have been a woman and I would have grown to kill myself like most trans. You think you’re doing the right thing, but you are a borderline pedophile. [BLEEP] you.
I’m sorry to make you relive that.
Dr. Angela Goepferd
00:09:54
Yeah. I mean, it’s, it’s not… it’s certainly not pleasant.
This is the kind of message they have to turn over to the hospital security team. How should I say this? It feels like we’ve seen this movie before, so to speak, when it comes to abortion clinics.
Dr. Angela Goepferd
00:10:18
Yes, it does feel familiar. I mean, this is the way I have felt over the last, you know, year, specifically kind of the last 6 to 9 months, is how my colleagues who have been, you know, women’s health providers or abortion health providers have felt for years. And there’s kind of two strategies when it comes to attacking reproductive rights, and that’s attack the providers and attack the patients. And some people do more one than the other. And I, and I think that that’s exactly what’s happening for us, both attacking the providers and attacking the kids.
And when we dug in to the news archives about this, for violence after the 1973 Supreme Court decision on Roe v Wade, it’s a lot.
Roe v Wade archival
00:11:07
In September, this Reno abortion clinic shut down after someone dumped a nauseating chemical inside. Blockades of clinics that perform abortions, acid attacks and other vandalism. The Redding, California Feminist Women’s Health Center was firebombed three times.
People were shot, both patients and doctors.
Newscast archival
00:11:26
Late term abortion doctor George Tiller has been gunned down during services at his church in Wichita, Kansas.
And then there were and continue to be reports of the protests, lawsuits and state legislation to ban specific procedures. So even though up until this summer, of course, abortion rights were constitutionally protected, access became a huge issue because clinics shut down. So given the history, it’s not a stretch to say that we could witness the same thing play out when it comes to care for transgender kids. Coming up, a doctor who has been at the center of these attacks speaks out.
Dr. Rob Garofalo
00:12:06
Someone somewhere is going to get hurt. And it’s like that when it’s going to end, you know, like there’s no room in this discussion for this kind of hate.
More in a minute. You know, Dr. Garofalo, I’m going to start just by saying that… This is the kind of interview that it’s nerve wracking as a journalist to ask people to do.
Dr. Rob Garofalo
00:12:39
Yeah, I can imagine.
But… are you scared to be doing an interview?
Dr. Rob Garofalo
00:12:45
Yeah, actually, this is the first time that I’ve ever sort of been nervous.
Rob Garofalo is in Chicago, which is where he co-directs the Gender and Sex Development Program at Lurie Children’s Hospital. And he’s also in charge of the division of Adolescent and Young Adult Medicine. One more very important credential to mention here — he’s also among a handful of researchers behind what might be the only National Institutes of Health funded study looking at the outcomes of medical interventions for gender affirming care in youth. So he’s got a long history in this work and he feels like he’s watched this slow rise in what he calls “misinformation” about gender affirming care.
Dr. Rob Garofalo
00:13:32
If you would’ve told me five years ago that this is where we would be in the current discussion around gender affirming care. I might never have believed you. You know, I think it was like during the Obama administration, the attorney general said that transgender kids and adolescents were seen. And that was, for me, like a seminal moment. And for, you know, many reasons, I think that optimism has just slowly eroded over the past, you know, three or four years. First, I think, sort of insidiously and sort of slowly. And then I think over the past year, it’s become much more organized and directive and structured and pervasive.
When it was insidious, what did it look and feel like? Can you give an example?
Dr. Rob Garofalo
00:14:18
I mean, I think there were always parts of society or segments of our culture that, that question some of the work that we do. Right. I mean, there are… I want to be careful how I say this so let me think about this. Um… let me give this some thought for a second. Sorry.
No. And I want you to take your time, because one of the things that I’ve noticed about the reporting on this, people can be taking it out of context pretty quickly.
Dr. Rob Garofalo
00:14:46
Yeah. Yeah. So I’m being, and I’ve never, I give a lot of interviews over the years and the level of anxiety and just concern I have about saying something that might be like incorrect or easily mischaracterized or reframed is super high even as we’re having this conversation. And yeah, that’s just so crazy to me on some level, you know, but that’s the world that we live in. And so I say insidious because there was, there’s always been sort of an undercurrent of a segment of our population that have been concerned about the work that we do that’s either wedded, usually in cultural or social or even religious mores. What I would say has changed recently is just the… tone and the pervasiveness of the rhetoric, which has gotten increasingly hostile and wedded in, I think, intentional attempts to misrepresent the work that we do. Intentional attempts to mischaracterize the work that we do. And in some ways, I think really has nothing to do with health or health care.
Yeah, because now you’re in an area of what we would call politically sensitive medical care.
Dr. Rob Garofalo
00:16:09
Yeah, I mean…
Abortion would be under that, I think, that label and that category as well. Do you remember a specific moment, event where, you know, you felt like something isn’t right?
Dr. Rob Garofalo
00:16:24
Well, yeah, I mean, a couple. I mean, one, I think when the legislative ban started to happen and really over the course of the last year, I think many of us were put on alert that, you know, shit was about to get real, pardon my language. So that was over the past year. But then a few months ago, you know, I had an incident, I was actually in Nigeria where I’m doing work for global health.
So you’re a world away from Chicago.
Dr. Rob Garofalo
00:16:50
Correct. I was I was in Lagos, Nigeria, really like unaware in some ways of what had happened on sort of the local news. And I listened to the voicemail and suddenly there was a man who said that I was a piece of shit and was going to rot in hell, and that he hoped that someone would run me down with a truck and kill me. And for me, that was a moment where I was just like, what the [BLEEP] is going on in the world?
Yeah. What is this? Why is this happening?
Dr. Rob Garofalo
00:17:22
Exactly. And then I was I turn on the news quite literally, you know, and it happened to be CNN, because that’s what we watch. Then there was a story about the bomb threat at Boston Children’s Hospital. And so I logged on to my Twitter account, which I don’t often use. And there were just hundreds upon hundreds of sort of messages related to a erroneous video that was a spliced job of interviews I had given, which had completely mischaracterized what I do, who I am, how I feel with regards to the care that we provide to these kids. And so it was in that moment, thousands of miles away from from Chicago or the United States, that I knew that this was going to get bad.
You know, people using your own words against you, right? Like taking interviews you’ve done, manipulating them, cutting them in a way that, as you said, is like mischaracterizing your work. Did that feel scary, personal? Like, what did you think of like the kind of impact of that?
Dr. Rob Garofalo
00:18:32
At first it felt just violating, right? You know, and in some ways very personal on any one of a number of levels. And I, just made me both sad and really enraged. I mean, I was really mad that, like, this was actually happening.
What does it look like, what does it feel like to be the focus of a kind of, just to start, social media onslaught?
Dr. Rob Garofalo
00:18:58
I mean, honestly, none of us who are pediatricians sort of went into this work to be prepared for this. So it was just felt really overwhelming. It’s almost like a wave crashing on you in some ways because you’re just ill equipped, I think, to manage just the sheer volume of messages. You know, I mean, all of a sudden, something that I had posted had 500,000 viewers and comments. And so it was sort of being without your consent thrust into this world that was filled with vitriol and hate in a way that just was deeply upsetting and really hard to manage. I mean, I would just describe it as just draining. I mean, I had a woman in my building, you know, who watched one of the videos on Twitter like harass me in the lobby, calling me a groomer and saying that I’m, I’m not going to say what she said because I don’t want to give those words air time. But saying that I did things to children, that is just repugnant and crazy, honestly.
So Dr. Garofalo says this leaves him and others in a kind of catch 22. Speak out, and see your words twisted against you; say nothing, and let the misinformation take over any meaningful debate. So it’s no wonder he and his colleagues are nervous to speak out.
Dr. Rob Garofalo
00:20:25
Right, because the hatred now is so targeted towards harming people and violence that it makes it difficult to know exactly what the best strategy is to respond, you know, for fear that any sort of response, either on social media or in real life, will sort of foment even more vitriol and anger and hate. And so that’s, I think, a really unique aspect of this. And it’s caught many of us and even pediatric institutions a bit off guard as to how to best respond.
What we are hearing about is that some clinics are, for instance, taking down the images of the medical care providers, right? Like taking down phone numbers off the Web sites, basically becoming less visible.
Dr. Rob Garofalo
00:21:14
Oh, for sure.
Seems kind of like the opposite of the mission, in a way.
Dr. Rob Garofalo
00:21:18
Completely. And that is exactly what’s happening. So people are scrubbing their presence to the outside world, either their social media presence, their websites scrutinizing material that’s being distributed to patients and families. And, and that’s, I think, carefully designed to limit access, right? I mean, you know, so by doing that, the very people that we need to reach are suddenly now not being reached.
It seems like the effect of this. Is naming and shaming of doctors. Have we seen this before?
Dr. Rob Garofalo
00:21:54
Oh, I mean, for sure. I mean, you mentioned it earlier. The reproductive justice field around abortion is, I think, a really good example of where we have seen this before.
Is, has that come up as, in an area of conversation in any way? I mean, I don’t want to force the analogy on you.
Dr. Rob Garofalo
00:22:11
No, you’re not. I mean, it’s it’s a real analogy. And I think many of us have asked and reached out to, you know, abortion providing organizations around communication strategies or safety for ourselves or for our patients. So we are trying to quickly, like, learn from one another and not reinvent the wheel because this, you know, while, I think what is new, I think is this is targeting pediatricians, you know, as a field, you know, the the the stereotype of the pediatrician is like a very kind person, like hugging a teddy bear, right?
Yeah with like lollipops in their coat jacket.
Dr. Rob Garofalo
00:22:51
Correct. We’re all I mean, I’m not, it’s very, we’re very kind and loving and, you know, and so the stereotype is in complete opposition to what the current rhetoric is saying. And I’m being really careful not to repeat the words, you know, that are being used, in part because I’ve been told now as some of the new communication trainings that we’ve received to be very careful, like not to repeat those words for, again, fear that they’re going to be misquoted, misrepresented. And so but yeah, it’s here it’s to your earlier question, this is not new. It’s just in some ways new targeting this particular population and these particular providers.
When I think back to the nineties, though, you know that, that ended in some murders of doctors.
Dr. Rob Garofalo
00:23:43
Well, you know. I get like emotional, even just thinking about it in some ways because one of my thoughts when I answered that phone call in Nigeria, honestly, like my first thought was… someone somewhere is going to get hurt. And it’s like that when it’s going to end, you know, like is it going to take someone getting hurt to wake up people to the reality that there’s no room in this discussion for this kind of hate? I mean, there were very real debates that maybe need to be had, but they can’t be had in an environment where violence and death threats are ruling the day. It honestly has kept me up at night, sometimes just fearing that like one day… like a colleague of mine or someone that I care about and know and and love, you know, may get hurt. And whether that’s a doctor or a staff person or even worse, like a parent or a patient. I mean… that’s just really hard to sort of navigate when your, when your training is really just designed to like care for people and make them better, you know? And provide them an environment that supports and affirms them.
Have you wanted to stop doing the work? And I don’t mean—
Dr. Rob Garofalo
00:25:26
Never.
You’re saying that, but you are on the edge here, like your, your emotions are right here.
Dr. Rob Garofalo
00:25:33
Yeah. Yeah, they are. But I’ve never once even considered not continuing to do this work. In fact, even with my emotions, which can run high and hot, I am more committed than ever to making sure that these young people and their families have the access they need to what I am convinced is life saving care.
What about the next generation of care providers? So what happened with abortion, right, is like there was a stigma and fewer people went in to learning about those services.
Dr. Rob Garofalo
00:26:13
I think that’s something that I am really personally concerned about. I mean, I’ve been doing this work for a really long time and I very much worry that what we need are more people doing this work and brighter people doing this work. And I’m concerned that, like, if you’re a medical student or, you know, a young pediatrician who would choose to go into a field when this is what they may face.
Are you also getting more attention because there are more people seeking the care?
Dr. Rob Garofalo
00:26:45
Oh.
And that has raised questions for a certain segment of the population.
Dr. Rob Garofalo
00:26:49
Yes. So I think… wait let me think about this for a second, because this is where I don’t want to be mischaracterized. Um, I definitely think that, that part of the concern has been the rapid rise of the sheer number of clinics that are doing this work. And I think there are legitimate questions that the field needs to ask itself about how we train providers and how we ensure that the models of care that we have are as focused on quality outcomes as they are on just access, right? I think for too long, in many ways, the trans community has accepted models of care that the outcome is strictly about access. And what I hope for for my patients are making sure that the models we care are as focused on health care quality as they are just on access and—
What’s happening to that discussion as, as, under the scrutiny?
Dr. Rob Garofalo
00:27:47
Well, that’s exactly right. You can’t have those kind of discussions under this kind of scrutiny because people are afraid to have, I think, very real conversations around some of the unanswered questions around models of care and, you know, ethics. But you can’t have serious scientific debate in a context where people are fearing for their lives.
I have to ask because, you know, as we just saw with reproductive rights and the end of Roe v Wade, it is effective, this kind of sustained naming, shaming, politicizing of medical care. There is now a kind of effective playbook for that.
Dr. Rob Garofalo
00:28:33
Yeah.
And there are a great number of states where it was down to one clinic or no clinic. Is that where this is headed?
Dr. Rob Garofalo
00:28:42
I mean, it’s not where it’s headed, it’s where we’re at in some of these states. I mean, I think there are some states where now there are virtually no clinics where to get this care. And thousands of children and their families now have to really scramble to think about where they can get health care.
On this show, we like to talk to people who we say are kind of living in the headlines. But your story is not over, right? Like it feels like this is in the middle of something. What have you learned so far?
Dr. Rob Garofalo
00:29:14
I mean, one, I’ve learned to just have a bit of a thicker skin, you know, like I mean, every morning I wake up and I recognize that I am needed to do this work and that I’ve got to show up and that I can’t afford to be tired or fatigued or cranky or upset because then the people that want to shut down this work win, and that’s a completely unacceptable option for me.
Dr. Rob Garofalo from Lurie Children’s Hospital in Chicago. That’s it for this episode of The Assignment. New episodes drop every Thursday, so please listen and follow wherever you get your podcasts. And if you like the show, leave us a rating and yes, a review. One more thing. If you have an assignment for us, a story that you want to hear more about or one that’s affecting your community, you can give us a call. Leave us a voicemail at (202) 854-8802 or record a voice memo on your phone and email that to us at theassignmentcnn, all lowercase, at gmail.com. The Assignment is a production of CNN Audio. Our producers are Madeleine Thompson, Jennifer Lai and Lori Galarreta. Our associate producers are Isoke Samuel, Allison Park and Sonia Htoon. Our senior producer is Haley Thomas and our editor is Rina Palta. Our supervising producer is Steve Lickteig. Mixing and Sound Design by David Shulman. Dan Dzula is our technical director. Abbie Fentress Swanson is our executive producer and special thanks to Katie Hinman. I’m Audie Cornish. Thanks for listening.
