SElling PrEP, part 2

Webinar held by the Quantitative Biosciences Institute, University of California

The Quantitative Biosciences Institute is linked to the University of California and based in San Francisco. The Institute held a webinar entitled ‘HIV 2020: Where Are We Now?; Beliefs and Barriers to PrEP Among Trans Men’.

The Quantitative Biosciences Institute (QBI) fosters collaborations across the biomedical and the physical sciences, seeking quantitative methods to address pressing problems in biology and biomedicine. Motivated by problems of human disease, QBI is committed to investigating fundamental biological mechanisms, because ultimately solutions to many diseases have been revealed by unexpected discoveries in the basic sciences. 

Mission Statement from website

The most important thing to note is that women on testosterone run the risk of kidney damage and liver damage, which are also listed as side effects of pre-exposure prophylaxis (PrEP) treatment to prevent HIV, making the subject of the seminar impossibly stupid. Why is a biomedical school even asking this question?

To discuss the issue was Stefan Rowniak (nurse practitioner) and Sean Senechal (therapist/ gender identity researcher). I think it’s fair to say that they did their best not to shine a light on the medical and ethical issues around PrEP use in women on testosterone.

The speakers

Senechal has her own wikipedia entry which describes her as an American futurist, previous software engineer, whose claim to fame is that she teaches dogs to sign language (from the book sample it appears her own dogs know how to ask for food – impressive). It appears that she may have started taking testosterone a few years ago (I’m just going by the photographs which have popped up in a Google search and the Wikipedia entry states that gender identity study began in 2013, previous articles refer to her as ‘she’). I suspect she is now a ‘they/them’ but oddly pronouns weren’t offered. Senechal said she was particularly interested in looking at models of gender and how chemicals affect gender and sexuality.

Rowniak is a full time faculty member at the University of San Francisco who has written extensively on the subject of transgender healthcare with a focus on females who identify as male and a previous career in nursing, particularly HIV/AIDS. As with a previous academic pushing PrEP, I suspect that Rowniak may possibly be a trans-identified female.

What were the barriers to care?

Senechal said that lots of mental health patients weren’t aware of PrEP and had no support in the community. Transgender people faced the barrier that clinicians didn’t understand how they might have sex. PrEP was also not affordable for them.

Rowniak repeated the cult line that ‘transgender patients have to educate doctors’ and that clinicians often didn’t obtain adequate sexual histories from trans-identified females. Rowniak said the whole thing had been made worse by Trump through ‘constant attacks’ mentioning the military ban and described Trump as the biggest threat to health of the American nation.

Senechal said that trans people had difficulty accessing health care because when they turn up to a clinic or hospital they will be faced with male and female bathrooms, making them feel uncomfortable on walking in and that non-binary people ‘might not even have a bathroom to go to’. Even in the Bay area they may encounter issues with pronouns, including seeing a doctor who may not introduce themselves with pronouns. Most people didn’t understand the many variations within the different genders. It was a question of how far clinicians would be prepared to vary protocol (in terms of liability) and how could patients give informed consent (for the high risks associated with a complex drug regimen). Thereby admitting, albeit in a very roundabout way, that testosterone and Truvada would be an extremely toxic mix indeed for females.

Senechal said one ‘transman’ she knew was turned down for PrEP treatment because there has been very little research had been done PrEP in women who take testosterone (I suspect the group is too small to test meaningfully). Senechal said the TIF had responded that ‘I’m not a martian’ and then Senechal confirmed that transgender people are not martians. (Well obviously not, but you can’t run a scientific study if you don’t have have the numbers, end of.)

Later in the discussion Senechal repeated that pharmacists were becoming more involved in treatment plans and needed to understand how cross sex hormone treatments and PrEP may interact and other any number of medical specialists may need to be involved – a bone specialist for example.

The host asked for a simple explanation of PrEP.

Rowniak explained that PrEP had previously been referred to as post-exposure prophylaxis (PEP) to prevent HIV from developing and had been prescribed for many years and could have an efficacy rate of up to 98%. More education was required to ascertain whether PrEP was suitable in the use of ‘transmen’ (i.e. women on or off testosterone).

Rowniak claimed that ‘transmen’ were especially disadvantaged as they couldn’t normally find a job and had unstable accommodation situations. If they needed to take a day for medical treatment they might get fired. There was also the fear of pregnancy and the need for contraception and providers were not taking this into consideration. (Rowniak forgot to mention that PrEP should not be used in pregnancy at all because of the damage it poses to unborn children.)

What improvements needed to be made to healthcare for trans men?

Rowniak said special health care modules on treating transgender people were a necessity.

Senechal wanted more research into gender variations and suggested that the differences in bodies might be huge and that institutions should have correct signage and information. Doctors should address the person, ‘not the trans’. Client feedback forms often result in change – so remember to always fill one out!

What would a trans-friendly clinic look like?

Senechal said that people should be able to see yourself when you arrive and said that non-binary and agender people had been left out of the conversation and were the most likely to be sidelined. We shouldn’t assume that a ‘transman’ has a vagina or ‘front hole’ nor that they would definitely be on hormones.

An anecdote she gave about a woman on testosterone was particularly revealing. The cardiac physician wanted to take the woman off testosterone to get her blood pressure down, and the TIF responded ‘would you accept being castrated to get your blood pressure down?’ Apparently patient and doctor laughed about this ‘hypocrisy’.

What’s going on?

This isn’t the first time I have come across academics or scientists who have presented drug use completely uncritically and I suspect the real audience for this broadcast will likely be the many trans-identified female students currently studying at the University of San Francisco, perhaps under the tutelage of Rowniak and Senechal themselves. That a biological science research unit could present this drivel shows how far the looking-glass academic scientists have gone.

Link to broadcast