‘Education Is Advocacy,’ FP and LGBTQ+ Care Champion Says

But Adkins — the new physician member of the AAFP’s Board of Directors, and a family physician with clinical and teaching expertise in LGBTQ+ care and health equity — needed to tell lawmakers just how the law would affect his patients in Ohio, which already bans gender-affirming surgery for patients under 18. So, after the Ohio Legislature overrode Gov. Mike DeWine’s veto of the bill this spring and the state’s health and mental health departments proposed adding burdensome administrative requirements for clinicians, he wrote detailed testimony and emailed it to the statehouse.

“No physician looked at this,” Adkins said of the proposed requirements, which would affect patients of all ages. (H.B. 68 is on hold until an ACLU lawsuit challenging the bill’s constitutionality is heard July 15.)

Adkins is an assistant program director at Grant Family Medicine Residency in Columbus and an adjunct clinical assistant professor at the Ohio University Heritage College of Osteopathic Medicine in Dublin, Ohio. He also serves as co-chair of the OhioHealth Gender Affirmation Council. During Pride Month, and ahead of three panels Adkins will lead in August at the National Conference of Family Medicine Residents and Medical Students, he talked with AAFP News about the intersection of his clinical practice, his work as an educator and the advocacy linking them.

What motivated you to write your own testimony against H.B. 68?

The administrative rules proposed following the bill were not reasonable and don’t follow standards of care. And overall the law would put the lives of my patients in danger.

This was the first time I’d done this, sat down and composed testimony, breaking down everything that what was wrong with a policy and how it would affect the care I give my patients. And more than once I said that it would simply put their health, their lives at risk.

We’re past the point of this being a medical debate. Everyone, in terms of major medical organizations, is on board with gender-affirming care. Among any of the guiding organizations, this hasn’t been a debate for a while. The debate is in the social sphere, the political sphere.

How does your work as a family physician support LGBTQ+ patients?

At Grant Family Medicine Residency, we have areas of concentration in both LGBTQ+ health and HIV medicine. I’m the supervisor for the clinics we have associated with those, and residents are able to do that specialized training, those tracks. We run an LGBTQ+ clinic that includes gender-affirming care, and we do HIV management from the family medicine offices. It’s a pretty large system: There are five family medicine resident systems in OhioHealth.

I also was one of the founders, and I’m co-chair now, of a gender-affirmation council for the OhioHealth system: a volunteer group of people meeting since 2018 trying to provide better coordination of care and resources for transgender and nonbinary folks.

The clinics are very busy with patients, as well as with learners. There’s this huge need, but LGBTQ+ medicine isn’t an area that’s been included in traditional education models. Within basic medical training and clinical years, rotation years, there just aren’t models for this. There is a clear, undeniable need for more education in this area of care. We need more support, more resources for both physicians, and for patients and communities.

You’re still a new physician but you’re also leading this unique care track and seeing this boom in the need for training. How did you get started?

My personal story, where I am with Grant Family Medicine, is that I trained at Grant. I chose it because of its mission-driven priorities, because it treats underserved and marginalized groups. So when I started practicing here, I put myself on an LGBTQ+ provider list. That was important to me as someone who grew up in a not-affirming environment. I put myself on that list — but then quickly learned, when patients found me on the list, that I didn’t know what to do.

But nobody really knew how to do gender-affirming care. When I had a transgender patient come to me as a second-year resident, we didn’t know what to do. So it was quickly: “Where do I go for guidelines?” I pulled up the University of California, San Francisco, guidelines online and began poring through the information to learn how to treat this patient who had driven from rural Ohio to see me.

And then, starting in 2015, I began to prescribe PrEP when no one else was doing it. I did my grand rounds on PrEP and have continued to teach and do this care.

I am nearing my seventh year out as a PGY10, and I regularly have colleagues — other faculty, residents in my program — tell me they’re not getting enough exposure. Which I think is part of the challenge. But LGBTQ+ people are everywhere.

You’ve also advocated at the national level. How was that experience?

I’ve been to Capitol Hill twice the past couple of months to advocate for the Academy’s priorities, including the Family Medicine Advocacy Summit. I met with aides working in my district’s legislative offices, and I think they understood our message.

At the federal level and in states, for all of the flaws, this is the system of government we have, and if we aren’t speaking up every time these things come up, every time we know our patients will be at risk, other voices will still show up and be heard instead. We have to continue to advocate and know it’s right for our patients and our communities.

To what extent is education such as what you do at Grant its own form of advocacy?

Especially when there’s this level of clear need, this much demand, being in the education space is 100% advocacy. Both seeing the patients and trying to improve education are forms of advocacy. That’s why I’m in this space of residency education. Because it can’t be just me. I have had to turn away patients, people who want to be able to see me. Even if I were doing full-capacity care and this were all I did, it wouldn’t be enough. The need is so great that even if I saw patients full time it would barely scratch the surface.

At this point, it isn’t just you, anymore, is it?

Graduates of the specialty track so far, the first three, everyone has stayed in Columbus. The people who are in the track right now are planning to stay here. That’s helpful for expanding access here. And other places from central Ohio are trying to send residents to me.

It’s one of the things I am reflecting on now, how to expand this past me. But expanding these models outside us is going to take more systemic support. There are talks about getting a fellowship started. Part of the work is to figure out how to keep spreading the education.

I compare it sometimes with when you learn how to treat diabetic patients. You can attend a full week of lectures on diabetic patients and of course that won’t enable you to care for them.

How have you found support and how do you help support your colleagues?

The Academy’s Member Interest Groups are an easy first step for finding community. In terms of delivering LGBTQ+ care specifically, it’s similar to the relationships you build as you go through residency and begin practicing and think about mentors and mentoring.  

I can think of several residents who have graduated the program here who didn’t do the LGBTQ+ concentration but will reach out or copy me on charts because they’ve been around our program and they realize this is care they can do as family physicians, the same as any other kind of care — easier in some cases.

When I have those interactions, those are rejuvenating to me when I’ve been feeling overwhelmed as the go-to person. They’re taking care of those patients in their family medicine offices without sending them elsewhere. We need that to keep happening.

That kind of connection also shows me that the work we’re doing is actually making a difference. A lot of times the social noise around this kind of care can make it feel more difficult. That goes for gender-affirming or HIV prevention, HIV care — which, PrEP is literally a single pill a day, without the drug interactions of past meds. But for me it really just took looking up things and taking care of patients. There are family physicians who are way smarter than me. It comes down to meeting the patients where they are and seeking a little education that we may not have gotten in traditional systems. There’s always stuff we’re missing.

If you can find someone else to talk about the case with. Staff messaging or emails or texts, and it’s all they really needed to feel like they’ve got this. It’s so important for family physicians to lean into the fact that these patients — who may fear not being accepted or not getting appropriate care and for whom it may be stressful to see a doctor — are showing up, and they need us. So ask for help if you need it.

I think there’s a willingness. Other programs want to do this, educate around this issue. It’s accepted fact that this is something we need to be doing. There are more and more programs searching for someone to help. That is the opportunity we have, both to find more people to educate who are already doing the care and then training people. All of us need to be doing it. It can’t just be a select few.