From Identity to Advocacy: A Neurologist’s Mission to Transform Transgender Care

The neurologic health of transgender and gender-diverse (TGD) individuals is an emerging area of clinical focus that has been historically underrecognized. Although research on mental health challenges and cardiovascular risks in TGD populations is growing, neurologic care remains largely unexplored.^1-4

In a 2019 survey of American Academy of Neurology (AAN) members, published in Neurology⁵, 44% of respondents viewed sexual orientation and gender identity as irrelevant to neurologic illness. Yet, a 2024 review published in Neurology Clinical Practice⁶ found that compared with other populations, TGD individuals have a higher prevalence of neurologic conditions. These conditions include migraine, functional disorders, cerebrovascular disease, sleep impairment, and subjective cognitive decline.

Z Paige L’Erario MD, LMSW: A Transgender Neurologist

Z Paige L’Erario MD, LMSW, an associate professor of neurology at Thomas Jefferson University Sidney Kimmel Medical College in Philadelphia, Pennsylvania, is a transgender neurologist and activist helping to close the gaps in care for TGD patients.

Dr L’Erario is a co-author of the 2024 Neurology Clinical Practice review⁶ as well as the 2025 AAN position statement⁵ on advancing equity for LGBTQI+ patients in neurology and other numerous studies on neurologic care in these populations.

We spoke with Dr L’Erario to learn more about their work, clinical considerations for TGD neurology patients, and other ongoing needs to improve treatment and outcomes for this community.

Personal and Professional Journey

What inspired you to pursue a career in the field of neurology?

Dr L’Erario: I had various reasons to choose neurology as a profession. In many ways, the brain was and still is a mystery. This is an intriguing aspect of the field. As a neurologist, I am often referred complex diagnostic cases that present a unique challenge and sustain interest in my work.

How has your identity as a transgender person shaped your experience working within neurology?

Dr L’Erario: Being transgender does not affect my clinical work or research in any significant way. My patients love me whether I identify as cisgender or transgender, and there have not been any patient issues regarding my gender identity. However, my lived experience as a person who is transgender provides valuable insight and expertise to my work as a transgender health care researcher.

Have you encountered specific challenges or supports in the medical community related to your identity? How have those experiences influenced your advocacy and research?

Dr L’Erario: Particularly in the current political environment, there is a lot of bias and misunderstanding about what it means to be transgender. Many medical professionals are unaware or misinformed about best practices with transgender patients. Much of my work aims to educate providers and increase affirming environments within neurologic practices, medical colleges, and professional organizations. My goal is to help transgender people receive quality, accessible, and culturally sensitive neurologic care.

Clinical Experience with TGD Patients

How did you begin focusing your clinical work on transgender and gender-diverse patients?

Dr L’Erario: Being someone who is an openly identifying transgender physician, I have unique insight into specific challenges our community faces within the health care system. I do not want future generations to face the same discrimination, bias, and sometimes frank mistreatment within medicine that I have, so I decided to refocus my career on this particular problem.

What unique neurologic care considerations arise in this population that clinicians might overlook?

Dr L’Erario: When I started this work 5 years ago, one of the most common questions I received after providing a transgender health care lecture to neurologists was, “What does being transgender have to do with neurology?” Indeed, at the time, there was nearly no research into this question. Since then, many scientific articles and studies have been published addressing the importance of transgender health care within neurology. These data are summarized within our review article⁶ published in Neurology: Clinical Practice [for which Dr L’Erario serves on the editorial board] in 2024 and include several key findings:

• There is an increased prevalence of neurologic conditions among transgender people, and the reasons are currently unknown. However, experts hypothesize that community-specific minority stressors may contribute to this phenomenon.
• Gender-affirming hormone therapy may influence the natural history of neurologic diseases and interact with commonly prescribed medications for neurologic conditions.
• Research has shown that nonaffirming clinical environments worsen the health status of and health care accessibility for transgender patients.
• There are a large overlap of intersex and racially diverse people who also identify as transgender, and these patients are largely excluded from research on transgender communities.

Can you share any aspects of your clinical experience that reflect the barriers or breakthroughs you’ve witnessed in caring for TGD patients?

Dr L’Erario: As a specialist in vascular neurology and functional neurologic disorder, I see 2 common anecdotal themes among the patients I treat. One is how my transgender patients are instructed by a health professional to discontinue their gender-affirming hormone therapy after having a stroke. This practice is not supported by any clinical evidence and ignores the many psychological benefits of gender-affirming hormones.^7,8

Secondly, I have observed many transgender patients with functional neurologic disorder who have symptoms that worsen with community-specific psychosocial stressors and improve with affirmative and supportive treatment.

2024 Review and Broader Implications

In your recent 2024 review article,⁶ what were the most significant gaps you identified in neurologic care for TGD people?

Dr L’Erario: There are many common neurologic conditions with little or no research on transgender communities. This includes treatment trials, so we do not know if neurologic medications could differentially affect transgender patients. There is scant data on neurologic diseases in transgender people who also are racially diverse, intersex, or pregnant.

What do these gaps tell us about the intersection of gender identity, access to care, and neurologic health?

Dr L’Erario: Large surveys of transgender people clearly demonstrate the adverse effects of nonaffirming environments on health care access and psychological state.^9,10 These differences are worse for people who are also marginalized within racially diverse communities. Although we need more research, it would be hard to believe that mistreatment of transgender people in neurologic clinics could improve their health outcomes.

How has the response been from your peers and the broader neurology community to this research?

Dr L’Erario: It varies from allyship to misunderstanding to indifference to rejection of these ideas, policies, and practices that are in the best interest of our transgender patients.

Barriers, Training, and Systemic Issues

What are the most urgent barriers to equitable neurologic care for transgender patients?

Dr L’Erario: Much of our medical workforce is not knowledgeable on transgender health care. We need more research, education, and advocacy to improve the health of our transgender patients.

Are medical training programs preparing neurologists to provide affirming care to TGD populations? If not, what needs to change?

Dr L’Erario: Historically, there has been no standardized training on transgender health care in medical school curricula and surprisingly few openly identifying students within medical colleges. Although this is changing in recent years, transgender health care education is inconsistent and inadequate in medical training. Given the reduction in diversity, equity, and inclusion (DEI) initiatives with the new administration’s policies, I believe the coverage of transgender health care in medical schools and residency programs will decrease. I and my co-authors published a 2024 article on the education of neurology trainees in the Resident & Fellow Section of Neurology.¹¹

How can cisgender providers become better allies and improve care for this community?

Dr L’Erario: I and my co-authors published a 2023 review article in Neurologic Clinics outlining how to improve affirming environments in medical settings.¹² Allies can undertake any and all of these suggested interventions to improve the experiences of their transgender patients:

• Adopt sensitive, community-based language in clinical communication and documentation
• Respect patient boundaries by avoiding incorrect assumptions or invasive questions out of curiosity
• Display welcoming and inclusive signage, gender-neutral facility options, and available nondiscrimination resources including the reporting of grievances and patient satisfaction
• Role model correct behaviors, collaborate with professional organizations dedicated to sex and gender equity, and advocate for patient rights with institutional leadership
• Increase programming and education on topics in sex and gender diversity, including implicit bias and bystander training for all staff

Advocacy and the Future of Inclusive Neurology

You have also been involved with Greenburgh Pride and other advocacy efforts. How does community-based work complement your clinical and academic roles?

Dr L’Erario: Our advocacy work in Westchester, New York has been entered into the historical record at the Westchester LGBTQ+ History Project and the Stonewall National Museum and Archives. Our advocacy was critical to the establishment of June as Pride Month in the village of Tarrytown. Although I have moved to Philadelphia to begin a neurology position at Thomas Jefferson University, I am happy to see that others are continuing the work we started in New York. I always take my learnings from local advocacy efforts to improve my ability to advocate for transgender health care rights in regional and national settings within neurology.

What gives you hope for the future of neurologic care for transgender and gender-diverse people?

Dr L’Erario: The next generation gives me hope — they are doing things I would have only dreamed about at their age.

If there’s one change you would like to see in neurology in the next 5 years, what would it be?

Dr L’Erario: There needs to be more transgender neurologists, and more specifically those in leadership positions who are openly identifying as transgender.