Pride Without Prejudice

A conversation with Bruno Ferraz-de-Souza, MD, PhD, and Stephen M. Rosenthal, MD

As part of Endocrine News LGBTQ+ Pride Month coverage, we caught up with Bruno Ferraz-de-Souza, MD, PhD, and Stephen M. Rosenthal, MD, who had a lot to say about being openly gay in the world of endocrinology, both in the U.S. and abroad, as they discuss their various challenges, successes, mentors, as well as the role the Endocrine Society has played in their careers.  

In observance of LGBTQ+ month, Endocrine News sat down for a Q&A with two well-known endocrinologists (and friends) to discuss their careers, how being gay has influenced those careers, and what being members of the Endocrine Society has meant for them.

Bruno Ferraz-de-Souza, MD, PhD, is an associate professor and chair of the Basic & Clinical Sciences Domain at the University of Notre Dame Australia School of Medicine in Fremantle, Western Australia, and also honorary principal investigator and postgraduate supervisor in endocrinology at the University of Sao Paulo School of Medicine, in Sao Paulo, Brazil. Stephen M. Rosenthal, MD, is professor of pediatrics and medical director of the Child and Adolescent Gender Center (CAGC) at the University of California, San Francisco (UCSF), as well as director of the World Professional Association for Transgender Health; past vice president and director of the Endocrine Society, and past president of the Pediatric Endocrine Society.

Rosenthal, a pediatric endocrinologist for 45 years as of next month, currently focuses on gender diverse/transgender adolescents and young adults both clinically and in the research realm. Ferraz-de-Souza is an adult endocrinologist whose current area of clinical focus is bone metabolism, with a research focus on the genetic basis of metabolic bone disorders.

Endocrine News: What milestones in your career stand out?

Rosenthal: The first was being accepted in 1979 into a fellowship program at UCSF run by three icons in pediatric endocrinology: Melvin Grumbach, a past-president (1981 – 1982) of the Endocrine Society, Selna Kaplan, and Felix Conte. It was a great highlight of my life to move from the East Coast, where I had spent all my life, to the city I fell in love with on a vacation a year prior.

I later was part of the team, along with my colleagues Stephen Gitelman, Brian Feldman, and Walter Miller that discovered a new disorder of water balance. In 2005, within just a few months of each other, two unrelated male infants presented with severe hyponatremia and laboratory profiles that were suggestive of syndrome of inappropriate antidiuretic hormone (SIADH) secretion, yet they had undetectable ADH levels. In the first patient, Gitelman suspected an activating mutation in the V2 vasopressin receptor, a G protein–coupled receptor. In fact, it turned out that both patients had activating mutations in this receptor, but they were different from each other, even though they occurred in the same codon for this receptor, and the constitutive activity of these mutant receptors was demonstrated by Feldman in Miller’s lab. So, we described the first cases  of what we called nephrogenic syndrome of inappropriate antidiuresis, and it was very exciting to be part of that.

“As an openly gay person, I had the experience of understanding what it was like to be different in a particular aspect of the human experience, and that contributed to who I am and my wanting to be supportive of others who might not fit into mainstream categories, such as people with diverse gender identities.” 

Stephen M. Rosenthal, MD, professor of pediatrics, medical director, Child and Adolescent Gender Center (CAGC), University of California, San Francisco; director, World Professional Association for Transgender Health

Then, at some point in my evolving career I realized that I needed to spend some time in the lab. I worked with a very stimulating and supportive group in Ira Goldfine’s lab that was focused mostly on the insulin receptor. They gave me a project to clone a cDNA for the insulin-like growth factor-1 (IGF-1) receptor. At that time, I didn’t even know what cDNA was, but with some wonderful support from the people around me, I was able to clone the cDNA and use that tool to study a new and evolving area, the role of IGF-1 in skeletal muscle cell differentiation, which led to a very exciting chapter in my life. I got my first NIH independent funding, and we made some very interesting observations about opposing effects of IGFs on proliferation and differentiation, which are typically thought of as mutually exclusive actions. We got to immerse ourselves in trying to understand that dilemma, and that was really fun. But I had my challenges trying to compete as a cell biologist while simultaneously being an almost full-time clinician. Later, I became director of the general pediatric endocrine clinic as well as the program director for endocrine fellowship training for pediatric endocrinology at UCSF. In 2009, a 12-year-old designated female at birth who identified as male had gone to a public health clinic that catered primarily to the LGBT community in San Francisco.

These people were very savvy and very aware of the pioneering work that a program in the Netherlands had done to offer clinical care for gender-diverse adolescents, in particular the use of puberty blockers (gonadotropin-releasing hormone agonists) for a certain phase of that care. But that public health clinic in San Francisco had very little experience with puberty blockers or working with really young, potentially transgender individuals, so they sent the patient to UCSF knowing that we had experience with puberty blockers. As a side highlight, back in the early 1980s, because of the “force” that was Melvin Grumbach and his connections with other significant investigators, we got to be one of the first pediatric endocrine programs in the world to study the use of puberty blockers in children with precocious puberty.

Because this all happened at the very beginning of my time on the faculty, I got to be involved in that. But we hadn’t used them in transgender patients until a very competent fellow, Will Charlton, read up on all the papers in the European endocrine literature showing the pioneering work of the Dutch, and all of a sudden, this light went on. This is where it becomes relevant to this theme. As an openly gay person, I had the experience of understanding what it was like to be different in a particular aspect of the human experience, and that contributed to who I am and my wanting to be supportive of others who might not fit into mainstream categories, such as people with diverse gender identities. I realized that even though being transgender or gender diverse was not a disease, there was a role for pediatric endocrinologists trained in the nuances of hormone treatments. At that time (2009), there was not much published — even the Endocrine Society’s first transgender clinical practice guideline hadn’t come out until June of that year. I saw an opportunity to contribute to the clinical care of transgender adolescents, and I felt really drawn to it, but almost nobody was doing this kind of medical work like what was being done in the Netherlands. So, we invited Norman Spack from Boston Children’s Hospital, who had gone to the Netherlands to learn their approach and was really the father of adolescent gender-affirming care in the United States, to mentor our program.

I was really the new kid on the block in terms of working in adolescent transgender medicine, but I could bring to the table my almost 30 years of experience working with puberty blockers, so, along with collaborators Diane Ehrensaft, a world-renowned child and developmental psychologist; Joel Baum, education and advocacy specialist; and Asaf Orr, an attorney focused on LGBT issues, we created the interdisciplinary Child and Adolescent Gender Center (CAGC), of which I became the medical director and still serve in that capacity. We’ve now served over 2,000 families. Given that this is a relatively new and evolving field, we have been committed to doing research to help move the field forward. Along with three other centers in the country, we received the first-ever NIH funding for long-term observational studies looking at the impact of gender-affirming care of transgender adolescents, now in its second five-year funding cycle. So, we’ve had incredible experiences along the way as well as incredible challenges because, starting about two plus years ago, this field found itself in the crosshairs of a culture war. As you can see, over the years, my career has taken so many different twists and turns that no one would ever call me “straight.”

Ferraz-de-Souza: I had three career-defining moments as an endocrinologist. The first was, as Steve mentioned, being accepted in the program that I was in. I did my clinical training in Brazil, and the program I entered is arguably the best in the country and collects the best people in endocrinology in Brazil. I was really proud — it’s a competitive program. In seeing the work they did both clinically and in research really stimulated me to do more. When I entered medical school, I didn’t have much ambition to be a researcher or furthering my career besides patient care, but it was really seeing people who were clinical and basic researchers that instigated me to pursue that avenue.

The second milestone would be when I went to the U.K. to do a PhD, which was hugely transformational for me. I was exposed to a whole different culture, in many senses, in terms of academia and research, and also in life. It’s really when I lived in the UK and was perhaps away from my background and my friends and family that I allowed myself to live a full gay life, and this was important as well. I will always remember that period with joy. I was doing research for a great group, and I was also living my life to the fullest.

“I need to be out because I want to be giving this example that you can be gay and be someone who contributes to the Society and be in leadership positions and help others as a doctor and researcher. Being completely out at work gives you a sense of freedom and not having to be safeguarding. When you obscure that part of your life, you become defensive about a lot of things, and it impacts how you relate to people.”

Bruno Ferraz-de-Souza, MD, PhD, associate professor, chair, Basic & Clinical Sciences Domain, University of Notre Dame Australia School of Medicine, Fremantle, Western Australia; honorary principal investigator, postgraduate supervisor, endocrinology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

The third milestone I want to mention is, really by chance, I got involved with the Endocrine Society leadership. I was invited to participate on the Committee on Diversity and Inclusion (CoDI), and, to this day I don’t know really why. I think it was a lucky coincidence because I had no inroads with anyone in the Society leadership, and I was probably most likely flying under the radar. But I got lucky to have this opportunity, and this really showed me another aspect of professional growth, in terms of meeting amazing people like Steve and learning about leadership and about how we can have multiple roles in multiple realms. This contributes to our growth and also gives us an opportunity to give back. Sometimes it’s easier to give back through societies such as the Endocrine Society than it is in our day-to-day jobs where what you give back is more limited to the people with whom you interact.

These three moments were really defining of how I ended up where I am right now.

EN: Who were some of your other important mentors along the way?

Ferraz-de-Souza: We have mentors all the time. For instance, when I served on CoDI, I met Steve, Beverly Biller, Sherri-Ann Burnett-Bowie, Alicia Diaz-Thomas, and Cherié Butts, so many people influenced and formed me in a way. I carry that with me.

But two people have been really fundamental. One of them is Berenice Bilharinho de Mendonca. When I joined my training program in Brazil, Berenice was one of the faculty. It really was very serendipitous — we were a group of eight fellows divided into twos, and each duo started in a different area of endocrinology. Berenice’s group was known as the difficult one because it was the rarer diseases — diseases that were the results of sex development, of adrenal developmental — all rare and more to do with pediatrics. So, it’s a group that people are scared to start with, but it’s where I was assigned, and I just fell in love with the subject and with her. Berenice is a very rigorous researcher and someone who is very sensible and has a sense of fairness and equity. She not only instigated my love of research, but she was also the first person that I saw in an academic hospital in a very rigorous situation, offering care for transgender people. This was the early 2000s, and we didn’t even learn about transgender in medical school in Brazil, except for maybe one lecture in psychiatry. It was very different from what we offer our students these days. It opened my mind to all the realms in which an endocrinologist can be of help to people in need, and it was through her work that I saw scientific validation of this care and of getting to know the patients. Transgender is such a hot topic, and there’s so much theoretical discussion, [but] being close to the people who live through that and hearing of their plight, of their life, their journey is really transformative. So, I credit Berenice as a mentor in general, but also in particular in this area. Besides advocacy, my direct work does not really touch much of the care of transgender people, but this experience left a great impression.

The second mentor I would like to mention was my PhD supervisor, John Achermann. John is a pediatric endocrinologist, and he’s just the best person. He’s a great human being and a great researcher, and he taught me a lot about being inclusive and seeing the world through the lens of inclusivity. Brazilian society is covertly prejudicial in many senses, and there’s a lot of hierarchy and even racism. So, John was really the first example of an enlightened person of a different cultural background I met. He introduced me to a lot of the language that years later would become familiar to me through CoDI, but John was the first person providing that besides everything else that he did.

Rosenthal: Not only do we have the opportunity to play a role as mentors, but we all have mentors at all stages of our careers. In addition to those I already mentioned, one thing I want to add is that I had a very similar experience to Bruno of being asked to join a particular Endocrine Society Committee, which in my case, was the Society’s Special Programs Committee way back by Dolores Shoback, an adult endocrinologist at UCSF. She’s one of those people you meet and recognize right away how incredibly special they are, like Beverly Biller, like Bruno — people who are really first-class human beings. Through the committee, I met some wonderful people, in particular some incredible staff from the Endocrine Society who made me feel so welcome.

When I think of the important people in my life outside of the strictly academic mentors, there would be Wanda Johnson and Rob Bartell who were the outward face for so many of us at the Endocrine Society. Because of their palpable, authentic commitment to the Society and to encouraging member participation, you really felt valued, and that made you want to contribute that much more. So, really as a result of those experiences, I got to be a vice president of the Endocrine Society, a title now replaced by director, which Bruno will soon be.

But it all started with Dolores and then Wanda and Rob and many other wonderful staff people that I met along the way. Just like Bruno was saying, on these committees, I suddenly had personal connections with people who had significant leadership roles, and I felt acknowledged and that I could contribute. It is a wonderful experience and is really one of the hallmarks of the Endocrine Society — the inclusiveness, not just in all the ways we’ve been talking about, but in really encouraging the participation of people who are at all levels of their careers. That’s something that I’ll always be very grateful for.

EN: This segues perfectly into the next question: what has the Endocrine Society meant to you?

Ferraz-de-Souza: I second every word that Steve has said. I’m a member of other societies, and I have participated in leadership of other societies, but I don’t find the same environment, necessarily, and I think the tone is set very much by staff. Steve mentioned Wanda, and I also have to mention Elizabeth Khan, who’s just wonderful [Steve wholeheartedly agreed]. I will mention one more: Kirsta Suggs. She’s not with the Society anymore, but she was instrumental in our work on CoDI, and she really helped us shape it. The staff creates this welcoming environment and provides an institutional memory that allows us for the short periods that we serve to thrive in what we do, see our ideas implemented, and have a result with the programs that the Society runs. This is unique to the Endocrine Society, and Kate Fryer is carrying it forward as CEO. I think this support and inclusivity is why we and others keep engaged with the Society. I’ve been chair of two committees, and I’m entering the board now. It’s a lot of work and a big time commitment, but I do it because I love it. You see change happening, and you get to meet wonderful people, which is so much more than sometimes we get from our day-to-day jobs, and that really makes it valuable.

Rosenthal: It all starts with feeling that you are appreciated and encouraged to contribute in a meaningful way. In the LGBT context now, I did mention that the Endocrine Society put out its first clinical practice guideline in June of 2009 focused on transgender individuals. That they jumped into that field with a commitment to clarifying evidence-based care was very meaningful to me, and it helped me feel encouraged and supported in the work I was just getting started in. I had the incredible opportunity starting in 2015 to be on the writing committee that updated the guideline for 2017 publication. I now have the wonderful opportunity to be on the committee that’s just embarking on the next revision, which is under the leadership of both Josh Safer and Vin Tangpricha with Maureen Corrigan on the staff.

The commitment that the Endocrine Society has, in a very calm, methodical way, to not run away from a politically charged issue is very reassuring to me. Mila Becker, the Society’s chief policy officer, has also been such a wise colleague and contributor. She has been extremely involved in the role that the Society would take in some of the legislation in the U.S. in terms of writing amicus briefs and in enlisting the support of colleagues to thoughtfully consider the content of these cases and to participate in how the Society, in the most thoughtful and effective way, could contribute to underscoring the importance of an evidence base in policy decisions. These things have really deepened my appreciation and respect for the Society.

EN: Has being a member of the LGBTQ+ community influenced your career path? If so, in what way?

Ferraz-de-Souza: It certainly influences my worldview and the way I see people. For minoritized individuals, there is a sense of collegiality, where you tend to better understand the hurdles other minorities go through. Steve mentioned, and this is something that Sherri-Ann Burnett-Bowie taught me too, is that we all belong to minorities and majorities. I’m a cis man, so I have some advantages in the world, but, at the same time, I’m gay, and this will sometimes put me at a disadvantage in certain contexts. So, I think being gay shapes my view to be inclusive and accepting — and celebrate diversity.

I come from a background where it was hard for me to come out to my family and friends. When I left Brazil for the U.K., I had only really told two friends. This was in 2005, and lots of people that I know would have been accepting, but I didn’t feel ready because I had issues myself. After I took myself out of that context and after I found love, it makes you confident in how you move about in the world. This helped me in this journey.

“There were the personal challenges … in coming out, perhaps some of the rejections, of course, fortunately balanced by positive experiences and also learning to believe in yourself — but finding this opportunity where I felt I could give back to the LGBT community was so important because I felt that there really was a role for physicians who are trained in the nuances of endocrine treatments. It made me feel drawn in large part to that part of my career, so the last 15 years have certainly been influenced by all of my prior experiences including coming to terms with who I am in terms of my sexual orientation.” 

Stephen M. Rosenthal, MD, professor of pediatrics, medical director, Child and Adolescent Gender Center (CAGC), University of California, San Francisco; director, World Professional Association for Transgender Health

Then I had a sort of second coming out to the endocrinology world. I had to sit down with my colleagues like Berenice in Sao Paulo and John in the U.K. and have conversations, which felt very weird, almost like coming out to my parents. But it’s how these things perhaps still operate. I’m surprised that in 2024 many people still struggle with coming out, even though society in general is more accepting (I’m not talking about silos here and there where things are getting worse), but even in countries where it is accepted and there are laws that protect us, it’s still very hard for some people. For a while I thought, do I need to come out professionally? I’m sure there is some detriment that can come with that because, at some point in career progression, decisions are still made at a clubby level where people relate to people that are similar to them, and if they see you as different, they might not relate to you initially or be as open.

But there was a point when learning through CoDI how important representation is that really makes sense to me. I need to be out because I want to be giving this example that you can be gay and be someone who contributes to the Society and be in leadership positions and help others as a doctor and researcher. There is a degree of tokenism that I’ve come to terms with. If I am the token gay, at least I’m representing in this and other forums. Being completely out at work gives you a sense of freedom and not having to be safeguarding. When you obscure that part of your life, you become defensive about a lot of things, and it impacts how you relate to people. So, there is a degree of freedom that you can really appreciate, but also, I think a lot about representing and making this space seen as a space that is welcoming to people of diverse sexual orientations.

Rosenthal: I want to address something that Bruno said. He gets these opportunities not because he’s gay or a token gay but because of the kind of person he is. I think that really comes across in his response.

I was coming out in the mid 70s, which was a different time. When I was a medical student in New York at Columbia University and just coming to terms with it myself, I was very much in the closet about it, enduring some of the experiences that gay people endure. You find people who support you, but you also find people who reject you. Reflecting back on that, I remember that when I was accepted into the fellowship program in San Francisco, part of what drew me there was not only the academic excellence of the mentors but also the feeling that it would be easier for me to feel free to be who I am there. So that influenced my choice of location for training. It’s always been important to me to try to have a work/life balance, to feel that I’m working in a program where I can feel happy to be contributing but also that I can be myself. I felt incredibly fortunate to land in San Francisco and to land in pediatric endocrinology because I really fell in love with the field. I would say that my sexual orientation didn’t really influence my choice of focus, until I had the situation in 2009, I explained previously.

I want to underscore that. Yes, there were the personal challenges that both Bruno and I have talked about in coming out, perhaps some of the rejections, of course, fortunately balanced by positive experiences and also learning to believe in yourself — but finding this opportunity where I felt I could give back to the LGBT community was so important because I felt that there really was a role for physicians who are trained in the nuances of endocrine treatments. It made me feel drawn in large part to that part of my career, so the last 15 years have certainly been influenced by all of my prior experiences including coming to terms with who I am in terms of my sexual orientation.

EN: What lies ahead, research or career-wise?

Rosenthal: I’m in various stages of my semi-retirement, but I became emeritus professor in 2015, and I have continued to be active clinically as the medical director of CAGC. I will be stepping down from that role at the end of June and will be the emeritus medical director, and I’m just delighted that two of the junior faculty (Janet Lee and Abby Cobb-Walch) that I fortunately had the wonderful opportunity to mentor are assuming the role of co-medical directors. I hope to continue to be a contributor in our research as well as through my work with the clinical practice guideline. I’m also on the board of directors of the World Professional Association for Transgender Health (WPATH). I’m still involved in writing book chapters for the Williams Textbook of Endocrinology, and I’m about to start co-authoring a chapter in Sperling Pediatric Endocrinology.

“I’m a cis man, so I have some advantages in the world, but, at the same time, I’m gay, and this will sometimes put me at a disadvantage in certain contexts. So, I think being gay shapes my view to be inclusive and accepting — and celebrate diversity.” 

Bruno Ferraz-de-Souza, MD, PhD, associate professor, chair, Basic & Clinical Sciences Domain, University of Notre Dame Australia School of Medicine, Fremantle, Western Australia; honorary principal investigator, postgraduate supervisor, endocrinology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

I’m at a point in my life where I should probably start to shift that work/life balance, but it’s hard for me to walk away from all of this. I’m going to be 74, and I can’t do everything I used to be able to do, but I try to remember how lucky I am that I can still go ice skating several days a week. So that’s what’s next. I take lessons from incredible coaches — Jeremy Abbott, a four-time U.S. National champion and Olympian and Massimo Scali, an Olympian and world medalist in ice dancing — and I get to be part of this crazy, passionate adult figure skating community and to compete in various adult national and international figure skating competitions, including the gay games.

Ferraz-de-Souza: You save this detail for last, Steve?

I’m super excited about joining the board of the Endocrine Society in June. This is a tremendous honor and an opportunity to make a contribution at a different level, so I’m really looking forward to that. About my career in general, I moved to Australia in 2022 because my husband, who is Australian, wanted to move back (we were living in Brazil), and we’re still finding our ground here, but so far, it’s been very good. Sometimes I think of how my career will progress here and how close to endocrinology I’ll be in five to 10 years. I’m involved with a lot of medical education and in leadership roles in medical school, and I’m finding that interesting. But I’m pleased that the Endocrine Society will always be my anchor point, and the main thing I’m excited about now is this upcoming role on the board.

Horvath is a freelance writer based in Baltimore, Md. In the May issue, she wrote the cover story on Joy Y. Wu, MD, PhD.