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- You have an absolutely
wonderful lecturer

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who's come to you from Stanford.

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He is so young and so accomplished

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that it makes me feel
like an underachiever

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and a slackard (chuckles).

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And I think the committee
that chose Dr. Turban

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chose very, very well.

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You should all be very
impressed by what he has to say,

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and he speaks with a lot of commitment

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and charity to his patients
and not just as a researcher.

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So I wish you well, this
lecture series was instigated

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by my commitment to increasing
diversity of all kinds

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at the College of Medicine,

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which was pretty monochromatic
back in 1981 to 1985.

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And it's so much, much less so.

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I cannot wait, I miss not
being in that room with you,

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with the dean and all the
students and the faculty,

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but I promise that for the ninth lecture,

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I'll be there next year.

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Enjoy the lecture folks, thank you.

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- Vito, thank you so much.

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And thank you, George,
again, for your support.

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This year's speaker is Dr. Jack Turban,

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a nationally recognized expert on child

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and adolescent health, and
particularly topics related

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to LGBTQ health.

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I'm very pleased to welcome Dr. Turban,

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and look forward to hearing his talk

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about this important topic.

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You'll hear more about
him in just a few minutes,

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I had a very nice chat with him earlier,

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and I share with you George, my admiration

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for the accomplishments
that he's already made

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in a relatively short career so far.

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I now want to introduce
Dr. Margaret Tandoh,

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our associate dean for
diversity, equity, and inclusion,

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and the Larner College of Metta

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and the Larner College of Medicine,

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and the Richard L.
Gemelli MD class of 1974,

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Green and Gold Professor of Surgery.

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Please join me in welcoming Dr. Tandoh.

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(audience clapping)

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- Thank you very much, Dean Page,

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and welcome to all in person and online.

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I wanna thank Dr. Imbasciani
too, hi, Vito, thank you.

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Hi, George, thank you (chuckles).

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I have a script that I have to go by.

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Thank you, Dean Page, today,
we have the pleasure of hearing

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from Jack Turban.

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Dr. Turban is a researcher,
a medical journalist,

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and he's a chief fellow in
child and adolescent psychiatry

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at Stanford University School of Medicine.

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He is coauthor of the book,
"Pediatric Gender Identity:

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Gender-affirming Care for Transgender

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and Gender Diverse Youth."

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He has consulted for the
US Department of Defense

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and major tech companies on issues related

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to LGBTQ mental health.

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He currently serves on the
scientific advisory board

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for the Upswing Fund, a
collaborative fund created

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by Melinda Gates to support
adolescent mental health

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during the COVID-19 pandemic.

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Dr. Turban's original research

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and opinion pieces have appeared

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in the New England Journal of Medicine,

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the Journal of the American
Medical Association,

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the New York Times, the Washington Post,

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and Los Angeles Times.

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Vox, Scientific American,
Eagles on and (indistinct).

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Stats, Psychology Today, JAMA
Pediatrics, JAMA Psychiatry,

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the American Journal of Public Health,

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and the Journal of the
American Academy of Child

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and Adolescent Psychiatry among others.

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Dr. Turban is regularly
consulted by the media

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to comment on issues regarding child

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and adolescent mental health

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and topics related to LGBTQ health.

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He and his work have now
quarter over a hundred times,

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four outlets, including
NPR's All Things Considered,

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The Daily Show with Trevor Noah,

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ABC's 2020 with Diane Sawyer,
the New York Times, NBC News,

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Rolling Stone, the Washington
Post, (indistinct), GQ Book,

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CBC, and Vanity Fair, among others.

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His research has also been
cited in major court cases

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regarding the civil rights of
transgender people in the US,

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in state legislative
debates around the country,

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and in the United Nations
Independent Expert Report

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on Conversion Therapy.

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Now, I would like to
introduce Dr. Michael Upton,

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who's the chair of the DiSalvo
Lecture Selection Committee.

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Let me just say thank you to you, Michael,

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and the members for choosing

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our incredible speaker today, Michael.

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(audience clapping)

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- Hi, Vito.

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- So on behalf of the selection committee,

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I'm gonna bring Dr. Turban up here today,

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but it is notable this is the first time

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that we've had an in-person speaker

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since before the pandemic.

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And so I'm gonna prepare
us for some things

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we may have forgotten.

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So people have screens open or
phones shining in their face.

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We can put them down and try
to be with each other in a way

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we haven't been able
to be for a long time.

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And try to relax and
enjoy this experience,

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you're not gonna be tested,

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and hopefully, we'll learn something.

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There's some impressive
data coming up here,

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and I think there's things to think about

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in the way medicine becomes activists

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and defends our patients.

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And more importantly,
what we all need to dig in

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and do all our work on oppression,

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and identify the ways of racism,

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sexism, homophobia, transphobia,

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and other forms of oppression,
infect us and our work.

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Today, we get to think a
little bit about what it's like

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for queer people to be in medicine.

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And Dr. Turban and I were just
talking before we started,

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about what it's been like
for us, and what it's like,

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even for some of you in a relative bubble

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at the Larner College of Medicine,

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which is a pretty affirming place,

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but not more than a few years goes by

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that I have somebody come to me and ask,

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"What's it really like?

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Can you go out and do this, and be out,

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and be proud, and be effective?"

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And Vito, thank you
for leading us in this,

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and giving us the opportunity
to show you all that

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that's true, that you can,
to believe in yourselves

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to do the work, and to be
ready to go out and be leaders

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because in a few short years,
you could be in a fellowship

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and be nationally famous
and coming to talk to us.

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So without further ado, Dr. Jack Turban.

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(audience clapping)

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- Can you hear me okay?

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So it's my first talk in
person in a long time,

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and then you guys made
me blush a whole bunch.

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So I'm gonna try and hold it together,

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but thank you to all of
you for coming in person,

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it's really nice to be around humans.

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And I'm excited to talk about
this topic and really excited

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that you're all gonna learn
about it because historically,

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I found that it's something
that we don't give

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enough attention to in
medical school curricula.

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This is very much just a primer,

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but I hope it will spark
some interest in the field,

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and hopefully get some people interested,

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either in research or advocacy

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or clinical work in this area.

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And I titled the talk,
Evolving Treatment Paradigms

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for Transgender and Gender Diverse Youth.

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And as you'll see,

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it's really been a huge
shift over the past,

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maybe two decades,

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and medicine has not such a great history.

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So I'll talk a bit about
how relatively recently

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we've really pathologized transgender

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and gender diverse people.

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Built structures within psychiatry

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and medicine that have
caused a lot of harm,

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and how people are starting to try

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and make more progress
towards making that better.

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In terms of disclosures,

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I received textbook royalties
from Springer Nature.

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I'm on the scientific advisory
board for that general fund

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we talked about to support
LGBTQ and racial minorities,

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mental health for
adolescents during COVID-19.

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Obviously, an expert witness
payments from the ACLU,

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Lambda Legal, and Cooley LLP.

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I have a pilot research award from AACAP

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and their pharmaceutical partners,

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including Arbor and Pfizer, the fellowship

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from the Sorenson Foundation

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and freelance payments
from various news outlets.

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So objectives for today,

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we're gonna go through basically
the developmental stages

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that are important to
think about when thinking

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about gender identity development
and gender diverse youth.

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So first, we'll talk
about prepubertal kids,

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the youngest kids.

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Then we'll talk about the
early stages of puberty.

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I think you've had your endo
module, maybe, like 10 or two.

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That's what we're talking
about, we'll go through that.

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And then we'll talk about
gender-affirming hormone treatment

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for transgender adolescents.

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And if there's time, I
also put in some slides

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about gender identity evolution,

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and we can spend a little
bit of time talking

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about how in the past people thought

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of gender identity is very static.

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That's something that develops
during this pre-pivotal phase

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and then stays the same throughout life.

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But starting to challenge that notion

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and noting that it's something
that can evolve over time

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and is much more multi-dimensional

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than people have generally thought.

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The first, terminology and background.

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I like this really cute gender bear.

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Thank you, Jacob, for making the bear.

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Four concepts that you
need to know for this talk.

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First, can you see that there?

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Yeah, so first is sex
assigned at birth, older terms

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includes natal sex, we don't
really use those words anymore.

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In child psychiatry, we often
use gender assigned at birth,

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and what this is is basically the gender

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that's put on a birth certificate

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when a baby is born, usually
based on external genitalia,

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sometimes based on prenatal ultrasound.

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This is different from gender identity,

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so gender identity is
one psychological sense

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of their gender, whether that's
male, female, both, neither,

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or some other gender identity.

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For someone whose gender
identity is in congruent

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with their gender assigned at birth,

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they may identify with the
term transgender for people

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whose sex assigned at birth is congruent

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with their gender identity,
they may use the word cisgender.

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Gender identity is different from romantic

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or sexual attraction, those
are the types of people

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towards whom you're romantically
or sexually attracted.

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And then a fourth term
is gender expression.

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So that is the way you present
to the world in a gender way.

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And some cultures, the fact
that I'm wearing a suit,

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maybe considered a male gender expression.

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If I were wearing a dress
that may be thought of

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as a female gender expression,

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but obviously, these
things change over time

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and with culture.

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One point I wanna make is that sexual

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and romantic attraction,
generally we use gender identity

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as the reference point, not
gender assigned at birth.

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So a trans woman who's
attracted to other women

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would likely identify as a lesbian,

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but you'll see sometimes in
less affirming literature

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and older literature
that that gets mixed up.

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So just keep it in mind if
you're doing any reading.

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Quick quiz, sorry about it (chuckles).

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The colors do not mean
anything on these cookies,

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I would usually make them for you,

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but that is a public health violation.

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So could anyone raise their
hand and just take a stab

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at describing this cookie?

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So again, this would be a
gender assigned at birth.

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This would be gender identity,

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and this would be romantic
or sexual attraction.

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Exactly, I couldn't see who
said that, but thank you.

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(chuckles) Thank you, could you walk us

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through your thought process

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just to catch everyone up to speed?

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00:12:48,975 --> 00:12:51,392
(indistinct)

254
00:13:06,600 --> 00:13:07,950
- Yeah, exactly, thank you.

255
00:13:09,920 --> 00:13:11,720
Anyone have thoughts on this cookie?

256
00:13:20,810 --> 00:13:21,658
Yeah, go for it.

257
00:13:21,658 --> 00:13:22,750
(indistinct)

258
00:13:22,750 --> 00:13:27,750
- Exactly (laughs) this is
CIS straight white cookie.

259
00:13:29,424 --> 00:13:32,424
(audience laughing)

260
00:13:36,429 --> 00:13:37,670
- And what about this one?

261
00:13:37,670 --> 00:13:42,170
This is more and more the
kind of kids you might meet

262
00:13:43,460 --> 00:13:44,913
on your pediatric rotations.

263
00:13:48,320 --> 00:13:50,830
There's no like, technical one
correct answer for this one,

264
00:13:50,830 --> 00:13:52,680
it's more kind of a conceptual thing.

265
00:14:02,600 --> 00:14:04,580
There are no name tags,
so I can't call on people,

266
00:14:04,580 --> 00:14:08,033
so it'd be really nice if
someone, say that again.

267
00:14:09,220 --> 00:14:12,270
Yeah, so pansexual queer person.

268
00:14:12,270 --> 00:14:14,590
This is just to point out
that none of these dimensions

269
00:14:14,590 --> 00:14:16,260
are necessarily binary.

270
00:14:16,260 --> 00:14:20,060
That you can be attracted
to both men and women

271
00:14:20,060 --> 00:14:22,750
or any other gender
identity or gender assigned

272
00:14:22,750 --> 00:14:24,140
at birth, et cetera,

273
00:14:24,140 --> 00:14:26,240
in terms of sexual or romantic attraction.

274
00:14:27,730 --> 00:14:30,040
And gender identity, for a lot of people,

275
00:14:30,040 --> 00:14:33,560
is not male or female, maybe
non-binary or gender queer

276
00:14:34,565 --> 00:14:36,650
or gender is neither genders.

277
00:14:36,650 --> 00:14:38,930
And also a lot of young
people are figuring it out

278
00:14:38,930 --> 00:14:40,760
because it's really complicated, right?

279
00:14:40,760 --> 00:14:43,110
So gender identity can
involve the way you think

280
00:14:43,110 --> 00:14:46,130
about gender roles, the way
you think about gender norms,

281
00:14:46,130 --> 00:14:47,740
the way you relate to your body.

282
00:14:47,740 --> 00:14:50,570
There can also be the kind of
like this transcendent sense

283
00:14:50,570 --> 00:14:53,103
of your that is hard to put into words.

284
00:14:55,470 --> 00:14:56,303
And just to say,

285
00:14:56,303 --> 00:14:59,883
it's not the simple way that a
lot of people think about it.

286
00:15:01,950 --> 00:15:04,670
Unfortunately, gender diverse
kids have really high rates

287
00:15:04,670 --> 00:15:06,810
of psychiatric morbidity.

288
00:15:06,810 --> 00:15:09,360
So rates of mood disorders,
mostly depression

289
00:15:09,360 --> 00:15:11,660
rather than bipolar
disorder are much higher

290
00:15:11,660 --> 00:15:13,760
than the general population,
depending on the study,

291
00:15:13,760 --> 00:15:16,233
as high as 64% of these kids.

292
00:15:17,140 --> 00:15:21,170
Anxiety disorders are also
really common up to 55%.

293
00:15:21,170 --> 00:15:23,240
And when we look at
the greatest predictors

294
00:15:23,240 --> 00:15:24,890
of mental health problems for these kids,

295
00:15:24,890 --> 00:15:28,450
they tend to be family rejection,

296
00:15:28,450 --> 00:15:31,550
peer rejection, or some
sort of societal stigma.

297
00:15:31,550 --> 00:15:33,940
And that stigma is really substantial,

298
00:15:33,940 --> 00:15:36,650
and you can see the rates of
bullying are as high as 80%

299
00:15:36,650 --> 00:15:37,513
for these kids.

300
00:15:39,250 --> 00:15:40,590
And unfortunately, because
of these high rates

301
00:15:40,590 --> 00:15:43,010
of internalizing psychopathology,

302
00:15:43,010 --> 00:15:45,290
that's just a fancy word
for anxiety and depression,

303
00:15:45,290 --> 00:15:47,253
we see high rates of suicidality.

304
00:15:50,000 --> 00:15:52,280
So in this graph, two lines,

305
00:15:52,280 --> 00:15:56,130
the black line each,
dot is a different study

306
00:15:56,130 --> 00:15:59,100
of gender diverse youth
with a different mean age.

307
00:15:59,100 --> 00:16:04,080
And the gray line is the US
average for those same ages.

308
00:16:04,080 --> 00:16:06,930
And you can see there's
a higher prevalence

309
00:16:06,930 --> 00:16:09,350
of lifetime suicide attempts
at pretty much every age

310
00:16:09,350 --> 00:16:11,100
for gender diverse people.

311
00:16:11,100 --> 00:16:14,650
And that seems to increase
during adolescence

312
00:16:14,650 --> 00:16:15,793
and early adulthood.

313
00:16:18,840 --> 00:16:21,210
I'm sorry, this is a little blurry.

314
00:16:21,210 --> 00:16:24,310
So the predominant framework for thinking

315
00:16:24,310 --> 00:16:27,170
about mental health disparities
among LGBTQ people broadly

316
00:16:27,170 --> 00:16:29,400
is the minority stress framework.

317
00:16:29,400 --> 00:16:32,063
Can I see a show of hands of
people who have heard of this?

318
00:16:33,970 --> 00:16:35,600
Okay, decent number.

319
00:16:35,600 --> 00:16:37,830
So it was first described
for lesbian, gay,

320
00:16:37,830 --> 00:16:40,453
and bisexual people by Elon Meyer at UCLA,

321
00:16:41,490 --> 00:16:43,530
and later adapted to be gender identity

322
00:16:43,530 --> 00:16:46,599
minority stress model for
gender diverse people,

323
00:16:46,599 --> 00:16:48,183
and that's the one I'll talk about now.

324
00:16:49,400 --> 00:16:51,950
The point of this model
is to describe the ways

325
00:16:51,950 --> 00:16:54,010
in which societal stigma
negatively impacts

326
00:16:54,010 --> 00:16:56,200
both mental and physical health.

327
00:16:56,200 --> 00:16:58,570
And there are two ways
in which that happens,

328
00:16:58,570 --> 00:16:59,950
there are two categories.

329
00:16:59,950 --> 00:17:02,660
So the first are these
distal stress factors.

330
00:17:02,660 --> 00:17:04,540
You can think of these
as like external factors

331
00:17:04,540 --> 00:17:06,010
that impact health.

332
00:17:06,010 --> 00:17:10,220
So that's things like
discrimination based on being trans,

333
00:17:10,220 --> 00:17:14,210
gender-related rejection,
physical victimization,

334
00:17:14,210 --> 00:17:16,960
other types of victimization,
and non affirmation

335
00:17:16,960 --> 00:17:19,740
of gender identities or
refusing to use someone's name

336
00:17:19,740 --> 00:17:20,777
or pronouns or accept someone

337
00:17:20,777 --> 00:17:22,327
for who they say that they are.

338
00:17:23,200 --> 00:17:26,160
We've had a lot of distal
stress factors recently, right?

339
00:17:26,160 --> 00:17:30,650
So in the media, we've seen
politicians say that trans youth

340
00:17:30,650 --> 00:17:33,803
are a risk to their
classmates on sports teams,

341
00:17:34,800 --> 00:17:36,980
that they are risks to
people in bathrooms,

342
00:17:36,980 --> 00:17:39,240
they're gonna sexually assault people.

343
00:17:39,240 --> 00:17:41,290
That their medical care
should be taken away,

344
00:17:41,290 --> 00:17:42,880
that their identities are invalid

345
00:17:42,880 --> 00:17:44,180
and they're just confused.

346
00:17:45,440 --> 00:17:47,010
You can imagine how those
things are gonna make

347
00:17:47,010 --> 00:17:49,300
people feel more depressed or hopeless.

348
00:17:49,300 --> 00:17:51,710
Impact self-esteem, become more anxious

349
00:17:51,710 --> 00:17:54,283
that they're gonna be
harassed about things.

350
00:17:55,644 --> 00:17:57,180
And the thing that was more novel

351
00:17:57,180 --> 00:17:59,460
about the minority stress theory was

352
00:17:59,460 --> 00:18:01,510
that these distal external factors

353
00:18:01,510 --> 00:18:03,260
can become internal factors.

354
00:18:03,260 --> 00:18:05,620
So if you're constantly
hearing negative messages

355
00:18:05,620 --> 00:18:09,417
about your demographic on TV,
you might start to think like,

356
00:18:09,417 --> 00:18:12,030
"Maybe I am a threat to my classmates.

357
00:18:12,030 --> 00:18:14,780
Maybe I am a threat to
people in the bathroom."

358
00:18:14,780 --> 00:18:18,120
Like, "Maybe my identity is invalid."

359
00:18:18,120 --> 00:18:20,960
And you may on a conscious
level know that's not true,

360
00:18:20,960 --> 00:18:23,860
but over time, those
things can kind of steep in

361
00:18:23,860 --> 00:18:26,260
and become like a really painful
thought in your unconscious

362
00:18:26,260 --> 00:18:28,010
that drives anxiety and depression.

363
00:18:29,290 --> 00:18:30,970
Another thing that
happens is you might start

364
00:18:30,970 --> 00:18:33,523
to expect negative things
to happen in the future.

365
00:18:34,460 --> 00:18:36,840
So similar to what you may
have learned in your lectures

366
00:18:36,840 --> 00:18:41,730
on psychological trauma, if
you've had a lot of experiences

367
00:18:41,730 --> 00:18:44,840
where bad things happen
to you for being trans,

368
00:18:44,840 --> 00:18:46,940
you're gonna expect that's gonna
happen again in the future,

369
00:18:46,940 --> 00:18:48,470
and it can be really hard to know

370
00:18:48,470 --> 00:18:50,730
when you enter a new situation,

371
00:18:50,730 --> 00:18:53,020
what your level of risk is,
'cause you're often gonna feel

372
00:18:53,020 --> 00:18:57,090
that it's very high, and that
of course, drives anxiety

373
00:18:57,090 --> 00:18:59,940
and can drive hopelessness,
which can lead to depression.

374
00:19:01,040 --> 00:19:04,320
And then concealment is the
final proximal stress factor.

375
00:19:04,320 --> 00:19:06,610
This is when one starts
to hide their identity,

376
00:19:06,610 --> 00:19:09,360
which can lead to a lot of
shame and also its problems.

377
00:19:10,370 --> 00:19:11,570
There are also resilience factors,

378
00:19:11,570 --> 00:19:13,810
so things like connecting
with the community,

379
00:19:13,810 --> 00:19:15,640
people who are like you
can buffer against some

380
00:19:15,640 --> 00:19:18,030
of these problems, and
also developing pride

381
00:19:18,030 --> 00:19:21,150
in your community, and
realizing that trans people

382
00:19:21,150 --> 00:19:23,650
have made major contributions to society,

383
00:19:23,650 --> 00:19:26,160
and that you may be part of
this really great community

384
00:19:26,160 --> 00:19:27,910
that's on great things in the world,

385
00:19:27,910 --> 00:19:29,963
which can buffer against
some of these negative,

386
00:19:30,830 --> 00:19:32,930
external factors that may become proximal.

387
00:19:35,251 --> 00:19:37,010
I think it's really
important to have the voices

388
00:19:37,010 --> 00:19:40,300
of trans youth themselves
in these lectures.

389
00:19:40,300 --> 00:19:44,810
So this is a focus group that
we published in 2017 in JAACAP

390
00:19:44,810 --> 00:19:46,750
from a bunch of transgender adolescents,

391
00:19:46,750 --> 00:19:48,280
and the top 10 things they said

392
00:19:48,280 --> 00:19:50,060
they wanted their doctors to know.

393
00:19:50,060 --> 00:19:51,460
And since you're about to be doctors,

394
00:19:51,460 --> 00:19:53,530
here's what they want you to know.

395
00:19:53,530 --> 00:19:54,363
Its number one,

396
00:19:54,363 --> 00:19:56,500
gender and sexuality are
totally different things.

397
00:19:56,500 --> 00:19:58,840
So they said that a lot of
times doctors would assume

398
00:19:58,840 --> 00:20:01,860
their sexual orientation based
on their gender identity.

399
00:20:01,860 --> 00:20:02,693
So they would say, you know,

400
00:20:02,693 --> 00:20:04,300
just because I'm a transgender woman,

401
00:20:04,300 --> 00:20:06,070
it doesn't mean I'm attracted to men,

402
00:20:06,070 --> 00:20:07,680
and please don't make that assumption

403
00:20:07,680 --> 00:20:10,330
and ask me if it's relevant.

404
00:20:10,330 --> 00:20:12,158
Also don't ask like
weird, creepy questions

405
00:20:12,158 --> 00:20:13,640
that didn't make it on the
slide, but it's a big one,

406
00:20:13,640 --> 00:20:14,940
like, ask what's relevant.

407
00:20:16,550 --> 00:20:19,050
Second was that non-binary people exist,

408
00:20:19,050 --> 00:20:20,550
so a lot of people in older generations

409
00:20:20,550 --> 00:20:22,920
have really been socialized
to think of gender identity

410
00:20:22,920 --> 00:20:26,173
as male or female, sexual
orientation is straight or gay,

411
00:20:27,170 --> 00:20:29,620
but a lot of people don't
experience it that way.

412
00:20:31,070 --> 00:20:33,190
Names, pronouns, and gender
markers are important.

413
00:20:33,190 --> 00:20:35,510
Number one, just because these adolescents

414
00:20:35,510 --> 00:20:37,440
are self-actualizing in
their gender identities

415
00:20:37,440 --> 00:20:39,870
and want to be respected for that.

416
00:20:39,870 --> 00:20:43,240
And they've often had bad experiences

417
00:20:43,240 --> 00:20:45,330
with people not using
their names and pronouns.

418
00:20:45,330 --> 00:20:50,330
So let's say you use the
wrong name or pronoun,

419
00:20:50,530 --> 00:20:53,620
all of a sudden, you
might be like their parent

420
00:20:53,620 --> 00:20:55,310
that kicked them out of the house, right?

421
00:20:55,310 --> 00:20:57,320
And told them they had
to live on the street.

422
00:20:57,320 --> 00:20:59,500
Or you might be the high
school bully who threw them

423
00:20:59,500 --> 00:21:02,188
into a locker and use slurs against them

424
00:21:02,188 --> 00:21:03,588
and wouldn't use their name.

425
00:21:05,780 --> 00:21:08,430
And so taking that context
into account is important.

426
00:21:10,310 --> 00:21:12,040
Another quote, "If I'm
depressed or anxious,

427
00:21:12,040 --> 00:21:13,900
it's likely not because I have issues

428
00:21:13,900 --> 00:21:16,750
with my gender identity, but
because everyone else does."

429
00:21:18,700 --> 00:21:21,950
Pointing out that a lot of times
these kids are not confused

430
00:21:21,950 --> 00:21:22,783
about their gender identity.

431
00:21:22,783 --> 00:21:25,209
Like, they know who exactly who they are,

432
00:21:25,209 --> 00:21:26,203
and that's not why they're coming to you.

433
00:21:26,203 --> 00:21:28,460
They might be coming to you
because they want support

434
00:21:28,460 --> 00:21:29,680
or they want help with, you know,

435
00:21:29,680 --> 00:21:30,660
the environment around them

436
00:21:30,660 --> 00:21:32,710
that's making their lives more difficult.

437
00:21:34,420 --> 00:21:38,010
And to let them know that
you're on their team.

438
00:21:38,010 --> 00:21:40,350
So a lot of these kids have
spent a lot of their lives

439
00:21:40,350 --> 00:21:41,890
surrounded by people who
are not on their team,

440
00:21:41,890 --> 00:21:44,400
who are not accepting them, and
to hear that there's someone

441
00:21:44,400 --> 00:21:46,170
there who's really gonna fight for them

442
00:21:46,170 --> 00:21:49,930
and fight for their gender
identity and to be who they are

443
00:21:49,930 --> 00:21:51,370
makes a big difference.

444
00:21:53,370 --> 00:21:56,460
Here, we're gonna get into
some boring stuff, I apologize.

445
00:21:56,460 --> 00:22:00,080
So I want to go through the
data in terms of what we know

446
00:22:00,080 --> 00:22:01,340
about how to best support kids

447
00:22:01,340 --> 00:22:03,090
at different developmental stages.

448
00:22:03,090 --> 00:22:05,177
So we're gonna start
with prepubertal kids,

449
00:22:05,177 --> 00:22:07,673
and then go into early
and late adolescents,

450
00:22:09,039 --> 00:22:10,089
and I have till 6:30.

451
00:22:11,360 --> 00:22:13,263
Okay, I'm going to keep watching my clock.

452
00:22:15,160 --> 00:22:17,160
Okay, so three approaches
have been described

453
00:22:17,160 --> 00:22:20,023
for prepubertal kids.

454
00:22:20,921 --> 00:22:23,110
I'm putting them all up here,

455
00:22:23,110 --> 00:22:25,170
and I want to be really
explicit in saying that one

456
00:22:25,170 --> 00:22:28,110
of these models is
illegal in many US states,

457
00:22:28,110 --> 00:22:29,150
and not recommended,

458
00:22:29,150 --> 00:22:32,080
and all major medical
organizations argue against it.

459
00:22:32,080 --> 00:22:35,870
However, it has been around
up until pretty recently

460
00:22:35,870 --> 00:22:37,190
from some pretty high profile people,

461
00:22:37,190 --> 00:22:39,070
so that's why it's on the slide.

462
00:22:39,070 --> 00:22:41,470
And that model is the living
in your own skin model,

463
00:22:41,470 --> 00:22:43,230
it was popularized by Ken Tucker who's

464
00:22:43,230 --> 00:22:46,230
at University of Toronto, or was.

465
00:22:46,230 --> 00:22:49,270
He also chaired the
DSM-V committee that made

466
00:22:49,270 --> 00:22:52,610
the diagnosis gender dysphoria
that you may have heard of.

467
00:22:52,610 --> 00:22:54,080
And what this is, is basically doing

468
00:22:54,080 --> 00:22:56,630
psychotherapeutic interventions
to push transgender youth

469
00:22:56,630 --> 00:22:58,260
to identify as cisgender,

470
00:22:58,260 --> 00:23:00,660
which many people would
call conversion therapy.

471
00:23:01,800 --> 00:23:03,390
I generally will call
it conversion efforts,

472
00:23:03,390 --> 00:23:04,920
pointing out that it's not therapeutic,

473
00:23:04,920 --> 00:23:06,800
and we'll go through some
of the research that shows

474
00:23:06,800 --> 00:23:09,750
that it's associated with
dangerous mental health outcomes.

475
00:23:10,850 --> 00:23:13,330
But given that it's been
talked about so recently

476
00:23:13,330 --> 00:23:14,570
in a pretty high profile way,

477
00:23:14,570 --> 00:23:16,010
and still some people
are talking about it,

478
00:23:16,010 --> 00:23:17,940
I wanna make sure we at least discuss it

479
00:23:17,940 --> 00:23:19,743
and then you can ask questions about it.

480
00:23:21,270 --> 00:23:22,450
Opposite end of the spectrum

481
00:23:22,450 --> 00:23:23,950
is the gender affirmative model.

482
00:23:23,950 --> 00:23:26,090
This is what most people in
the United States practice,

483
00:23:26,090 --> 00:23:28,023
it was popularized by Diane Ehrensaft.

484
00:23:29,550 --> 00:23:32,600
And what they say is don't
try and force a child

485
00:23:32,600 --> 00:23:35,790
to be cisgender because
that can instill shame,

486
00:23:35,790 --> 00:23:38,500
damaged relationships between
the therapist and the child,

487
00:23:38,500 --> 00:23:41,920
damaged relationships between
the parents and the child.

488
00:23:41,920 --> 00:23:45,540
And also separate from that,
if a prepubertal child wants

489
00:23:45,540 --> 00:23:47,360
to go through a social transition,

490
00:23:47,360 --> 00:23:50,900
so taking on name,
pronouns, gender expression,

491
00:23:50,900 --> 00:23:51,733
that matches their gender identity,

492
00:23:51,733 --> 00:23:53,210
you should let them do so,

493
00:23:53,210 --> 00:23:57,450
because if you place limits
on that, all the same things,

494
00:23:57,450 --> 00:23:58,960
instilling shame, sending this message

495
00:23:58,960 --> 00:24:00,960
that being gender diverse
is wrong, et cetera.

496
00:24:00,960 --> 00:24:03,510
That under the minority
stress model would be expected

497
00:24:03,510 --> 00:24:04,493
to cause problems.

498
00:24:05,660 --> 00:24:08,240
Third model is the watchful waiting model.

499
00:24:08,240 --> 00:24:12,220
This is what's described by
the Dutch Group in Amsterdam.

500
00:24:12,220 --> 00:24:14,030
They were the first people
that ever used puberty blockers

501
00:24:14,030 --> 00:24:15,090
to give you a sense of how important

502
00:24:15,090 --> 00:24:16,440
they've been in this field.

503
00:24:17,640 --> 00:24:20,140
And what they say is don't
do any conversion efforts,

504
00:24:20,140 --> 00:24:22,780
don't try and push the prepubertal child

505
00:24:22,780 --> 00:24:25,713
to identify as their
gender assigned at birth,

506
00:24:26,630 --> 00:24:28,940
but also tell them to wait
to socially transition

507
00:24:28,940 --> 00:24:30,190
until they reach puberty.

508
00:24:32,440 --> 00:24:34,600
This is a little confusing, but
it boils down to two things,

509
00:24:34,600 --> 00:24:37,977
number one, do you practice
conversion efforts?

510
00:24:37,977 --> 00:24:40,420
And number two, if a
prepubertal child wants

511
00:24:40,420 --> 00:24:42,770
to socially transition,
do you facilitate that?

512
00:24:45,328 --> 00:24:48,670
A little bit of background
on why there's this fighting

513
00:24:48,670 --> 00:24:52,650
is there something called the
quote, assistance literature.

514
00:24:52,650 --> 00:24:55,410
So this is a number of studies
where they looked at kids

515
00:24:55,410 --> 00:24:57,250
who were referred to gender clinics,

516
00:24:57,250 --> 00:24:58,940
very young prepubertal kids.

517
00:24:58,940 --> 00:25:01,470
And they followed them longitudinally,

518
00:25:01,470 --> 00:25:04,710
and they found that in
adolescents and young adulthood,

519
00:25:04,710 --> 00:25:07,720
most of them did not
identify as transgender.

520
00:25:07,720 --> 00:25:11,220
And so you'll often hear
that this kind of statistic

521
00:25:11,220 --> 00:25:13,890
that 80% of prepubertal
trans kids are gonna change

522
00:25:13,890 --> 00:25:16,920
their minds, identify as
cisgender later on in life.

523
00:25:16,920 --> 00:25:20,340
That is not the proper way
to interpret those studies.

524
00:25:20,340 --> 00:25:23,090
So these were kids who were
referred to gender clinics,

525
00:25:24,070 --> 00:25:25,690
but they didn't establish that these kids

526
00:25:25,690 --> 00:25:27,130
were actually transgender.

527
00:25:27,130 --> 00:25:29,100
So a lot of the kids
may have been referred

528
00:25:29,100 --> 00:25:30,680
because they were cisgender kids

529
00:25:30,680 --> 00:25:32,490
who had gender typical interests, right?

530
00:25:32,490 --> 00:25:34,910
So cis-gender boys who
liked dolls and dresses

531
00:25:34,910 --> 00:25:39,170
or cisgender girls who all
we think of as like tomboys,

532
00:25:39,170 --> 00:25:40,470
for lack of a better word.

533
00:25:41,590 --> 00:25:43,110
And in fact, when you look at the studies,

534
00:25:43,110 --> 00:25:44,730
large numbers of those kids

535
00:25:44,730 --> 00:25:47,730
didn't meet criteria for
the diagnosis at the time,

536
00:25:47,730 --> 00:25:49,653
which was gender identity disorder.

537
00:25:51,310 --> 00:25:53,700
Some of them did, but it's
important to also note

538
00:25:53,700 --> 00:25:56,090
that that diagnosis didn't require you

539
00:25:56,090 --> 00:25:58,040
to identify as a gender different

540
00:25:58,040 --> 00:26:00,390
than your sex assigned at birth.

541
00:26:00,390 --> 00:26:03,130
And it was largely based on
gender roles and gender norms.

542
00:26:03,130 --> 00:26:05,990
So again, even those kids
may have been cisgender kids

543
00:26:05,990 --> 00:26:09,660
who just express gender behavior

544
00:26:09,660 --> 00:26:11,963
that wasn't expected
based on societal norms.

545
00:26:14,110 --> 00:26:18,980
So in the US, we don't put a
lot of weight on those studies,

546
00:26:18,980 --> 00:26:21,970
but they are often used when
we're talking about this.

547
00:26:21,970 --> 00:26:24,280
We don't have great studies
following prepubertal kids

548
00:26:24,280 --> 00:26:27,660
longitudinally to see how flexible

549
00:26:27,660 --> 00:26:29,863
or dynamic their identities may be,

550
00:26:31,960 --> 00:26:33,440
but it raises other questions, right?

551
00:26:33,440 --> 00:26:35,490
Does it even matter?

552
00:26:35,490 --> 00:26:37,160
If a kid at this point in time wants

553
00:26:37,160 --> 00:26:39,100
to express themselves in a certain way,

554
00:26:39,100 --> 00:26:41,933
even if they are gonna later
express themselves differently,

555
00:26:43,636 --> 00:26:44,670
telling them they can't do that,

556
00:26:44,670 --> 00:26:46,970
and instilling shame
could still be dangerous.

557
00:26:48,040 --> 00:26:50,060
So in general, long story short,

558
00:26:50,060 --> 00:26:52,760
most people in the US practice
gender affirmative model,

559
00:26:52,760 --> 00:26:54,420
that's what is endorsed by pretty much

560
00:26:54,420 --> 00:26:55,870
all major medical organizations right now,

561
00:26:55,870 --> 00:26:57,860
so no conversion efforts.

562
00:26:57,860 --> 00:27:01,130
And if a child wants to
express their gender identity

563
00:27:01,130 --> 00:27:02,910
in a way that is not expected based

564
00:27:02,910 --> 00:27:07,263
on what is generally societaly expected,

565
00:27:08,220 --> 00:27:09,520
that we would let them do.

566
00:27:11,280 --> 00:27:12,870
Let's go through the data,
so question number one,

567
00:27:12,870 --> 00:27:14,090
early social transitions.

568
00:27:14,090 --> 00:27:16,390
This question is, do you
allow a prepubertal child

569
00:27:16,390 --> 00:27:18,740
and facilitate them
socially transition or not?

570
00:27:19,611 --> 00:27:21,050
We don't have a ton of data,

571
00:27:21,050 --> 00:27:22,700
this is pretty much what we have.

572
00:27:23,860 --> 00:27:25,900
So going from left to right,

573
00:27:25,900 --> 00:27:29,140
those are increasing rates
of anxiety and depression.

574
00:27:29,140 --> 00:27:31,890
Green is the pre (indistinct)
or like the normal range,

575
00:27:33,250 --> 00:27:35,800
orange is the preclinical range,

576
00:27:35,800 --> 00:27:37,300
and red is the clinical range.

577
00:27:38,150 --> 00:27:40,540
And we have three populations of kids.

578
00:27:40,540 --> 00:27:42,010
So kids from a Amsterdam clinic,

579
00:27:42,010 --> 00:27:44,800
where they tell them not
to socially transition,

580
00:27:44,800 --> 00:27:46,540
kids from a Toronto clinic,

581
00:27:46,540 --> 00:27:48,690
where they tell them not
to socially transition,

582
00:27:48,690 --> 00:27:51,770
and then kids who were
recruited by Christina Olson

583
00:27:51,770 --> 00:27:54,450
at Princeton who had socially transitioned

584
00:27:54,450 --> 00:27:55,560
and were in the US.

585
00:27:55,560 --> 00:27:57,050
And as you can see, the
kids who were allowed

586
00:27:57,050 --> 00:28:01,260
to socially transition have
developmentally normative rates

587
00:28:01,260 --> 00:28:02,240
of anxiety and depression,

588
00:28:02,240 --> 00:28:04,230
and the kids who were told
they can't socially transition

589
00:28:04,230 --> 00:28:06,483
are on average in the preclinical pinch.

590
00:28:07,330 --> 00:28:08,900
These are imperfect comparisons, right?

591
00:28:08,900 --> 00:28:12,170
You're not randomizing
kids to these three groups.

592
00:28:12,170 --> 00:28:14,370
They're kids from three
different countries.

593
00:28:15,530 --> 00:28:17,290
We can get in some more of the details

594
00:28:17,290 --> 00:28:19,280
that people are interested,

595
00:28:19,280 --> 00:28:21,120
but I think what we can
definitely conclude from this

596
00:28:21,120 --> 00:28:23,210
is that a prepubertal social transition

597
00:28:23,210 --> 00:28:24,990
at the very least is not dangerous.

598
00:28:24,990 --> 00:28:28,180
The kids who do that are
doing exceptionally well,

599
00:28:28,180 --> 00:28:31,250
particularly if you're
working with the community

600
00:28:31,250 --> 00:28:32,183
to make sure that
they're gonna be affirmed

601
00:28:32,183 --> 00:28:34,083
and supported and not bullied.

602
00:28:36,820 --> 00:28:39,710
Second question is conversion efforts.

603
00:28:39,710 --> 00:28:42,763
So this is a study we
published in JAMA Psychiatry.

604
00:28:43,630 --> 00:28:46,663
We used a survey over
27,000 transgender adults,

605
00:28:48,130 --> 00:28:50,450
and we looked at only
those who had ever spoken

606
00:28:50,450 --> 00:28:53,630
to a professional about
their gender identity, right?

607
00:28:53,630 --> 00:28:54,463
So we didn't look at people

608
00:28:54,463 --> 00:28:56,370
who didn't get any therapy at all,

609
00:28:56,370 --> 00:28:57,870
'cause some people would
argue that if you're referred

610
00:28:57,870 --> 00:29:01,040
to therapy, you may be more
mentally ill broadly, right?

611
00:29:01,040 --> 00:29:03,020
That's been a problem with trans studies.

612
00:29:03,020 --> 00:29:04,740
So just people who had
ever spoken to a therapist

613
00:29:04,740 --> 00:29:05,800
about their gender identity,

614
00:29:05,800 --> 00:29:07,840
and then compared those
whose therapists tried

615
00:29:07,840 --> 00:29:10,490
to make them cisgender to
those whose therapists didn't.

616
00:29:10,490 --> 00:29:12,860
And what we found was that people exposed

617
00:29:12,860 --> 00:29:14,510
to these gender identity change efforts,

618
00:29:14,510 --> 00:29:17,990
so trying to force them to be
cisgender had a higher odds

619
00:29:17,990 --> 00:29:20,070
of almost every adverse
mental health outcome

620
00:29:20,070 --> 00:29:21,250
that we looked at.

621
00:29:21,250 --> 00:29:22,860
And you can see those on the slide.

622
00:29:22,860 --> 00:29:26,390
So greater odds of
past-year suicidal ideation,

623
00:29:26,390 --> 00:29:29,080
suicidal ideation with plan,
lifetime suicide attempts,

624
00:29:29,080 --> 00:29:31,157
past-month severe psychological distress.

625
00:29:31,157 --> 00:29:32,620
And this was after adjusting

626
00:29:32,620 --> 00:29:34,860
for a wide range of potential confounders,

627
00:29:34,860 --> 00:29:37,263
including family support
for gender identity.

628
00:29:39,710 --> 00:29:42,000
The impact was even more dramatic

629
00:29:42,000 --> 00:29:43,750
if people said that they were exposed

630
00:29:43,750 --> 00:29:45,720
to those conversion
efforts during childhood.

631
00:29:45,720 --> 00:29:48,510
So during this prepubertal
phase that we're talking about,

632
00:29:48,510 --> 00:29:50,250
for people who are
exposed during childhood,

633
00:29:50,250 --> 00:29:53,430
they had a four fold adjusted odds ratio

634
00:29:53,430 --> 00:29:55,663
of lifetime suicide attempts.

635
00:29:57,890 --> 00:30:00,590
And you can see there's
almost a dose response curve

636
00:30:00,590 --> 00:30:01,433
in the data.

637
00:30:02,360 --> 00:30:05,330
So this is a therapy
without conversion efforts.

638
00:30:05,330 --> 00:30:07,480
This is if you were exposed
to conversion efforts

639
00:30:07,480 --> 00:30:09,150
at some point in your lifetime,

640
00:30:09,150 --> 00:30:11,020
and this is a few were
exposed during childhood.

641
00:30:11,020 --> 00:30:13,570
And this seems to suggest
that that earlier exposure

642
00:30:13,570 --> 00:30:15,970
and most about comes
has like a dose response

643
00:30:15,970 --> 00:30:17,350
with it being dangerous.

644
00:30:17,350 --> 00:30:19,580
So not only does it seem
that conversion therapy

645
00:30:19,580 --> 00:30:21,400
is linked to bad outcomes,

646
00:30:21,400 --> 00:30:23,170
but that doing it for
the prepubertal kids,

647
00:30:23,170 --> 00:30:25,130
which is the one place
that people are advocating

648
00:30:25,130 --> 00:30:28,020
for doing it, is actually
the most dangerous.

649
00:30:28,020 --> 00:30:31,890
From the data we have
their imperfections, right?

650
00:30:31,890 --> 00:30:34,800
There's no direct comparisons
of these three approaches.

651
00:30:34,800 --> 00:30:37,700
You're not randomizing kids
to these different conditions.

652
00:30:38,780 --> 00:30:40,550
We talk about this more at
the end, the limitations,

653
00:30:40,550 --> 00:30:41,810
but all data we have suggests

654
00:30:41,810 --> 00:30:43,190
that conversion efforts are dangerous,

655
00:30:43,190 --> 00:30:45,080
and social transition
generally seems to lead

656
00:30:45,080 --> 00:30:48,030
to good mental health outcomes,
at least in the short term.

657
00:30:49,810 --> 00:30:52,280
Despite this, conversion
efforts are still legal

658
00:30:52,280 --> 00:30:53,543
in most US states.

659
00:30:54,680 --> 00:30:58,070
So here you can see this tan color,

660
00:30:58,070 --> 00:31:01,700
those are states that have
bans on conversion efforts.

661
00:31:01,700 --> 00:31:05,143
These light tan states are
states that do not have bans.

662
00:31:06,780 --> 00:31:09,550
It seems that gender
identity conversion efforts

663
00:31:09,550 --> 00:31:13,940
are pretty common experience
among trans adults in the US.

664
00:31:13,940 --> 00:31:15,370
This is a study we published
in American Journal

665
00:31:15,370 --> 00:31:18,550
of Public Health, and you can see 13.5%

666
00:31:18,550 --> 00:31:21,300
of trans adults report
that they were exposed

667
00:31:21,300 --> 00:31:23,100
to conversion efforts at
some point in their life.

668
00:31:23,100 --> 00:31:25,110
And there is some geographic variability

669
00:31:25,110 --> 00:31:27,060
and where that seems to be most common.

670
00:31:29,860 --> 00:31:33,530
And this is potentially
an active legal question,

671
00:31:33,530 --> 00:31:35,950
so two federal appeals circuits have ruled

672
00:31:35,950 --> 00:31:39,520
that conversion therapy
bans are constitutional.

673
00:31:39,520 --> 00:31:42,670
Recently, two Trump-appointed judges ruled

674
00:31:42,670 --> 00:31:45,700
in the 11th Circuit that
conversion therapy bans

675
00:31:45,700 --> 00:31:49,060
are a violation of
professional free speech,

676
00:31:49,060 --> 00:31:50,603
and are unconstitutional.

677
00:31:53,130 --> 00:31:54,510
Interestingly, in their decision,

678
00:31:54,510 --> 00:31:58,170
they acknowledged that all
professional organizations

679
00:31:58,170 --> 00:32:00,340
have said that conversion
therapy is dangerous,

680
00:32:00,340 --> 00:32:02,923
both for sexual orientation
and gender identity.

681
00:32:04,260 --> 00:32:07,530
However, they say that the
American Psychiatric Association

682
00:32:07,530 --> 00:32:10,600
is essentially too
capricious for them to trust

683
00:32:10,600 --> 00:32:13,280
because they once said
homosexuality was a disease,

684
00:32:13,280 --> 00:32:16,010
and now they say that it doesn't.

685
00:32:16,010 --> 00:32:17,730
So their argument is basically
that they might change

686
00:32:17,730 --> 00:32:19,880
their mind about
conversion therapy as well,

687
00:32:19,880 --> 00:32:22,520
which is obviously a
very dangerous argument

688
00:32:22,520 --> 00:32:25,420
and an easy way to throw out
kind of all medical evidence.

689
00:32:26,890 --> 00:32:29,480
Now that there is this split
between the two circuits,

690
00:32:29,480 --> 00:32:30,810
there's a possibility that this could go

691
00:32:30,810 --> 00:32:32,850
to the Supreme Court and what
the current composition people

692
00:32:32,850 --> 00:32:35,750
are concerned about what the
outcome could potentially be.

693
00:32:38,597 --> 00:32:39,430
It's three people, children.

694
00:32:39,430 --> 00:32:41,800
Next, we're gonna talk
about early adolescents

695
00:32:41,800 --> 00:32:43,713
and pubertal blockade or suppression.

696
00:32:45,470 --> 00:32:48,100
I'm sorry, this is another
boring part (chuckles)

697
00:32:48,100 --> 00:32:51,830
but review of little bit of basic science.

698
00:32:51,830 --> 00:32:53,903
So during the prepubertal phase,

699
00:32:55,290 --> 00:33:00,290
your hypothalamus releases
GnRH at this low level, right?

700
00:33:00,770 --> 00:33:03,820
Once you get to early to mid
puberty, you get little pulses,

701
00:33:03,820 --> 00:33:04,940
and by mid to late puberty,

702
00:33:04,940 --> 00:33:07,043
you have this nice sinusoidal release.

703
00:33:07,950 --> 00:33:10,570
You need that sinusoidal pulsatile release

704
00:33:10,570 --> 00:33:13,920
in order for the pituitary
to make FSH and LH,

705
00:33:13,920 --> 00:33:17,053
which you need to make
estrogen and testosterone.

706
00:33:18,330 --> 00:33:19,610
Puberty blockers are confusing

707
00:33:19,610 --> 00:33:21,400
because they do not block GnRH,

708
00:33:21,400 --> 00:33:23,540
they're actually GnRH agonists,

709
00:33:23,540 --> 00:33:25,480
so they activate the receptor.

710
00:33:25,480 --> 00:33:26,360
And essentially, what they do

711
00:33:26,360 --> 00:33:29,440
is they make this tonically high.

712
00:33:29,440 --> 00:33:32,350
And when it's tonically
high and not pulsatile,

713
00:33:32,350 --> 00:33:34,523
the pituitary will not make FSH and LH,

714
00:33:36,110 --> 00:33:38,570
which means you won't make
estrogen or testosterone.

715
00:33:38,570 --> 00:33:40,360
If you remove the drug,

716
00:33:40,360 --> 00:33:43,483
which is either a depo injection
or a subcutaneous implant,

717
00:33:44,670 --> 00:33:46,267
that pulsatile nature comes back,

718
00:33:46,267 --> 00:33:48,030
and indogenous puberty proceeds.

719
00:33:48,030 --> 00:33:51,270
So in that sense, puberty
blockers are reversible.

720
00:33:51,270 --> 00:33:53,730
And most clinicians think of them as a way

721
00:33:53,730 --> 00:33:57,160
to buy adolescents more time to decide

722
00:33:57,160 --> 00:33:58,690
whether or not they want
to go on to the next step

723
00:33:58,690 --> 00:34:00,410
of gender-affirming hormones like estrogen

724
00:34:00,410 --> 00:34:02,930
or testosterone, without developing

725
00:34:02,930 --> 00:34:05,700
irreversible secondary
sex characteristics,

726
00:34:05,700 --> 00:34:07,370
which are irreversible, right?

727
00:34:07,370 --> 00:34:08,730
So by not doing a puberty blocker,

728
00:34:08,730 --> 00:34:12,280
you're putting something in
process that is irreversible.

729
00:34:12,280 --> 00:34:13,580
Whereas the puberty blocker itself,

730
00:34:13,580 --> 00:34:15,133
you can reverse by stopping it.

731
00:34:18,300 --> 00:34:19,290
These medications have been used

732
00:34:19,290 --> 00:34:21,430
since at least the 70s
for precocious puberty,

733
00:34:21,430 --> 00:34:23,800
that is their original
pediatric indication.

734
00:34:23,800 --> 00:34:25,980
They do not have an indication

735
00:34:25,980 --> 00:34:28,120
for gender-affirming medical care,

736
00:34:28,120 --> 00:34:30,170
mostly because that's clinical
trials to be very expensive,

737
00:34:30,170 --> 00:34:31,300
and there's not a great incentive

738
00:34:31,300 --> 00:34:32,900
for pharma companies to do them.

739
00:34:33,860 --> 00:34:37,263
However, they started being
used off label in Amsterdam.

740
00:34:38,870 --> 00:34:40,120
Amsterdam is very pretty.

741
00:34:42,850 --> 00:34:45,000
This was their landmark case report

742
00:34:46,010 --> 00:34:47,863
that they published in 1998.

743
00:34:48,930 --> 00:34:52,410
It was about a young transmasculine person

744
00:34:52,410 --> 00:34:56,673
who had severe gender dysphoria
and suicidality due to it.

745
00:34:57,820 --> 00:34:59,870
They gave this patient
pubertal suppression

746
00:34:59,870 --> 00:35:01,800
followed by testosterone treatment

747
00:35:01,800 --> 00:35:03,580
and gender-affirming surgery.

748
00:35:03,580 --> 00:35:05,440
And in adulthood, that person

749
00:35:05,440 --> 00:35:07,490
had very positive mental health outcomes.

750
00:35:09,680 --> 00:35:12,300
We talked about this, these
are the different ways

751
00:35:12,300 --> 00:35:13,580
you can give puberty blockers.

752
00:35:13,580 --> 00:35:16,863
Again, either a depo injection
or the subcutaneous implant.

753
00:35:17,960 --> 00:35:20,370
The implant is marketed to last a year,

754
00:35:20,370 --> 00:35:22,033
it often last around two years.

755
00:35:23,330 --> 00:35:26,080
And this is the data that we have

756
00:35:26,080 --> 00:35:29,700
about the impact of pubertal suppression.

757
00:35:29,700 --> 00:35:30,990
So you can see there have
been a bunch of studies,

758
00:35:30,990 --> 00:35:33,910
most of them are
longitudinal cohort studies

759
00:35:33,910 --> 00:35:38,280
that have largely found lower depression

760
00:35:38,280 --> 00:35:41,730
and increases in global
functioning, less suicidal ideation,

761
00:35:41,730 --> 00:35:43,600
less internalizing psychopathology,

762
00:35:43,600 --> 00:35:46,923
so that's anxiety and depression
kind of composite score.

763
00:35:50,070 --> 00:35:52,130
And there've been two comparative studies,

764
00:35:52,130 --> 00:35:54,160
so one was ours where we looked at people

765
00:35:54,160 --> 00:35:56,510
who ever desired pubertal suppression.

766
00:35:56,510 --> 00:35:58,810
These were adults, and we said okay just

767
00:35:58,810 --> 00:36:01,190
to people who ever
wanted puberty blockers.

768
00:36:01,190 --> 00:36:02,410
Let's compare people who got them

769
00:36:02,410 --> 00:36:03,820
to people who couldn't get them.

770
00:36:03,820 --> 00:36:06,070
And people who got them had lower odds

771
00:36:06,070 --> 00:36:07,993
of lifetime suicidal ideation.

772
00:36:08,930 --> 00:36:10,970
There was another study
from the Netherlands

773
00:36:10,970 --> 00:36:13,410
where they compared people who
had gotten puberty blockers

774
00:36:13,410 --> 00:36:14,680
to people who were presenting

775
00:36:14,680 --> 00:36:17,110
for the first time asking for them.

776
00:36:17,110 --> 00:36:18,710
And they found that
those who had gotten them

777
00:36:18,710 --> 00:36:21,433
had lower rates of anxiety and depression.

778
00:36:22,550 --> 00:36:25,880
Again, no like randomized
controlled trials,

779
00:36:25,880 --> 00:36:27,730
and it's probably not something
that's going to happen

780
00:36:27,730 --> 00:36:29,990
given that we have so
much data showing that

781
00:36:29,990 --> 00:36:30,960
from these longitudinal studies,

782
00:36:30,960 --> 00:36:33,070
that it seems mental health improves.

783
00:36:33,070 --> 00:36:34,610
The most (indistinct)
is considered unethical

784
00:36:34,610 --> 00:36:36,910
to randomize people to
a control (indistinct).

785
00:36:37,800 --> 00:36:38,920
One thing that someone could do,

786
00:36:38,920 --> 00:36:40,340
is there any budding researchers?

787
00:36:40,340 --> 00:36:41,803
Is there a waitlist control?

788
00:36:42,830 --> 00:36:44,280
So the unfortunate reality is that a lot

789
00:36:44,280 --> 00:36:45,700
of clinics have very long waitlists,

790
00:36:45,700 --> 00:36:47,320
so you can compare people
who are on the waitlist

791
00:36:47,320 --> 00:36:49,260
to people who are receiving treatment,

792
00:36:49,260 --> 00:36:51,893
and that might be a
better comparative study.

793
00:36:57,100 --> 00:36:59,123
These are things I'm gonna
save for the questions.

794
00:37:01,250 --> 00:37:02,540
Next is gender-affirming hormones.

795
00:37:02,540 --> 00:37:06,150
So traditionally in the old
endocrine society guidelines,

796
00:37:06,150 --> 00:37:09,440
these were not a possibility until age 16.

797
00:37:09,440 --> 00:37:11,790
So that's the age when adolescents
might consider starting

798
00:37:11,790 --> 00:37:15,680
estrogen or testosterone
to induce physical changes

799
00:37:15,680 --> 00:37:17,580
that align with their gender identity.

800
00:37:18,820 --> 00:37:20,880
However, the new under
consignee guidelines say

801
00:37:20,880 --> 00:37:24,003
you could consider these
as early as 13 and a half,

802
00:37:24,870 --> 00:37:26,980
and generally, that's not to be in cases

803
00:37:27,910 --> 00:37:31,640
that are relatively straightforward.

804
00:37:31,640 --> 00:37:33,520
Often kids who socially
transitioned very young

805
00:37:33,520 --> 00:37:35,810
had been on puberty
blockers for a long time.

806
00:37:35,810 --> 00:37:37,810
Well, it makes sense to keep
them on a puberty blocker

807
00:37:37,810 --> 00:37:41,113
for a long time, that risk
is, risks bone health.

808
00:37:42,460 --> 00:37:43,850
Also, a lot of adolescents will say

809
00:37:43,850 --> 00:37:45,800
that they don't like that
all their peers are going

810
00:37:45,800 --> 00:37:47,000
through puberty, and they're not,

811
00:37:47,000 --> 00:37:50,193
that can be socially
stigmatizing and uncomfortable.

812
00:37:51,080 --> 00:37:55,970
But the 13 and a half age is
interpreted different ways

813
00:37:55,970 --> 00:37:57,490
by different clinics.

814
00:37:57,490 --> 00:38:00,700
Main things to think about
are that estrogen increases

815
00:38:00,700 --> 00:38:04,260
your blood clot risk
from the studies we have,

816
00:38:04,260 --> 00:38:05,093
and they're not great.

817
00:38:05,093 --> 00:38:07,800
It doesn't seem there's a huge
increase in blood clot risk

818
00:38:08,750 --> 00:38:10,940
for people who are taking estrogen

819
00:38:10,940 --> 00:38:12,590
for gender-affirming medical care

820
00:38:12,590 --> 00:38:14,900
at the doses that are
generally prescribed.

821
00:38:14,900 --> 00:38:17,650
However, always counsel
patients on the potential risk.

822
00:38:17,650 --> 00:38:19,280
And you may encounter a lot of patients

823
00:38:19,280 --> 00:38:21,730
because like I was saying,
the waitlists are so long

824
00:38:21,730 --> 00:38:23,080
and it's so hard to access care

825
00:38:23,080 --> 00:38:26,420
that many patients may get
the hormones off the internet

826
00:38:26,420 --> 00:38:27,253
or the black market,

827
00:38:27,253 --> 00:38:29,100
and they may be taking
doses that are higher

828
00:38:29,100 --> 00:38:31,050
than one would generally take.

829
00:38:31,050 --> 00:38:32,470
They may not be monitoring their levels,

830
00:38:32,470 --> 00:38:37,083
so they may be at a very
high risk of PE, DVT stroke,

831
00:38:38,510 --> 00:38:40,110
particularly if they're smoking.

832
00:38:41,740 --> 00:38:44,793
Testosterone can increase
your red blood cell count.

833
00:38:45,910 --> 00:38:49,660
And I put on these tables of
the general physical effects

834
00:38:49,660 --> 00:38:53,670
that you get from
estrogen and testosterone,

835
00:38:53,670 --> 00:38:55,530
but these are in the
endocrine society guidelines

836
00:38:55,530 --> 00:38:57,070
that you can look up if
you want to read them

837
00:38:57,070 --> 00:38:57,903
in more detail.

838
00:38:59,890 --> 00:39:01,090
Once again, the data.

839
00:39:01,090 --> 00:39:03,180
So again, we have a lot of
longitudinal cohort studies

840
00:39:03,180 --> 00:39:05,810
that generally show an
improvement in mental health,

841
00:39:05,810 --> 00:39:09,030
decreasing suicidality,
improved quality of life,

842
00:39:09,030 --> 00:39:11,683
decreases in anxiety and
depression, et cetera.

843
00:39:13,160 --> 00:39:15,610
There have not been any
comparative studies published,

844
00:39:15,610 --> 00:39:17,040
so comparing people who access for months

845
00:39:17,040 --> 00:39:18,610
to people who haven't.

846
00:39:18,610 --> 00:39:20,960
We have a paper under review now,

847
00:39:20,960 --> 00:39:24,460
where similar to that
people's depression study.

848
00:39:24,460 --> 00:39:27,780
We looked at people who ever
desired gender-free hormones,

849
00:39:27,780 --> 00:39:29,550
and then looked at people who got them

850
00:39:29,550 --> 00:39:31,610
versus people who weren't
able to access them.

851
00:39:31,610 --> 00:39:34,430
And people who were able to
access them had lower odds

852
00:39:34,430 --> 00:39:36,200
of past-year suicidal ideation,

853
00:39:36,200 --> 00:39:39,510
and past-month severe
psychological distress.

854
00:39:39,510 --> 00:39:41,960
This was true, whether
they access them as adults

855
00:39:42,980 --> 00:39:44,410
during the age group

856
00:39:44,410 --> 00:39:47,870
from the old Endocrine Society
guidelines of 16 to 17.

857
00:39:47,870 --> 00:39:49,610
Also, the expanded age group

858
00:39:49,610 --> 00:39:52,120
in the new Endocrine Society
guidelines, 14 to 15.

859
00:39:52,120 --> 00:39:53,760
And then put it on this slide,

860
00:39:53,760 --> 00:39:55,970
but we also compared
people who access hormones

861
00:39:55,970 --> 00:39:57,400
during adolescents to
people who weren't able

862
00:39:57,400 --> 00:39:59,370
to access them until adulthood.

863
00:39:59,370 --> 00:40:02,070
And people who access them
during adolescents had lower odds

864
00:40:02,070 --> 00:40:04,520
of suicidality and severe
psychological distress.

865
00:40:07,040 --> 00:40:08,940
Well, we did well on time, unexpected.

866
00:40:09,870 --> 00:40:10,850
Okay, so we have a little bit of time

867
00:40:10,850 --> 00:40:13,050
for talking about dynamic
gender identities.

868
00:40:15,260 --> 00:40:19,970
So what you will probably hear
in your psychology class is

869
00:40:19,970 --> 00:40:23,050
that gender identity children
identify their own gender

870
00:40:23,050 --> 00:40:24,200
at age three.

871
00:40:24,200 --> 00:40:27,110
They can identify that gender
doesn't change over time

872
00:40:27,110 --> 00:40:29,206
around age three or five.

873
00:40:29,206 --> 00:40:31,350
(indistinct) these are from
small observational studies

874
00:40:31,350 --> 00:40:32,490
of cisgender youth,

875
00:40:32,490 --> 00:40:37,423
and aren't really very
quantitatively kind of thing.

876
00:40:38,520 --> 00:40:41,830
And the research for gender
diverse youth might end up

877
00:40:41,830 --> 00:40:43,500
being a little bit different.

878
00:40:43,500 --> 00:40:46,050
We talked a little bit about
those desistance studies

879
00:40:46,050 --> 00:40:47,413
and the problems with them.

880
00:40:50,300 --> 00:40:54,600
I will say that the studies
we have of trans adolescents

881
00:40:54,600 --> 00:40:58,100
who have started, who've
presented to clinics asking

882
00:40:58,100 --> 00:41:00,560
for say, pubertal suppression,
it seems pretty rare for them

883
00:41:00,560 --> 00:41:03,710
to identify as cisgender in the future.

884
00:41:03,710 --> 00:41:05,330
So a small number of
them, like on the order

885
00:41:05,330 --> 00:41:07,970
of one to 2% may choose to
stop the puberty blocker

886
00:41:07,970 --> 00:41:10,670
and not go on to
gender-affirming hormones.

887
00:41:10,670 --> 00:41:12,990
But it doesn't seem that
there are a sizeable number

888
00:41:12,990 --> 00:41:17,990
that come off the hormones
or regret the hormones.

889
00:41:18,230 --> 00:41:19,260
And a lot of times,

890
00:41:19,260 --> 00:41:22,540
what is most commonly seen
is adolescents may identify

891
00:41:22,540 --> 00:41:23,830
as trans in a binary way,

892
00:41:23,830 --> 00:41:25,670
and then later identify as non-binary,

893
00:41:25,670 --> 00:41:28,440
and then may choose to
stop hormones, which again,

894
00:41:28,440 --> 00:41:32,830
won't necessarily be linked
to regret about the hormones.

895
00:41:32,830 --> 00:41:34,140
And some kids will say that the hormones

896
00:41:34,140 --> 00:41:35,950
really were necessary
for them to consolidate

897
00:41:35,950 --> 00:41:38,000
and understand themselves.

898
00:41:38,000 --> 00:41:40,190
That being said, there are a
very small number of patients

899
00:41:40,190 --> 00:41:41,890
who start hormones and
do later regret some

900
00:41:41,890 --> 00:41:44,020
of the irreversible physical changes.

901
00:41:44,020 --> 00:41:45,760
And so that's part of the
informed consent process

902
00:41:45,760 --> 00:41:47,480
when we talk to families.

903
00:41:47,480 --> 00:41:50,060
But what you're doing is
weighing the potential benefits,

904
00:41:50,060 --> 00:41:53,373
providing the therapy with
this unlikely potential harm.

905
00:41:54,530 --> 00:41:57,078
And in most cases, the
benefits outweigh the risks,

906
00:41:57,078 --> 00:42:02,078
but it's something to
talk to families about.

907
00:42:02,670 --> 00:42:04,270
We published this paper
in JAACAP about thinking

908
00:42:04,270 --> 00:42:06,830
about dynamic gender presentations,

909
00:42:06,830 --> 00:42:08,303
or dynamic gender identities.

910
00:42:09,510 --> 00:42:11,650
And we talked about if a
patient comes to you saying

911
00:42:11,650 --> 00:42:13,640
they wanna stop hormones,
or their gender identity

912
00:42:13,640 --> 00:42:16,980
is changing in some way, then
you can use this framework

913
00:42:16,980 --> 00:42:20,130
of thinking about internal
and external factors.

914
00:42:20,130 --> 00:42:22,990
So internal factors are things
like your gender identity

915
00:42:22,990 --> 00:42:24,560
has evolved and changed,

916
00:42:24,560 --> 00:42:27,660
or you're feeling unsure
about your gender identity.

917
00:42:27,660 --> 00:42:30,070
External factors are those
things we talked about before.

918
00:42:30,070 --> 00:42:32,700
So you're being mistreated at school,

919
00:42:32,700 --> 00:42:34,990
your family's rejecting you,

920
00:42:34,990 --> 00:42:36,470
you're being harassed
or discriminated against

921
00:42:36,470 --> 00:42:37,887
in your community, et cetera.

922
00:42:37,887 --> 00:42:39,940
And those external factors
could be what's driving

923
00:42:39,940 --> 00:42:42,530
someone's desire to
present again as cisgender

924
00:42:42,530 --> 00:42:44,259
or stop medical interventions,

925
00:42:44,259 --> 00:42:46,100
and it's important to counsel them on that

926
00:42:46,100 --> 00:42:47,970
'cause some of those things
might be modifiable, right?

927
00:42:47,970 --> 00:42:49,470
That if it's a family problem,

928
00:42:49,470 --> 00:42:50,910
you could do family therapy.

929
00:42:50,910 --> 00:42:53,850
If the school is treating this child

930
00:42:53,850 --> 00:42:54,700
in a way that's not affirming,

931
00:42:54,700 --> 00:42:55,610
you could work with the school

932
00:42:55,610 --> 00:42:58,303
to create a safer environment, et cetera.

933
00:42:59,370 --> 00:43:00,380
To complicate things further,

934
00:43:00,380 --> 00:43:02,230
it's important to keep in
mind the external factors,

935
00:43:02,230 --> 00:43:03,240
as we know from the minority,

936
00:43:03,240 --> 00:43:06,210
stress theory can become internal factors.

937
00:43:06,210 --> 00:43:07,360
So when you're sitting with a cat,

938
00:43:07,360 --> 00:43:08,450
it can be hard to tease out,

939
00:43:08,450 --> 00:43:11,530
but worth trying to see that
if they're feeling confused

940
00:43:11,530 --> 00:43:12,380
about their gender identity,

941
00:43:12,380 --> 00:43:14,920
how much of that is coming
from an internal place

942
00:43:14,920 --> 00:43:18,330
versus how much of it may be
that they're internalizing

943
00:43:18,330 --> 00:43:20,130
stigma that they're hearing in the news

944
00:43:20,130 --> 00:43:22,563
or media, families,
communities, et cetera.

945
00:43:25,170 --> 00:43:26,970
Just to highlight that this
is a study we published

946
00:43:26,970 --> 00:43:29,600
in LGBT health, where we asked

947
00:43:29,600 --> 00:43:32,037
those same 27,000 transgender adults,

948
00:43:32,037 --> 00:43:33,510
"Have you ever
de-transitioned at some point

949
00:43:33,510 --> 00:43:36,080
in your life, broadly defined?"

950
00:43:36,080 --> 00:43:38,660
13.1% of them said they had at some point.

951
00:43:38,660 --> 00:43:40,890
So it seems, this is not
an uncommon experience

952
00:43:40,890 --> 00:43:43,230
that trans people will
de-transition largely

953
00:43:43,230 --> 00:43:44,480
because of some external factor.

954
00:43:44,480 --> 00:43:47,290
So 82% of them said it was
one of those external things

955
00:43:48,470 --> 00:43:50,900
like family stigma, societal stigma,

956
00:43:50,900 --> 00:43:52,900
lost health insurance coverage,

957
00:43:52,900 --> 00:43:56,640
military forced them to
de-transition, all kinds of things.

958
00:43:56,640 --> 00:43:57,720
So when you're sitting
with someone who says

959
00:43:57,720 --> 00:44:00,270
they're transitioning, quote, unquote,

960
00:44:00,270 --> 00:44:02,503
just keeping in mind that that
doesn't mean their identity

961
00:44:02,503 --> 00:44:04,690
will evolve for their
expression will evolve again

962
00:44:04,690 --> 00:44:06,090
at some point in the future.

963
00:44:09,290 --> 00:44:10,370
This is the table of the reasons

964
00:44:10,370 --> 00:44:12,420
that they gave for why that happened.

965
00:44:12,420 --> 00:44:14,997
And just some of the
qualitative quotes, so,

966
00:44:14,997 --> 00:44:16,460
"I live in a very conservative place

967
00:44:16,460 --> 00:44:17,790
and was afraid for my safety."

968
00:44:17,790 --> 00:44:19,810
A lot of people talk about moving,

969
00:44:19,810 --> 00:44:24,190
so they might start hormones
in a city where they feel safe.

970
00:44:24,190 --> 00:44:26,070
And then maybe you have
to go back and take care

971
00:44:26,070 --> 00:44:28,790
of a family member who's sick
or move somewhere for a job,

972
00:44:28,790 --> 00:44:31,550
and then feel that they're
forced to de-transition.

973
00:44:31,550 --> 00:44:32,740
Similarly, "The military forced me

974
00:44:32,740 --> 00:44:35,370
to de-transition on service."

975
00:44:35,370 --> 00:44:37,180
Or, "School staff harassed
and abused me daily

976
00:44:37,180 --> 00:44:38,880
for my gender expression."

977
00:44:38,880 --> 00:44:41,023
In child psychiatry,
you'll see this a lot.

978
00:44:42,098 --> 00:44:44,290
Otherwise, those who may live
in a pretty affirming place,

979
00:44:44,290 --> 00:44:46,630
then maybe haven't even experienced

980
00:44:46,630 --> 00:44:47,980
a lot of transphobia per se,

981
00:44:47,980 --> 00:44:51,550
and then you move somewhere
or start a new college,

982
00:44:51,550 --> 00:44:53,010
it's a very different social environment

983
00:44:53,010 --> 00:44:54,710
and it can be difficult to manage.

984
00:44:56,670 --> 00:44:58,473
Of course, there are data
limitations with this,

985
00:44:58,473 --> 00:45:00,870
so I just wanna clarify
these are transgender adults.

986
00:45:00,870 --> 00:45:02,560
So anyone who de-transitioned

987
00:45:02,560 --> 00:45:05,460
and then identified as cisgender
would not be in the study.

988
00:45:06,510 --> 00:45:07,860
And there's no published
peer review literature

989
00:45:07,860 --> 00:45:09,370
about adolescents who de-transition

990
00:45:09,370 --> 00:45:11,570
and then identify as cisgender,

991
00:45:11,570 --> 00:45:14,660
but based on what we know
so far, it seems uncommon,

992
00:45:14,660 --> 00:45:15,920
but it could be that there will be

993
00:45:15,920 --> 00:45:18,533
more emerging literature
about that in the future.

994
00:45:21,530 --> 00:45:23,980
This is an interesting read from Slate.

995
00:45:23,980 --> 00:45:27,770
So this is about somebody
who transitioned,

996
00:45:27,770 --> 00:45:29,640
had medical interventions and then stopped

997
00:45:29,640 --> 00:45:31,930
those medical interventions
and de-transitioned,

998
00:45:31,930 --> 00:45:35,110
and actually became a
pretty prominent activist,

999
00:45:35,110 --> 00:45:37,270
arguing that gender-affirming
medical intervention

1000
00:45:37,270 --> 00:45:39,810
should not be offered to minors.

1001
00:45:39,810 --> 00:45:43,930
And then later, came out
and wrote this article

1002
00:45:43,930 --> 00:45:46,180
and said that they felt
that actually they had been

1003
00:45:46,180 --> 00:45:49,230
indoctrinated into that idea by a group

1004
00:45:49,230 --> 00:45:51,170
of trans exclusionary, radical feminists,

1005
00:45:51,170 --> 00:45:56,080
who kind of convinced them
that a trans masculine identity

1006
00:45:56,080 --> 00:45:59,033
was just a manifestation
of internalized misogyny,

1007
00:46:01,320 --> 00:46:02,540
and that, you know, they felt that

1008
00:46:02,540 --> 00:46:03,930
they got good community there,

1009
00:46:03,930 --> 00:46:05,940
firms that worked for them,

1010
00:46:05,940 --> 00:46:08,560
that de-transition identity,
but then their gender dysphoria

1011
00:46:08,560 --> 00:46:10,690
towards their body continued,

1012
00:46:10,690 --> 00:46:13,452
and then eventually, they re-transitioned.

1013
00:46:13,452 --> 00:46:16,070
So I only bring this up to
keep in mind of that interplay

1014
00:46:16,070 --> 00:46:17,543
between internal and external factors,

1015
00:46:17,543 --> 00:46:19,730
that can be extraordinarily complicated.

1016
00:46:19,730 --> 00:46:21,513
It may take time to sort out,

1017
00:46:22,780 --> 00:46:23,613
but I think at the end of the day,

1018
00:46:23,613 --> 00:46:24,600
when you're working with patients,

1019
00:46:24,600 --> 00:46:27,637
you just need to tell them
that you are a safe place,

1020
00:46:27,637 --> 00:46:29,740
it's the right time to evolve in any way,

1021
00:46:29,740 --> 00:46:31,643
and you're gonna support
them no matter what.

1022
00:46:32,520 --> 00:46:34,920
And there's no like bad
outcome from your mind

1023
00:46:34,920 --> 00:46:37,220
to like you're gonna be
there to support them.

1024
00:46:39,210 --> 00:46:41,260
But of course, these
de-transition narratives

1025
00:46:41,260 --> 00:46:43,410
have been widely politicized.

1026
00:46:43,410 --> 00:46:45,970
You may have seen that over
20 bills were introduced

1027
00:46:45,970 --> 00:46:47,600
in state legislative sessions last year,

1028
00:46:47,600 --> 00:46:49,930
that would have banned
gender-affirming medical care

1029
00:46:49,930 --> 00:46:52,093
for trans adolescents.

1030
00:46:53,320 --> 00:46:56,070
None of them passed,
thankfully, except for two.

1031
00:46:56,070 --> 00:46:57,520
One was in Tennessee, where they banned

1032
00:46:57,520 --> 00:46:59,200
gender-affirming medical interventions

1033
00:46:59,200 --> 00:47:00,800
for prepubertal children,

1034
00:47:00,800 --> 00:47:02,900
which you now know is not
something people do anyway.

1035
00:47:02,900 --> 00:47:06,180
So that was largely symbolic

1036
00:47:06,180 --> 00:47:09,220
and does not impact care in the state.

1037
00:47:09,220 --> 00:47:13,090
However, in Arkansas, the state
legislature passed a bill,

1038
00:47:13,090 --> 00:47:14,770
the governor vetoed it,

1039
00:47:14,770 --> 00:47:17,510
the state legislature
actually overrode the veto,

1040
00:47:17,510 --> 00:47:19,300
and so it would have become law

1041
00:47:19,300 --> 00:47:21,900
if not for the ACLU filing a lawsuit.

1042
00:47:21,900 --> 00:47:23,850
And a preliminary injunction was issued,

1043
00:47:23,850 --> 00:47:24,850
so that bill is not active.

1044
00:47:24,850 --> 00:47:26,940
So right now, there are no active bans

1045
00:47:26,940 --> 00:47:28,410
on gender-affirming medical care

1046
00:47:28,410 --> 00:47:29,810
for trans adolescents,

1047
00:47:29,810 --> 00:47:31,420
but it's likely these
bills are gonna come back

1048
00:47:31,420 --> 00:47:33,790
in a big way next legislative session,

1049
00:47:33,790 --> 00:47:35,750
so that's why I'm glad we were
talking about all of this,

1050
00:47:35,750 --> 00:47:37,340
so you can know the data, look it up,

1051
00:47:37,340 --> 00:47:39,290
and hopefully, advocate
as these things start

1052
00:47:39,290 --> 00:47:41,640
to come up in state
legislature's next session.

1053
00:47:42,560 --> 00:47:45,280
This is an article we
have in JAMA that provides

1054
00:47:46,290 --> 00:47:48,500
a lot of information
about why what's contained

1055
00:47:48,500 --> 00:47:50,253
in those bills, it's inaccurate.

1056
00:47:52,970 --> 00:47:55,070
So take home points, gender
identity and expression

1057
00:47:55,070 --> 00:47:56,920
are not always static for all people.

1058
00:47:58,260 --> 00:48:00,000
De-transition and gender
identity evolution

1059
00:48:00,000 --> 00:48:01,290
can be understood using this framework

1060
00:48:01,290 --> 00:48:03,540
of internal and external factors.

1061
00:48:03,540 --> 00:48:04,680
It's important to think about whether

1062
00:48:04,680 --> 00:48:07,903
or not external factors are
driving internal factors.

1063
00:48:08,830 --> 00:48:10,830
And these identities have
been highly politicized,

1064
00:48:10,830 --> 00:48:13,200
and we need to focus on providing
the best care to patients

1065
00:48:13,200 --> 00:48:15,490
while advocating for
accurate public discourse

1066
00:48:15,490 --> 00:48:16,590
about these questions.

1067
00:48:19,700 --> 00:48:21,180
Okay, time for questions,

1068
00:48:21,180 --> 00:48:25,120
I do have appendix slides
about hot topics (chuckles)

1069
00:48:25,120 --> 00:48:27,520
people wanna talk about them.

1070
00:48:27,520 --> 00:48:29,550
But thank you for dealing
with me talking really fast,

1071
00:48:29,550 --> 00:48:31,712
I wanna make sure we got everything.

1072
00:48:31,712 --> 00:48:34,712
(audience clapping)

1073
00:48:44,088 --> 00:48:46,505
(indistinct)

1074
00:49:12,400 --> 00:49:17,360
- [Participant] Hi, for the
prepuberty blockers or sorry,

1075
00:49:17,360 --> 00:49:21,230
puberty blockers, how
long, what is the timeframe

1076
00:49:21,230 --> 00:49:25,990
for using a puberty
blocker before starting

1077
00:49:25,990 --> 00:49:29,870
either hormone therapy or reversing

1078
00:49:29,870 --> 00:49:31,090
and stopping the puberty blocker?

1079
00:49:31,090 --> 00:49:33,810
Like, how long do you have

1080
00:49:33,810 --> 00:49:35,510
to use a puberty blocker and wait?

1081
00:49:36,540 --> 00:49:38,990
- This is an area of
somewhat ongoing controversy.

1082
00:49:38,990 --> 00:49:41,500
So what people worry about with prolonged

1083
00:49:41,500 --> 00:49:43,630
pubertal suppression is
that you need estrogen

1084
00:49:43,630 --> 00:49:46,460
or testosterone to induce
bone mineralization.

1085
00:49:46,460 --> 00:49:47,770
So while you're on the blocker,

1086
00:49:47,770 --> 00:49:49,940
you're gonna fall behind
on bone age compared

1087
00:49:49,940 --> 00:49:52,560
to age matched peers.

1088
00:49:52,560 --> 00:49:55,020
The clinical significance
of that is somewhat unclear.

1089
00:49:55,020 --> 00:49:56,990
So there was a really
great perspective published

1090
00:49:56,990 --> 00:49:58,400
in pediatrics, where they talked

1091
00:49:58,400 --> 00:50:00,150
about a non-binary adolescent

1092
00:50:00,150 --> 00:50:01,320
who didn't wanna start hormones,

1093
00:50:01,320 --> 00:50:03,193
and they didn't want to
come off the blocker.

1094
00:50:04,600 --> 00:50:08,120
They calculated, say like the
five to 10-year fracture risk,

1095
00:50:08,120 --> 00:50:11,450
was really low on the order
of one to 2% of doing that,

1096
00:50:11,450 --> 00:50:13,400
but they're based on adult calculators

1097
00:50:13,400 --> 00:50:14,560
because this isn't something we think

1098
00:50:14,560 --> 00:50:16,160
about for adolescent patients,

1099
00:50:16,160 --> 00:50:18,370
so it's not hard to figure out.

1100
00:50:18,370 --> 00:50:20,530
Most providers will want somebody

1101
00:50:20,530 --> 00:50:22,370
to start gender-affirming
hormones around age,

1102
00:50:22,370 --> 00:50:24,570
like 16 to 18, and won't want people

1103
00:50:24,570 --> 00:50:26,920
to be on the blockers for much longer.

1104
00:50:26,920 --> 00:50:29,110
That being said, there's
interesting science

1105
00:50:29,110 --> 00:50:29,943
you could do here.

1106
00:50:29,943 --> 00:50:32,660
You could use like a selective
estrogen receptor modulator

1107
00:50:32,660 --> 00:50:33,900
that would mineralize the bones,

1108
00:50:33,900 --> 00:50:37,063
but not induce other
secondary sex characteristics.

1109
00:50:37,900 --> 00:50:40,760
But that's not something people
have done in large numbers,

1110
00:50:40,760 --> 00:50:42,450
but maybe something that's
coming in the future,

1111
00:50:42,450 --> 00:50:43,660
particularly, because more and more,

1112
00:50:43,660 --> 00:50:46,520
we're seeing non-binary
patients come to clinics.

1113
00:50:46,520 --> 00:50:47,353
And like you're saying,

1114
00:50:47,353 --> 00:50:49,783
they don't necessarily
want to start the hormones.

1115
00:50:52,560 --> 00:50:55,650
- [Participant] Hi, so I think a lot

1116
00:50:55,650 --> 00:50:59,960
of these research studies
to a trans person sort

1117
00:50:59,960 --> 00:51:03,210
of feel like pretty
obvious, like of course,

1118
00:51:03,210 --> 00:51:04,530
like anxiety goes down

1119
00:51:04,530 --> 00:51:06,710
when gender-affirming care is available.

1120
00:51:06,710 --> 00:51:09,460
Like of course, that, you
know, someone's ability

1121
00:51:09,460 --> 00:51:11,910
to continue to transition is probably due

1122
00:51:11,910 --> 00:51:13,080
mostly to external factors.

1123
00:51:13,080 --> 00:51:15,030
So my conversion therapy is bad?

1124
00:51:15,030 --> 00:51:16,730
Right, yeah (chuckles).

1125
00:51:16,730 --> 00:51:17,810
So I guess I'm curious, like,

1126
00:51:17,810 --> 00:51:22,810
how do you balance the need
for research that is required

1127
00:51:22,900 --> 00:51:26,630
to justify gender-affirming
care from like a political

1128
00:51:26,630 --> 00:51:30,470
and like a insurance standpoint
versus the need for research

1129
00:51:30,470 --> 00:51:33,460
that would affect a trans person's visit

1130
00:51:33,460 --> 00:51:35,840
to the doctor's office?

1131
00:51:35,840 --> 00:51:36,930
- Yeah, I think it's hard,

1132
00:51:36,930 --> 00:51:39,430
I think we need both, unfortunately.

1133
00:51:39,430 --> 00:51:41,560
Ideally, we would live in a
world where we didn't have

1134
00:51:41,560 --> 00:51:43,653
to prove things that were obvious.

1135
00:51:44,770 --> 00:51:47,500
I totally hear that most of
my work is proving things

1136
00:51:47,500 --> 00:51:51,210
that are largely obvious (chuckles)

1137
00:51:51,210 --> 00:51:52,780
but at the end of the day,

1138
00:51:52,780 --> 00:51:56,580
there are powerful politicians
and people who are willing

1139
00:51:56,580 --> 00:51:58,757
to serve as expert witnesses
to go out and say like,

1140
00:51:58,757 --> 00:52:00,630
"No, actually, gender-free
medical care makes

1141
00:52:00,630 --> 00:52:01,820
people's mental health worse."

1142
00:52:01,820 --> 00:52:03,710
You know, they'll cite that Jane study,

1143
00:52:03,710 --> 00:52:06,240
and plus one, you know,

1144
00:52:06,240 --> 00:52:08,858
as a study where they used a registry

1145
00:52:08,858 --> 00:52:12,367
of people who got gender-affirming
surgery, and they said,

1146
00:52:12,367 --> 00:52:14,100
"Look, after the gender-affirming surgery,

1147
00:52:14,100 --> 00:52:16,410
these people had higher
rates of suicidality

1148
00:52:16,410 --> 00:52:17,650
than the general population."

1149
00:52:17,650 --> 00:52:20,680
Like, "Gender-affirming
medical care should be banned."

1150
00:52:20,680 --> 00:52:21,530
It sounds good, right?

1151
00:52:21,530 --> 00:52:22,740
Like convincing now.

1152
00:52:22,740 --> 00:52:26,160
So their mental health
improved actually before

1153
00:52:26,160 --> 00:52:28,860
and after the surgery, but you can't use

1154
00:52:28,860 --> 00:52:30,750
like cisgender people
as the comparison group

1155
00:52:30,750 --> 00:52:32,303
for transgender people
who have had surgery,

1156
00:52:32,303 --> 00:52:33,650
because they're still dealing with all

1157
00:52:33,650 --> 00:52:36,560
of the societal stigma
that we talked about.

1158
00:52:36,560 --> 00:52:40,300
But the problem is, there's
so many people trying

1159
00:52:40,300 --> 00:52:44,530
to make conversion therapy
legal and practice it

1160
00:52:44,530 --> 00:52:47,280
and ban medical care that
we get stuck doing a lot

1161
00:52:47,280 --> 00:52:49,800
of this research that feels obvious,

1162
00:52:49,800 --> 00:52:51,900
which is understandably really frustrating

1163
00:52:51,900 --> 00:52:53,970
to like the trans community.

1164
00:52:53,970 --> 00:52:56,960
Like, why are you wasting your
time on this stupid stuff?

1165
00:52:56,960 --> 00:52:58,970
But that's the reason, I think
the good news is there's more

1166
00:52:58,970 --> 00:53:00,850
and more research interests,
so there are people

1167
00:53:00,850 --> 00:53:03,600
who are doing things that
are more useful, if you will,

1168
00:53:04,730 --> 00:53:07,410
like they gave out, can we use like SERMs

1169
00:53:07,410 --> 00:53:09,360
to prolong pubertal suppression
for non-binary kids?

1170
00:53:09,360 --> 00:53:11,490
Like what fertility options
can we use for people

1171
00:53:11,490 --> 00:53:14,340
who do want to have biological children?

1172
00:53:14,340 --> 00:53:17,980
How do different, like
hormone regimens change

1173
00:53:17,980 --> 00:53:19,740
side effects and outcomes?

1174
00:53:19,740 --> 00:53:22,230
So luckily, more of that
research is being done,

1175
00:53:22,230 --> 00:53:23,070
but I hear you totally,

1176
00:53:23,070 --> 00:53:26,053
that we do a lot of research
that oops, maybe obvious.

1177
00:53:29,070 --> 00:53:31,220
- [Participant] Hi there,
thank you for coming.

1178
00:53:31,220 --> 00:53:34,550
I have a question as all of
us, our future positions,

1179
00:53:34,550 --> 00:53:37,060
but those of us who are looking
to go into family practice

1180
00:53:37,060 --> 00:53:39,470
and maybe are from more rural areas,

1181
00:53:39,470 --> 00:53:40,980
I'm Keen, moved here from Montana,

1182
00:53:40,980 --> 00:53:43,830
which was bright red
and one of those maps.

1183
00:53:43,830 --> 00:53:48,830
So how, in your research and
your work with this population,

1184
00:53:48,950 --> 00:53:52,210
how do physicians go
about signaling in an area

1185
00:53:52,210 --> 00:53:55,160
that might be more
rural, more conservative,

1186
00:53:55,160 --> 00:53:57,770
that they are someone
who can be spoken to,

1187
00:53:57,770 --> 00:54:02,610
or kind of how do people,
how do you go about starting,

1188
00:54:02,610 --> 00:54:04,170
not even starting that conversation,

1189
00:54:04,170 --> 00:54:06,700
but just signaling that you're
open to that conversation

1190
00:54:06,700 --> 00:54:11,700
if you do live in kind of a
more conservative location,

1191
00:54:12,460 --> 00:54:14,702
that folks might not expect?

1192
00:54:14,702 --> 00:54:16,810
- One really easy thing you can do is join

1193
00:54:16,810 --> 00:54:20,400
the World Professional Association
for Transgender Health.

1194
00:54:20,400 --> 00:54:22,320
And they actually have a provider database

1195
00:54:22,320 --> 00:54:25,380
that you can put yourself
on, so people in your area,

1196
00:54:25,380 --> 00:54:26,317
they can go and search like,

1197
00:54:26,317 --> 00:54:30,550
"Is there a family medicine
doctor who at least

1198
00:54:30,550 --> 00:54:32,820
is interested enough
in like, my health care

1199
00:54:32,820 --> 00:54:34,970
that they put themselves
on this database?"

1200
00:54:35,810 --> 00:54:37,330
So that's one, and there
are a lot of things you can

1201
00:54:37,330 --> 00:54:39,580
do in your office, right?

1202
00:54:39,580 --> 00:54:44,170
Like, flags posters, try and do a good job

1203
00:54:44,170 --> 00:54:45,480
with your medical records
to make sure you're not

1204
00:54:45,480 --> 00:54:47,080
misgendering people
(chuckles) doing a good job

1205
00:54:47,080 --> 00:54:49,480
with your letters to not
be misgendering people.

1206
00:54:50,510 --> 00:54:51,350
It sounds like your question is more

1207
00:54:51,350 --> 00:54:53,410
to get them in the door, I
think the useful thing is

1208
00:54:53,410 --> 00:54:55,210
to be on some of those websites.

1209
00:54:55,210 --> 00:54:58,233
And a lot of local places
will have referral networks.

1210
00:54:59,510 --> 00:55:02,520
So in my area, we have
something called Mind the Gap.

1211
00:55:02,520 --> 00:55:05,810
That's a consortium, people who work

1212
00:55:05,810 --> 00:55:07,600
with gender diverse people.

1213
00:55:07,600 --> 00:55:09,950
And so word gets around that
you can call this organization

1214
00:55:09,950 --> 00:55:12,000
and they'll tell you people in your area.

1215
00:55:15,180 --> 00:55:16,167
- [Participant] I think, well, hi,

1216
00:55:16,167 --> 00:55:18,893
thank you for coming, right over here.

1217
00:55:19,998 --> 00:55:21,134
- I can tell it's coming from there.

1218
00:55:21,134 --> 00:55:23,900
(audience laughing)

1219
00:55:23,900 --> 00:55:26,260
- [Participant] So I kind
of had a more question

1220
00:55:26,260 --> 00:55:27,750
in regards to the blockers.

1221
00:55:27,750 --> 00:55:31,070
Aside from the bone density,
has there been any studies

1222
00:55:31,070 --> 00:55:33,610
in regards to like the
long-term effects of being,

1223
00:55:33,610 --> 00:55:35,490
'cause I know you said they're reversible,

1224
00:55:35,490 --> 00:55:38,730
but if we're gonna be
providing these services,

1225
00:55:38,730 --> 00:55:42,530
and in regards to the informed
consent and everything,

1226
00:55:42,530 --> 00:55:44,370
has there been any studies
in like long-term effects?

1227
00:55:44,370 --> 00:55:47,030
And if so, has anything come of it?

1228
00:55:47,030 --> 00:55:48,380
- Yeah, so here's what you can say,

1229
00:55:48,380 --> 00:55:49,670
they've been used for precocious puberty

1230
00:55:49,670 --> 00:55:52,570
since the 70s, and there's been
post-marketing surveillance

1231
00:55:52,570 --> 00:55:56,430
for pediatric populations
in particular since then.

1232
00:55:56,430 --> 00:55:58,010
No big red flags have come up.

1233
00:55:58,010 --> 00:56:00,230
There have been studies of fertility

1234
00:56:00,230 --> 00:56:02,600
after pubertal suppression
for people who took them

1235
00:56:02,600 --> 00:56:03,710
for central precocious puberty,

1236
00:56:03,710 --> 00:56:07,100
and it does not seem their
fertility has been impacted.

1237
00:56:07,100 --> 00:56:09,490
Another question that's
come up is cognitive impact.

1238
00:56:09,490 --> 00:56:11,830
The studies we have so far suggest

1239
00:56:11,830 --> 00:56:13,440
that it doesn't impact cognition,

1240
00:56:13,440 --> 00:56:16,080
at least on executive functioning tasks

1241
00:56:16,080 --> 00:56:17,273
in particular for adolescents.

1242
00:56:17,273 --> 00:56:19,520
I think the thing that's
tough here, right,

1243
00:56:19,520 --> 00:56:22,130
is politically, people have
asked questions of these drugs

1244
00:56:22,130 --> 00:56:24,450
that are not asked about
any other drugs, right?

1245
00:56:24,450 --> 00:56:25,873
Like, I've never had someone
come up to me and say like,

1246
00:56:25,873 --> 00:56:28,490
"Can you tell me how Prozac will impair

1247
00:56:28,490 --> 00:56:30,760
the Wisconsin card
sorting test in 10 years?"

1248
00:56:30,760 --> 00:56:34,458
But people ask me that about
puberty blockers all the time.

1249
00:56:34,458 --> 00:56:36,130
At the end of the day, no medication

1250
00:56:36,130 --> 00:56:37,530
is without risks and benefits,

1251
00:56:37,530 --> 00:56:38,830
there are certainly gonna be unknowns

1252
00:56:38,830 --> 00:56:40,270
about pubertal suppression.

1253
00:56:40,270 --> 00:56:42,060
While we know as they've
been used since the 70s

1254
00:56:42,060 --> 00:56:44,030
for precocious puberty,
those people have done well.

1255
00:56:44,030 --> 00:56:45,870
Specifically, we've looked at fertility,

1256
00:56:45,870 --> 00:56:48,360
executive functioning, and
bone density that does seem

1257
00:56:48,360 --> 00:56:49,497
you fall behind on bone density,

1258
00:56:49,497 --> 00:56:51,900
and that's an important
thing to think about.

1259
00:56:51,900 --> 00:56:53,310
- [Participant] Awesome, thank you.

1260
00:56:53,310 --> 00:56:54,169
- We're gonna peek

1261
00:56:54,169 --> 00:56:57,919
through online (indistinct).

1262
00:57:00,780 --> 00:57:01,680
Okay (indistinct).

1263
00:57:06,480 --> 00:57:07,313
Yeah.

1264
00:57:08,234 --> 00:57:10,651
(indistinct)

1265
00:57:15,625 --> 00:57:18,042
The questions are here, okay?

1266
00:57:21,590 --> 00:57:22,930
- First question from Andy is,

1267
00:57:22,930 --> 00:57:25,446
is this meeting accessible by phone?

1268
00:57:25,446 --> 00:57:29,231
(audience laughing)

1269
00:57:29,231 --> 00:57:30,793
- (laughs) Sorry, I don't know.

1270
00:57:36,020 --> 00:57:40,197
Okay, next question is from Nick Lemon,

1271
00:57:40,197 --> 00:57:42,500
"How do you approach
conversations with hesitant

1272
00:57:42,500 --> 00:57:45,270
or non-supportive family
members who have not been privy

1273
00:57:45,270 --> 00:57:47,800
to the internal experiences
trans youth go through

1274
00:57:47,800 --> 00:57:49,230
as they determine their gender identity

1275
00:57:49,230 --> 00:57:51,890
and decided like, to transition?"

1276
00:57:51,890 --> 00:57:53,740
Obviously, a very important question.

1277
00:57:56,100 --> 00:57:59,620
What I think is really
important is that parents

1278
00:57:59,620 --> 00:58:02,203
have a space to process
away from their kids.

1279
00:58:04,055 --> 00:58:06,823
There are a lot of common
things that come up for parents.

1280
00:58:07,770 --> 00:58:09,160
And it's usually transient, you know,

1281
00:58:09,160 --> 00:58:11,097
they'll have thoughts like,

1282
00:58:11,097 --> 00:58:14,140
"Oh, I miss the daughter I
thought I was gonna have."

1283
00:58:14,140 --> 00:58:17,220
Or, "Oh my God, I put so
much thought into that name."

1284
00:58:17,220 --> 00:58:21,257
Or like, "I'm really worried
about my child's future."

1285
00:58:21,257 --> 00:58:24,150
Things that a lot of
parents are gonna think.

1286
00:58:24,150 --> 00:58:26,977
Also things like, "Is it a phase?"

1287
00:58:29,222 --> 00:58:31,790
But not things you want the kids to hear.

1288
00:58:31,790 --> 00:58:33,890
Because if that kid
does grow up to continue

1289
00:58:33,890 --> 00:58:35,190
to identify as trans,

1290
00:58:35,190 --> 00:58:37,090
like those small comments
are the kinds of things

1291
00:58:37,090 --> 00:58:38,370
that stick in someone's head

1292
00:58:38,370 --> 00:58:41,150
and impact self-esteem, anxiety,

1293
00:58:41,150 --> 00:58:43,480
depression, relationship
with parent for a long time.

1294
00:58:43,480 --> 00:58:45,860
So I think if you notice that
some of that stuff's starting

1295
00:58:45,860 --> 00:58:47,910
to bubble to the surface
in front of the kid,

1296
00:58:47,910 --> 00:58:51,000
see if you can pull the parents
aside and be validating.

1297
00:58:51,000 --> 00:58:52,600
And be like, "I can understand."

1298
00:58:53,660 --> 00:58:55,280
Validating is different than agreeing,

1299
00:58:55,280 --> 00:58:58,000
big thing you learn on
your psychiatry rotation.

1300
00:58:58,000 --> 00:58:59,680
But you can say, "I can understand

1301
00:58:59,680 --> 00:59:01,450
why you would have these
thoughts and feelings.

1302
00:59:01,450 --> 00:59:04,440
I am worried about the impact
that can have on your kid.

1303
00:59:04,440 --> 00:59:06,047
So I'm not telling you
what to think or feel,

1304
00:59:06,047 --> 00:59:08,040
but can I please work
with you to find a space

1305
00:59:08,040 --> 00:59:09,760
where you can explore this in a way

1306
00:59:09,760 --> 00:59:11,670
to really make sure you
understand your own thoughts

1307
00:59:11,670 --> 00:59:13,140
and feelings before expressing
them to your child?"

1308
00:59:13,140 --> 00:59:17,060
And I think that can, a lot
of parents kind of say yes,

1309
00:59:17,060 --> 00:59:18,760
as long as you're being validated.

1310
00:59:20,134 --> 00:59:22,620
One thing that you sell
about puberty blockers

1311
00:59:22,620 --> 00:59:25,450
is in many ways, it's, you
kind of talk to parents

1312
00:59:25,450 --> 00:59:28,650
about delaying a decision, right?

1313
00:59:28,650 --> 00:59:29,830
Because if you don't
do the puberty blocker,

1314
00:59:29,830 --> 00:59:31,670
you're making a decision
like you're putting that kid

1315
00:59:31,670 --> 00:59:32,850
through indogenous puberty.

1316
00:59:32,850 --> 00:59:35,557
That's not reversible,
whereas the puberty blockers,

1317
00:59:35,557 --> 00:59:37,157
it's to me, more time to decide.

1318
00:59:39,580 --> 00:59:42,220
There's a book that's a
good example about this,

1319
00:59:42,220 --> 00:59:46,320
we reviewed it for JAACAP
called "Found in Transition".

1320
00:59:46,320 --> 00:59:49,300
And it's written by a mom who's
like a liberal pediatrician

1321
00:59:49,300 --> 00:59:52,100
in LA, but liberal pediatricians

1322
00:59:52,100 --> 00:59:54,503
in LA can have like
transphobic thoughts, right?

1323
00:59:54,503 --> 00:59:59,480
This is not something unique
to like social conservatives.

1324
00:59:59,480 --> 01:00:01,260
And she talks about a lot of these ideas

1325
01:00:01,260 --> 01:00:02,093
that she went through.

1326
01:00:02,093 --> 01:00:04,420
And I think it's a great
book to give to parents,

1327
01:00:04,420 --> 01:00:07,370
'cause they can kind of go
through that journey with her,

1328
01:00:07,370 --> 01:00:09,630
and at the same time, not a
great book to give to kids.

1329
01:00:09,630 --> 01:00:11,850
'Cause they're ideas that
will stick in their minds,

1330
01:00:11,850 --> 01:00:13,050
it kind of impacts them.

1331
01:00:14,480 --> 01:00:15,960
Parents' support groups
can be really great.

1332
01:00:15,960 --> 01:00:18,500
A lot of areas have them
'cause there'll be parents

1333
01:00:18,500 --> 01:00:19,500
at different stages

1334
01:00:19,500 --> 01:00:21,650
of their kids coming
out and transitioning.

1335
01:00:22,850 --> 01:00:24,640
It could be helpful just to
have another parent who's gone

1336
01:00:24,640 --> 01:00:26,240
through something you've gone through.

1337
01:00:26,240 --> 01:00:27,970
Maybe has had the same
thoughts you've had,

1338
01:00:27,970 --> 01:00:29,590
who can validate and help you understand

1339
01:00:29,590 --> 01:00:31,973
how things evolved for them at least.

1340
01:00:33,705 --> 01:00:36,122
(indistinct)

1341
01:00:46,240 --> 01:00:48,447
- Trying to decide then the best one.

1342
01:01:01,010 --> 01:01:03,770
So none of these are short ones.

1343
01:01:05,940 --> 01:01:08,047
Okay, let's just do maybe this one,

1344
01:01:08,047 --> 01:01:12,020
"How do you feel about people
who choose to raise their baby

1345
01:01:12,020 --> 01:01:15,177
with a non-binary gender
identity from birth?"

1346
01:01:16,231 --> 01:01:18,010
It's a thing we do in
the Bay Area sometimes.

1347
01:01:18,010 --> 01:01:20,320
(audience laughing)

1348
01:01:20,320 --> 01:01:24,113
- So I think this gender
neutral parenting idea,

1349
01:01:25,640 --> 01:01:27,380
I don't see any inherent harm in it.

1350
01:01:27,380 --> 01:01:29,710
Obviously, the nice part
about it is you're not forcing

1351
01:01:29,710 --> 01:01:32,090
any gender norms on the child.

1352
01:01:32,090 --> 01:01:35,280
I don't think it's so much
that you're like raising

1353
01:01:35,280 --> 01:01:38,320
a non-binary child from birth,
so much as you're creating

1354
01:01:38,320 --> 01:01:40,512
a space where you don't
force anything on the kid.

1355
01:01:40,512 --> 01:01:45,280
Let your kid, if your kid goes
and wants to buy the unicorn

1356
01:01:45,280 --> 01:01:47,080
and you know it's a reasonable time

1357
01:01:47,080 --> 01:01:49,430
to buy a unicorn you can
afford, buy a unicorn.

1358
01:01:50,720 --> 01:01:53,973
So I don't think it's
so much about creating,

1359
01:01:55,120 --> 01:01:56,750
you're not forcing a non-binary identity,

1360
01:01:56,750 --> 01:01:59,060
you're not forcing the
kid of a certain identity,

1361
01:01:59,060 --> 01:02:02,070
but just letting the child explore.

1362
01:02:02,070 --> 01:02:04,540
There's this other question
of some technicalities

1363
01:02:04,540 --> 01:02:05,930
where you have to do things,

1364
01:02:05,930 --> 01:02:10,020
so some parents will
choose to use pronouns

1365
01:02:10,020 --> 01:02:11,650
that are thought of as non-binary,

1366
01:02:11,650 --> 01:02:13,380
may use the them pronouns for their child

1367
01:02:13,380 --> 01:02:16,120
until their child says, "I
wanna use these pronouns,"

1368
01:02:16,120 --> 01:02:18,600
I see no inherent harm in that.

1369
01:02:18,600 --> 01:02:21,440
I think what you'll hear
people concerned about

1370
01:02:21,440 --> 01:02:22,550
is that they're worried that

1371
01:02:22,550 --> 01:02:25,190
if you affirm a young
person's nonsense identity,

1372
01:02:25,190 --> 01:02:27,260
that you're like making
them more likely to grow up

1373
01:02:27,260 --> 01:02:29,270
to be trans, a lot to unpack there.

1374
01:02:29,270 --> 01:02:30,890
Number one, it's not
a bad thing to grow up

1375
01:02:30,890 --> 01:02:33,056
to be trans, don't be a jerk.

1376
01:02:33,056 --> 01:02:37,630
Number two, that's not
true scientifically.

1377
01:02:37,630 --> 01:02:41,220
So Christina Olson from
Princeton ran a study

1378
01:02:41,220 --> 01:02:43,260
where she looked at prepubertal children

1379
01:02:43,260 --> 01:02:45,620
who socially transitioned
to see if their degree

1380
01:02:45,620 --> 01:02:49,900
of gender and congruence
between self and gender identity

1381
01:02:49,900 --> 01:02:51,550
was more after a social transition,

1382
01:02:51,550 --> 01:02:52,830
and she found it was not.

1383
01:02:52,830 --> 01:02:55,000
So it doesn't seem that
affirming someone changes

1384
01:02:55,000 --> 01:02:57,623
their gender identity,
at least in that study.

1385
01:02:58,820 --> 01:03:01,890
She even did measures of
implicit gender association.

1386
01:03:01,890 --> 01:03:04,070
So I don't know if you've seen
those implicit association

1387
01:03:04,070 --> 01:03:07,110
tasks to see what your
subconscious is thinking basically,

1388
01:03:07,110 --> 01:03:09,350
but she did that with self in gender,

1389
01:03:09,350 --> 01:03:11,070
and it didn't seem that social transition

1390
01:03:11,070 --> 01:03:13,560
made that more dramatic, but rather,

1391
01:03:13,560 --> 01:03:15,540
the people who go on to socially
transition to begin with,

1392
01:03:15,540 --> 01:03:18,481
had a greater degree of incongruence

1393
01:03:18,481 --> 01:03:20,017
between their sex assigned at birth

1394
01:03:20,017 --> 01:03:21,543
and their gender identity.

1395
01:03:22,980 --> 01:03:25,163
So I hope that answers the question.

1396
01:03:25,163 --> 01:03:27,580
(indistinct)

1397
01:03:30,130 --> 01:03:31,540
- [Participant] Yeah, thank you.

1398
01:03:31,540 --> 01:03:32,480
Thank you so much for your talk,

1399
01:03:32,480 --> 01:03:35,120
I was wondering, in bringing
up legislation that happen

1400
01:03:35,120 --> 01:03:37,160
to block evidence-based practice,

1401
01:03:37,160 --> 01:03:39,330
I was wondering if you had
any advice for physicians

1402
01:03:39,330 --> 01:03:42,050
interesting in advocating
for evidence-based medicine,

1403
01:03:42,050 --> 01:03:44,440
especially if it's politically charged,

1404
01:03:44,440 --> 01:03:47,600
not just in the clinic, but in
the greater political sphere,

1405
01:03:47,600 --> 01:03:49,510
as well as to either
counter these attempts

1406
01:03:49,510 --> 01:03:51,750
or right protections for these into law.

1407
01:03:51,750 --> 01:03:54,330
- Sorry, could you repeat the last part?

1408
01:03:54,330 --> 01:03:57,990
- [Participant] If you
could trying to advocate

1409
01:03:57,990 --> 01:03:59,000
for evidence-based medicine,

1410
01:03:59,000 --> 01:04:00,240
especially if it's politically charged,

1411
01:04:00,240 --> 01:04:01,170
not just in the clinic,

1412
01:04:01,170 --> 01:04:03,820
but in the greater political
sphere to either counter

1413
01:04:03,820 --> 01:04:06,810
the legislation or to also
try to write protections

1414
01:04:06,810 --> 01:04:08,123
for these into law.

1415
01:04:09,110 --> 01:04:11,394
- Where you plant it,
this is like my shtick.

1416
01:04:11,394 --> 01:04:14,360
(audience laughing)

1417
01:04:14,360 --> 01:04:15,630
- There are so many things you can do,

1418
01:04:15,630 --> 01:04:17,760
and we are not trained
to do them as physicians,

1419
01:04:17,760 --> 01:04:18,910
but I think it's so important.

1420
01:04:18,910 --> 01:04:22,930
One thing that I actually
learned when I like felt

1421
01:04:22,930 --> 01:04:25,050
I was too young to decide
I wanted to be a doctor.

1422
01:04:25,050 --> 01:04:27,190
So when I was a pharma
consultant for a year,

1423
01:04:27,190 --> 01:04:28,742
that was awful, don't do it.

1424
01:04:28,742 --> 01:04:30,210
(audience laughing)

1425
01:04:30,210 --> 01:04:33,720
- But I learned that doctors
are the weakest lobby

1426
01:04:33,720 --> 01:04:35,830
of all of the lobbies,
and we don't have a lot

1427
01:04:35,830 --> 01:04:37,840
of political power and we're not trained

1428
01:04:37,840 --> 01:04:40,260
to change the political system at all,

1429
01:04:40,260 --> 01:04:42,470
but there are a lot of
things you can learn to do.

1430
01:04:42,470 --> 01:04:45,320
So I've done a lot of opinion writing.

1431
01:04:45,320 --> 01:04:46,850
If you wanna learn more
about op-ed writing,

1432
01:04:46,850 --> 01:04:49,840
you can school with the OpEd Project,

1433
01:04:49,840 --> 01:04:50,840
they'll assign you a mentor,

1434
01:04:50,840 --> 01:04:53,080
they'll teach you how to pitch newspapers,

1435
01:04:53,080 --> 01:04:56,620
and you can write op-eds
detailing the science

1436
01:04:56,620 --> 01:04:59,193
around what a policy should be.

1437
01:05:00,100 --> 01:05:03,870
So I wrote one for the New
York Times when this first bill

1438
01:05:03,870 --> 01:05:05,930
was introduced, allied
gender-affirming medical care,

1439
01:05:05,930 --> 01:05:08,660
just going through all the
things they said in the bill

1440
01:05:08,660 --> 01:05:11,120
that weren't true, and showing the data

1441
01:05:11,120 --> 01:05:14,263
about why doctors consider
these interventions for kids.

1442
01:05:15,350 --> 01:05:16,880
And there's strategic
ways to do that, right?

1443
01:05:16,880 --> 01:05:18,710
You see where bills are being introduced

1444
01:05:18,710 --> 01:05:20,420
and where people need to hear the data

1445
01:05:20,420 --> 01:05:22,450
and then kind of send
it to local newspapers,

1446
01:05:22,450 --> 01:05:23,550
things like that.

1447
01:05:23,550 --> 01:05:27,090
I'm also a huge advocate
for social media involvement

1448
01:05:27,090 --> 01:05:29,940
if you want training on that,
like bias does a psychiatrist,

1449
01:05:29,940 --> 01:05:31,940
the American Psychiatric
Association has training

1450
01:05:31,940 --> 01:05:33,310
on how to do that.

1451
01:05:33,310 --> 01:05:36,220
But a lot of problems come
from misinformation spreading

1452
01:05:36,220 --> 01:05:40,020
online, not just through
major media outlets,

1453
01:05:40,020 --> 01:05:42,700
where that happens, but
also on things like Twitter,

1454
01:05:42,700 --> 01:05:44,650
Instagram, TikTok, et cetera.

1455
01:05:44,650 --> 01:05:48,100
So those, I think in
medicine traditionally,

1456
01:05:48,100 --> 01:05:50,790
we're taught like, that's
always the time, like, go learn

1457
01:05:50,790 --> 01:05:52,002
the Krebs cycle.

1458
01:05:52,002 --> 01:05:54,031
(audience laughing)

1459
01:05:54,031 --> 01:05:55,181
- (chuckles) I'm sorry.

1460
01:05:58,310 --> 01:05:59,980
But you can make a huge impact

1461
01:05:59,980 --> 01:06:02,270
through that advocacy and
spreading information,

1462
01:06:02,270 --> 01:06:04,220
and there's a lot of
power on the other side

1463
01:06:04,220 --> 01:06:08,450
of people sending messages that are false.

1464
01:06:08,450 --> 01:06:10,803
But nonetheless, drive policy.

1465
01:06:12,816 --> 01:06:15,638
- Dr. Tandoh, I think Dr.
Imbasciani actually would like

1466
01:06:15,638 --> 01:06:17,650
to, he has his hand raised and
would like to ask a question,

1467
01:06:17,650 --> 01:06:19,667
so we're just gonna pull him back up.

1468
01:06:19,667 --> 01:06:22,110
(indistinct)

1469
01:06:22,110 --> 01:06:24,760
- Dr. Jack, it's Dr. Vito in Los Angeles.

1470
01:06:24,760 --> 01:06:28,550
Hey, you're probably aware of efforts

1471
01:06:28,550 --> 01:06:32,140
from your local state Senator
up there in Sacramento

1472
01:06:32,140 --> 01:06:34,710
to create legislation in California,

1473
01:06:34,710 --> 01:06:37,800
and it's probably gonna be
mimicked in other states,

1474
01:06:37,800 --> 01:06:40,560
that would disallow surgeons like myself

1475
01:06:40,560 --> 01:06:45,560
from doing gender-affirming
surgery at infancy

1476
01:06:45,850 --> 01:06:47,680
or shortly thereafter?

1477
01:06:47,680 --> 01:06:51,500
I'm thinking children with
congenital adrenal hyperplasia.

1478
01:06:51,500 --> 01:06:54,390
So what advice would you
give somebody like me

1479
01:06:54,390 --> 01:06:58,610
as to what age, how
old does the child have

1480
01:06:58,610 --> 01:07:00,283
to be to give consent?

1481
01:07:02,010 --> 01:07:04,102
- Well, this is gonna
be the last question.

1482
01:07:04,102 --> 01:07:06,739
(audience laughing)

1483
01:07:06,739 --> 01:07:10,790
- So this is not my area, I
think you're kind of referring

1484
01:07:10,790 --> 01:07:12,230
to differences of sexual development,

1485
01:07:12,230 --> 01:07:13,310
which has a broad range

1486
01:07:13,310 --> 01:07:15,790
of what were previously
called intersex conditions.

1487
01:07:15,790 --> 01:07:18,220
And historically, there's
been a practice of trying

1488
01:07:18,220 --> 01:07:21,160
to predict what gender identity
the person's gonna have

1489
01:07:21,160 --> 01:07:23,770
in the future, and then
performing some sort

1490
01:07:23,770 --> 01:07:28,770
of genital surgery in
line with that prediction.

1491
01:07:29,030 --> 01:07:30,350
This has been a controversial practice

1492
01:07:30,350 --> 01:07:32,120
because a lot of adults
have later come out

1493
01:07:32,120 --> 01:07:33,680
and said that there was a presumption

1494
01:07:33,680 --> 01:07:35,160
about what their gender identity would be,

1495
01:07:35,160 --> 01:07:37,983
surgery was done, and they
wish that surgery had not been.

1496
01:07:39,350 --> 01:07:40,553
I will say that that's
totally outside my area,

1497
01:07:40,553 --> 01:07:43,260
I don't think I can
appropriately answer the question

1498
01:07:43,260 --> 01:07:45,740
with the expertise that would be needed

1499
01:07:45,740 --> 01:07:50,400
for gender-affirming genital
surgery for trans adolescents.

1500
01:07:50,400 --> 01:07:53,453
All current guidelines say
that no person has to be 18.

1501
01:07:54,550 --> 01:07:57,550
So age of majority and
the country where they are

1502
01:07:57,550 --> 01:08:00,240
in contrast to
gender-affirming top surgery.

1503
01:08:00,240 --> 01:08:03,720
So things for transmasculine
patients like masculinizing

1504
01:08:03,720 --> 01:08:06,750
chest reconstruction, that
is sometimes done earlier

1505
01:08:06,750 --> 01:08:08,940
on a case by case basis,
and it's really up

1506
01:08:08,940 --> 01:08:11,710
to the mental health professional

1507
01:08:11,710 --> 01:08:14,520
and the surgeon to weigh the
risks and benefits of that.

1508
01:08:14,520 --> 01:08:16,450
Surgery data we have so far

1509
01:08:16,450 --> 01:08:20,440
on top surgery for transmasculine
adolescents is reassuring,

1510
01:08:20,440 --> 01:08:22,440
it seems that it improves chest dysphoria

1511
01:08:22,440 --> 01:08:23,760
and in general, functioning,

1512
01:08:23,760 --> 01:08:26,473
but it's an area where the
research is still developing.

1513
01:08:28,910 --> 01:08:31,400
And again, the kids
don't give the consent,

1514
01:08:31,400 --> 01:08:34,770
this is something that I think
people get confused about.

1515
01:08:34,770 --> 01:08:37,190
This is a big problem, in the
Belle versus Tavistock case

1516
01:08:37,190 --> 01:08:40,030
in the UK, they probably
don't have time for.

1517
01:08:40,030 --> 01:08:42,690
But right, except for a few
very specific areas of medicine

1518
01:08:42,690 --> 01:08:46,010
in the United States,
minors don't give consent

1519
01:08:46,010 --> 01:08:47,060
for their medical interventions,

1520
01:08:47,060 --> 01:08:49,090
their parents give consent, they give us,

1521
01:08:49,090 --> 01:08:51,150
and that alone is usually not sufficient

1522
01:08:51,150 --> 01:08:54,160
for a doctor to prescribe the medication.

1523
01:08:54,160 --> 01:08:55,360
There are exceptions, right?

1524
01:08:55,360 --> 01:08:57,760
Like reproductive health
care, things like that.

1525
01:08:58,950 --> 01:09:00,610
But I just wanna be clear about that

1526
01:09:00,610 --> 01:09:01,510
'cause it comes up a lot

1527
01:09:01,510 --> 01:09:03,724
in the political debates in particular.

1528
01:09:03,724 --> 01:09:04,800
But I'm sorry, that was not an answer

1529
01:09:04,800 --> 01:09:05,830
to your question.

1530
01:09:05,830 --> 01:09:06,783
- [Dr. Vito] Thanks.

1531
01:09:10,809 --> 01:09:13,027
- [Dr. Tandoh] Thank you, very, very much.

1532
01:09:13,027 --> 01:09:13,860
- Thank you.

1533
01:09:13,860 --> 01:09:16,860
(audience clapping)

1534
01:09:30,290 --> 01:09:33,160
- I wanna thank you all
for joining us today online

1535
01:09:33,160 --> 01:09:35,033
and also the classes here in person.

1536
01:09:36,232 --> 01:09:38,620
I also wanna thank Dr. Imbasciani

1537
01:09:38,620 --> 01:09:42,200
and Mr. George DiSalvo, again
for the generous support,

1538
01:09:42,200 --> 01:09:44,470
which made this lecture possible.

1539
01:09:44,470 --> 01:09:46,520
And also I'd like to thank Dean Page

1540
01:09:46,520 --> 01:09:50,190
for his ongoing leadership
in the College of Medicine

1541
01:09:50,190 --> 01:09:53,640
and the pursuit of equity and
training of future physicians,

1542
01:09:53,640 --> 01:09:56,095
better prepared to care
for all their patients.

1543
01:09:56,095 --> 01:09:59,460
This lecture was very informative for me,

1544
01:09:59,460 --> 01:10:01,370
and I think it will help me as I take care

1545
01:10:01,370 --> 01:10:03,480
of my patients even as a trauma surgeon.

1546
01:10:03,480 --> 01:10:06,500
So again, thank you all, and stay safe

1547
01:10:06,500 --> 01:10:08,480
and have a wonderful evening, everyone.

1548
01:10:08,480 --> 01:10:11,213
(audience clapping)