- You have an absolutely wonderful lecturer
who's come to you from Stanford.
He is so young and so accomplished
that it makes me feel like an underachiever
and a slackard (chuckles).
And I think the committee that chose Dr. Turban
chose very, very well.
You should all be very impressed by what he has to say,
and he speaks with a lot of commitment
and charity to his patients and not just as a researcher.
So I wish you well, this lecture series was instigated
by my commitment to increasing diversity of all kinds
at the College of Medicine,
which was pretty monochromatic back in 1981 to 1985.
And it's so much, much less so.
I cannot wait, I miss not being in that room with you,
with the dean and all the students and the faculty,
but I promise that for the ninth lecture,
I'll be there next year.
Enjoy the lecture folks, thank you.
- Vito, thank you so much.
And thank you, George, again, for your support.
This year's speaker is Dr. Jack Turban,
a nationally recognized expert on child
and adolescent health, and particularly topics related
to LGBTQ health.
I'm very pleased to welcome Dr. Turban,
and look forward to hearing his talk
about this important topic.
You'll hear more about him in just a few minutes,
I had a very nice chat with him earlier,
and I share with you George, my admiration
for the accomplishments that he's already made
in a relatively short career so far.
I now want to introduce Dr. Margaret Tandoh,
our associate dean for diversity, equity, and inclusion,
and the Larner College of Metta
and the Larner College of Medicine,
and the Richard L. Gemelli MD class of 1974,
Green and Gold Professor of Surgery.
Please join me in welcoming Dr. Tandoh.
(audience clapping)
- Thank you very much, Dean Page,
and welcome to all in person and online.
I wanna thank Dr. Imbasciani too, hi, Vito, thank you.
Hi, George, thank you (chuckles).
I have a script that I have to go by.
Thank you, Dean Page, today, we have the pleasure of hearing
from Jack Turban.
Dr. Turban is a researcher, a medical journalist,
and he's a chief fellow in child and adolescent psychiatry
at Stanford University School of Medicine.
He is coauthor of the book, "Pediatric Gender Identity:
Gender-affirming Care for Transgender
and Gender Diverse Youth."
He has consulted for the US Department of Defense
and major tech companies on issues related
to LGBTQ mental health.
He currently serves on the scientific advisory board
for the Upswing Fund, a collaborative fund created
by Melinda Gates to support adolescent mental health
during the COVID-19 pandemic.
Dr. Turban's original research
and opinion pieces have appeared
in the New England Journal of Medicine,
the Journal of the American Medical Association,
the New York Times, the Washington Post,
and Los Angeles Times.
Vox, Scientific American, Eagles on and (indistinct).
Stats, Psychology Today, JAMA Pediatrics, JAMA Psychiatry,
the American Journal of Public Health,
and the Journal of the American Academy of Child
and Adolescent Psychiatry among others.
Dr. Turban is regularly consulted by the media
to comment on issues regarding child
and adolescent mental health
and topics related to LGBTQ health.
He and his work have now quarter over a hundred times,
four outlets, including NPR's All Things Considered,
The Daily Show with Trevor Noah,
ABC's 2020 with Diane Sawyer, the New York Times, NBC News,
Rolling Stone, the Washington Post, (indistinct), GQ Book,
CBC, and Vanity Fair, among others.
His research has also been cited in major court cases
regarding the civil rights of transgender people in the US,
in state legislative debates around the country,
and in the United Nations Independent Expert Report
on Conversion Therapy.
Now, I would like to introduce Dr. Michael Upton,
who's the chair of the DiSalvo Lecture Selection Committee.
Let me just say thank you to you, Michael,
and the members for choosing
our incredible speaker today, Michael.
(audience clapping)
- Hi, Vito.
- So on behalf of the selection committee,
I'm gonna bring Dr. Turban up here today,
but it is notable this is the first time
that we've had an in-person speaker
since before the pandemic.
And so I'm gonna prepare us for some things
we may have forgotten.
So people have screens open or phones shining in their face.
We can put them down and try to be with each other in a way
we haven't been able to be for a long time.
And try to relax and enjoy this experience,
you're not gonna be tested,
and hopefully, we'll learn something.
There's some impressive data coming up here,
and I think there's things to think about
in the way medicine becomes activists
and defends our patients.
And more importantly, what we all need to dig in
and do all our work on oppression,
and identify the ways of racism,
sexism, homophobia, transphobia,
and other forms of oppression, infect us and our work.
Today, we get to think a little bit about what it's like
for queer people to be in medicine.
And Dr. Turban and I were just talking before we started,
about what it's been like for us, and what it's like,
even for some of you in a relative bubble
at the Larner College of Medicine,
which is a pretty affirming place,
but not more than a few years goes by
that I have somebody come to me and ask,
"What's it really like?
Can you go out and do this, and be out,
and be proud, and be effective?"
And Vito, thank you for leading us in this,
and giving us the opportunity to show you all that
that's true, that you can, to believe in yourselves
to do the work, and to be ready to go out and be leaders
because in a few short years, you could be in a fellowship
and be nationally famous and coming to talk to us.
So without further ado, Dr. Jack Turban.
(audience clapping)
- Can you hear me okay?
So it's my first talk in person in a long time,
and then you guys made me blush a whole bunch.
So I'm gonna try and hold it together,
but thank you to all of you for coming in person,
it's really nice to be around humans.
And I'm excited to talk about this topic and really excited
that you're all gonna learn about it because historically,
I found that it's something that we don't give
enough attention to in medical school curricula.
This is very much just a primer,
but I hope it will spark some interest in the field,
and hopefully get some people interested,
either in research or advocacy
or clinical work in this area.
And I titled the talk, Evolving Treatment Paradigms
for Transgender and Gender Diverse Youth.
And as you'll see,
it's really been a huge shift over the past,
maybe two decades,
and medicine has not such a great history.
So I'll talk a bit about how relatively recently
we've really pathologized transgender
and gender diverse people.
Built structures within psychiatry
and medicine that have caused a lot of harm,
and how people are starting to try
and make more progress towards making that better.
In terms of disclosures,
I received textbook royalties from Springer Nature.
I'm on the scientific advisory board for that general fund
we talked about to support LGBTQ and racial minorities,
mental health for adolescents during COVID-19.
Obviously, an expert witness payments from the ACLU,
Lambda Legal, and Cooley LLP.
I have a pilot research award from AACAP
and their pharmaceutical partners,
including Arbor and Pfizer, the fellowship
from the Sorenson Foundation
and freelance payments from various news outlets.
So objectives for today,
we're gonna go through basically the developmental stages
that are important to think about when thinking
about gender identity development and gender diverse youth.
So first, we'll talk about prepubertal kids,
the youngest kids.
Then we'll talk about the early stages of puberty.
I think you've had your endo module, maybe, like 10 or two.
That's what we're talking about, we'll go through that.
And then we'll talk about gender-affirming hormone treatment
for transgender adolescents.
And if there's time, I also put in some slides
about gender identity evolution,
and we can spend a little bit of time talking
about how in the past people thought
of gender identity is very static.
That's something that develops during this pre-pivotal phase
and then stays the same throughout life.
But starting to challenge that notion
and noting that it's something that can evolve over time
and is much more multi-dimensional
than people have generally thought.
The first, terminology and background.
I like this really cute gender bear.
Thank you, Jacob, for making the bear.
Four concepts that you need to know for this talk.
First, can you see that there?
Yeah, so first is sex assigned at birth, older terms
includes natal sex, we don't really use those words anymore.
In child psychiatry, we often use gender assigned at birth,
and what this is is basically the gender
that's put on a birth certificate
when a baby is born, usually based on external genitalia,
sometimes based on prenatal ultrasound.
This is different from gender identity,
so gender identity is one psychological sense
of their gender, whether that's male, female, both, neither,
or some other gender identity.
For someone whose gender identity is in congruent
with their gender assigned at birth,
they may identify with the term transgender for people
whose sex assigned at birth is congruent
with their gender identity, they may use the word cisgender.
Gender identity is different from romantic
or sexual attraction, those are the types of people
towards whom you're romantically or sexually attracted.
And then a fourth term is gender expression.
So that is the way you present to the world in a gender way.
And some cultures, the fact that I'm wearing a suit,
maybe considered a male gender expression.
If I were wearing a dress that may be thought of
as a female gender expression,
but obviously, these things change over time
and with culture.
One point I wanna make is that sexual
and romantic attraction, generally we use gender identity
as the reference point, not gender assigned at birth.
So a trans woman who's attracted to other women
would likely identify as a lesbian,
but you'll see sometimes in less affirming literature
and older literature that that gets mixed up.
So just keep it in mind if you're doing any reading.
Quick quiz, sorry about it (chuckles).
The colors do not mean anything on these cookies,
I would usually make them for you,
but that is a public health violation.
So could anyone raise their hand and just take a stab
at describing this cookie?
So again, this would be a gender assigned at birth.
This would be gender identity,
and this would be romantic or sexual attraction.
Exactly, I couldn't see who said that, but thank you.
(chuckles) Thank you, could you walk us
through your thought process
just to catch everyone up to speed?
(indistinct)
- Yeah, exactly, thank you.
Anyone have thoughts on this cookie?
Yeah, go for it.
(indistinct)
- Exactly (laughs) this is CIS straight white cookie.
(audience laughing)
- And what about this one?
This is more and more the kind of kids you might meet
on your pediatric rotations.
There's no like, technical one correct answer for this one,
it's more kind of a conceptual thing.
There are no name tags, so I can't call on people,
so it'd be really nice if someone, say that again.
Yeah, so pansexual queer person.
This is just to point out that none of these dimensions
are necessarily binary.
That you can be attracted to both men and women
or any other gender identity or gender assigned
at birth, et cetera,
in terms of sexual or romantic attraction.
And gender identity, for a lot of people,
is not male or female, maybe non-binary or gender queer
or gender is neither genders.
And also a lot of young people are figuring it out
because it's really complicated, right?
So gender identity can involve the way you think
about gender roles, the way you think about gender norms,
the way you relate to your body.
There can also be the kind of like this transcendent sense
of your that is hard to put into words.
And just to say,
it's not the simple way that a lot of people think about it.
Unfortunately, gender diverse kids have really high rates
of psychiatric morbidity.
So rates of mood disorders, mostly depression
rather than bipolar disorder are much higher
than the general population, depending on the study,
as high as 64% of these kids.
Anxiety disorders are also really common up to 55%.
And when we look at the greatest predictors
of mental health problems for these kids,
they tend to be family rejection,
peer rejection, or some sort of societal stigma.
And that stigma is really substantial,
and you can see the rates of bullying are as high as 80%
for these kids.
And unfortunately, because of these high rates
of internalizing psychopathology,
that's just a fancy word for anxiety and depression,
we see high rates of suicidality.
So in this graph, two lines,
the black line each, dot is a different study
of gender diverse youth with a different mean age.
And the gray line is the US average for those same ages.
And you can see there's a higher prevalence
of lifetime suicide attempts at pretty much every age
for gender diverse people.
And that seems to increase during adolescence
and early adulthood.
I'm sorry, this is a little blurry.
So the predominant framework for thinking
about mental health disparities among LGBTQ people broadly
is the minority stress framework.
Can I see a show of hands of people who have heard of this?
Okay, decent number.
So it was first described for lesbian, gay,
and bisexual people by Elon Meyer at UCLA,
and later adapted to be gender identity
minority stress model for gender diverse people,
and that's the one I'll talk about now.
The point of this model is to describe the ways
in which societal stigma negatively impacts
both mental and physical health.
And there are two ways in which that happens,
there are two categories.
So the first are these distal stress factors.
You can think of these as like external factors
that impact health.
So that's things like discrimination based on being trans,
gender-related rejection, physical victimization,
other types of victimization, and non affirmation
of gender identities or refusing to use someone's name
or pronouns or accept someone
for who they say that they are.
We've had a lot of distal stress factors recently, right?
So in the media, we've seen politicians say that trans youth
are a risk to their classmates on sports teams,
that they are risks to people in bathrooms,
they're gonna sexually assault people.
That their medical care should be taken away,
that their identities are invalid
and they're just confused.
You can imagine how those things are gonna make
people feel more depressed or hopeless.
Impact self-esteem, become more anxious
that they're gonna be harassed about things.
And the thing that was more novel
about the minority stress theory was
that these distal external factors
can become internal factors.
So if you're constantly hearing negative messages
about your demographic on TV, you might start to think like,
"Maybe I am a threat to my classmates.
Maybe I am a threat to people in the bathroom."
Like, "Maybe my identity is invalid."
And you may on a conscious level know that's not true,
but over time, those things can kind of steep in
and become like a really painful thought in your unconscious
that drives anxiety and depression.
Another thing that happens is you might start
to expect negative things to happen in the future.
So similar to what you may have learned in your lectures
on psychological trauma, if you've had a lot of experiences
where bad things happen to you for being trans,
you're gonna expect that's gonna happen again in the future,
and it can be really hard to know
when you enter a new situation,
what your level of risk is, 'cause you're often gonna feel
that it's very high, and that of course, drives anxiety
and can drive hopelessness, which can lead to depression.
And then concealment is the final proximal stress factor.
This is when one starts to hide their identity,
which can lead to a lot of shame and also its problems.
There are also resilience factors,
so things like connecting with the community,
people who are like you can buffer against some
of these problems, and also developing pride
in your community, and realizing that trans people
have made major contributions to society,
and that you may be part of this really great community
that's on great things in the world,
which can buffer against some of these negative,
external factors that may become proximal.
I think it's really important to have the voices
of trans youth themselves in these lectures.
So this is a focus group that we published in 2017 in JAACAP
from a bunch of transgender adolescents,
and the top 10 things they said
they wanted their doctors to know.
And since you're about to be doctors,
here's what they want you to know.
Its number one,
gender and sexuality are totally different things.
So they said that a lot of times doctors would assume
their sexual orientation based on their gender identity.
So they would say, you know,
just because I'm a transgender woman,
it doesn't mean I'm attracted to men,
and please don't make that assumption
and ask me if it's relevant.
Also don't ask like weird, creepy questions
that didn't make it on the slide, but it's a big one,
like, ask what's relevant.
Second was that non-binary people exist,
so a lot of people in older generations
have really been socialized to think of gender identity
as male or female, sexual orientation is straight or gay,
but a lot of people don't experience it that way.
Names, pronouns, and gender markers are important.
Number one, just because these adolescents
are self-actualizing in their gender identities
and want to be respected for that.
And they've often had bad experiences
with people not using their names and pronouns.
So let's say you use the wrong name or pronoun,
all of a sudden, you might be like their parent
that kicked them out of the house, right?
And told them they had to live on the street.
Or you might be the high school bully who threw them
into a locker and use slurs against them
and wouldn't use their name.
And so taking that context into account is important.
Another quote, "If I'm depressed or anxious,
it's likely not because I have issues
with my gender identity, but because everyone else does."
Pointing out that a lot of times these kids are not confused
about their gender identity.
Like, they know who exactly who they are,
and that's not why they're coming to you.
They might be coming to you because they want support
or they want help with, you know,
the environment around them
that's making their lives more difficult.
And to let them know that you're on their team.
So a lot of these kids have spent a lot of their lives
surrounded by people who are not on their team,
who are not accepting them, and to hear that there's someone
there who's really gonna fight for them
and fight for their gender identity and to be who they are
makes a big difference.
Here, we're gonna get into some boring stuff, I apologize.
So I want to go through the data in terms of what we know
about how to best support kids
at different developmental stages.
So we're gonna start with prepubertal kids,
and then go into early and late adolescents,
and I have till 6:30.
Okay, I'm going to keep watching my clock.
Okay, so three approaches have been described
for prepubertal kids.
I'm putting them all up here,
and I want to be really explicit in saying that one
of these models is illegal in many US states,
and not recommended,
and all major medical organizations argue against it.
However, it has been around up until pretty recently
from some pretty high profile people,
so that's why it's on the slide.
And that model is the living in your own skin model,
it was popularized by Ken Tucker who's
at University of Toronto, or was.
He also chaired the DSM-V committee that made
the diagnosis gender dysphoria that you may have heard of.
And what this is, is basically doing
psychotherapeutic interventions to push transgender youth
to identify as cisgender,
which many people would call conversion therapy.
I generally will call it conversion efforts,
pointing out that it's not therapeutic,
and we'll go through some of the research that shows
that it's associated with dangerous mental health outcomes.
But given that it's been talked about so recently
in a pretty high profile way,
and still some people are talking about it,
I wanna make sure we at least discuss it
and then you can ask questions about it.
Opposite end of the spectrum
is the gender affirmative model.
This is what most people in the United States practice,
it was popularized by Diane Ehrensaft.
And what they say is don't try and force a child
to be cisgender because that can instill shame,
damaged relationships between the therapist and the child,
damaged relationships between the parents and the child.
And also separate from that, if a prepubertal child wants
to go through a social transition,
so taking on name, pronouns, gender expression,
that matches their gender identity,
you should let them do so,
because if you place limits on that, all the same things,
instilling shame, sending this message
that being gender diverse is wrong, et cetera.
That under the minority stress model would be expected
to cause problems.
Third model is the watchful waiting model.
This is what's described by the Dutch Group in Amsterdam.
They were the first people that ever used puberty blockers
to give you a sense of how important
they've been in this field.
And what they say is don't do any conversion efforts,
don't try and push the prepubertal child
to identify as their gender assigned at birth,
but also tell them to wait to socially transition
until they reach puberty.
This is a little confusing, but it boils down to two things,
number one, do you practice conversion efforts?
And number two, if a prepubertal child wants
to socially transition, do you facilitate that?
A little bit of background on why there's this fighting
is there something called the quote, assistance literature.
So this is a number of studies where they looked at kids
who were referred to gender clinics,
very young prepubertal kids.
And they followed them longitudinally,
and they found that in adolescents and young adulthood,
most of them did not identify as transgender.
And so you'll often hear that this kind of statistic
that 80% of prepubertal trans kids are gonna change
their minds, identify as cisgender later on in life.
That is not the proper way to interpret those studies.
So these were kids who were referred to gender clinics,
but they didn't establish that these kids
were actually transgender.
So a lot of the kids may have been referred
because they were cisgender kids
who had gender typical interests, right?
So cis-gender boys who liked dolls and dresses
or cisgender girls who all we think of as like tomboys,
for lack of a better word.
And in fact, when you look at the studies,
large numbers of those kids
didn't meet criteria for the diagnosis at the time,
which was gender identity disorder.
Some of them did, but it's important to also note
that that diagnosis didn't require you
to identify as a gender different
than your sex assigned at birth.
And it was largely based on gender roles and gender norms.
So again, even those kids may have been cisgender kids
who just express gender behavior
that wasn't expected based on societal norms.
So in the US, we don't put a lot of weight on those studies,
but they are often used when we're talking about this.
We don't have great studies following prepubertal kids
longitudinally to see how flexible
or dynamic their identities may be,
but it raises other questions, right?
Does it even matter?
If a kid at this point in time wants
to express themselves in a certain way,
even if they are gonna later express themselves differently,
telling them they can't do that,
and instilling shame could still be dangerous.
So in general, long story short,
most people in the US practice gender affirmative model,
that's what is endorsed by pretty much
all major medical organizations right now,
so no conversion efforts.
And if a child wants to express their gender identity
in a way that is not expected based
on what is generally societaly expected,
that we would let them do.
Let's go through the data, so question number one,
early social transitions.
This question is, do you allow a prepubertal child
and facilitate them socially transition or not?
We don't have a ton of data,
this is pretty much what we have.
So going from left to right,
those are increasing rates of anxiety and depression.
Green is the pre (indistinct) or like the normal range,
orange is the preclinical range,
and red is the clinical range.
And we have three populations of kids.
So kids from a Amsterdam clinic,
where they tell them not to socially transition,
kids from a Toronto clinic,
where they tell them not to socially transition,
and then kids who were recruited by Christina Olson
at Princeton who had socially transitioned
and were in the US.
And as you can see, the kids who were allowed
to socially transition have developmentally normative rates
of anxiety and depression,
and the kids who were told they can't socially transition
are on average in the preclinical pinch.
These are imperfect comparisons, right?
You're not randomizing kids to these three groups.
They're kids from three different countries.
We can get in some more of the details
that people are interested,
but I think what we can definitely conclude from this
is that a prepubertal social transition
at the very least is not dangerous.
The kids who do that are doing exceptionally well,
particularly if you're working with the community
to make sure that they're gonna be affirmed
and supported and not bullied.
Second question is conversion efforts.
So this is a study we published in JAMA Psychiatry.
We used a survey over 27,000 transgender adults,
and we looked at only those who had ever spoken
to a professional about their gender identity, right?
So we didn't look at people
who didn't get any therapy at all,
'cause some people would argue that if you're referred
to therapy, you may be more mentally ill broadly, right?
That's been a problem with trans studies.
So just people who had ever spoken to a therapist
about their gender identity,
and then compared those whose therapists tried
to make them cisgender to those whose therapists didn't.
And what we found was that people exposed
to these gender identity change efforts,
so trying to force them to be cisgender had a higher odds
of almost every adverse mental health outcome
that we looked at.
And you can see those on the slide.
So greater odds of past-year suicidal ideation,
suicidal ideation with plan, lifetime suicide attempts,
past-month severe psychological distress.
And this was after adjusting
for a wide range of potential confounders,
including family support for gender identity.
The impact was even more dramatic
if people said that they were exposed
to those conversion efforts during childhood.
So during this prepubertal phase that we're talking about,
for people who are exposed during childhood,
they had a four fold adjusted odds ratio
of lifetime suicide attempts.
And you can see there's almost a dose response curve
in the data.
So this is a therapy without conversion efforts.
This is if you were exposed to conversion efforts
at some point in your lifetime,
and this is a few were exposed during childhood.
And this seems to suggest that that earlier exposure
and most about comes has like a dose response
with it being dangerous.
So not only does it seem that conversion therapy
is linked to bad outcomes,
but that doing it for the prepubertal kids,
which is the one place that people are advocating
for doing it, is actually the most dangerous.
From the data we have their imperfections, right?
There's no direct comparisons of these three approaches.
You're not randomizing kids to these different conditions.
We talk about this more at the end, the limitations,
but all data we have suggests
that conversion efforts are dangerous,
and social transition generally seems to lead
to good mental health outcomes, at least in the short term.
Despite this, conversion efforts are still legal
in most US states.
So here you can see this tan color,
those are states that have bans on conversion efforts.
These light tan states are states that do not have bans.
It seems that gender identity conversion efforts
are pretty common experience among trans adults in the US.
This is a study we published in American Journal
of Public Health, and you can see 13.5%
of trans adults report that they were exposed
to conversion efforts at some point in their life.
And there is some geographic variability
and where that seems to be most common.
And this is potentially an active legal question,
so two federal appeals circuits have ruled
that conversion therapy bans are constitutional.
Recently, two Trump-appointed judges ruled
in the 11th Circuit that conversion therapy bans
are a violation of professional free speech,
and are unconstitutional.
Interestingly, in their decision,
they acknowledged that all professional organizations
have said that conversion therapy is dangerous,
both for sexual orientation and gender identity.
However, they say that the American Psychiatric Association
is essentially too capricious for them to trust
because they once said homosexuality was a disease,
and now they say that it doesn't.
So their argument is basically that they might change
their mind about conversion therapy as well,
which is obviously a very dangerous argument
and an easy way to throw out kind of all medical evidence.
Now that there is this split between the two circuits,
there's a possibility that this could go
to the Supreme Court and what the current composition people
are concerned about what the outcome could potentially be.
It's three people, children.
Next, we're gonna talk about early adolescents
and pubertal blockade or suppression.
I'm sorry, this is another boring part (chuckles)
but review of little bit of basic science.
So during the prepubertal phase,
your hypothalamus releases GnRH at this low level, right?
Once you get to early to mid puberty, you get little pulses,
and by mid to late puberty,
you have this nice sinusoidal release.
You need that sinusoidal pulsatile release
in order for the pituitary to make FSH and LH,
which you need to make estrogen and testosterone.
Puberty blockers are confusing
because they do not block GnRH,
they're actually GnRH agonists,
so they activate the receptor.
And essentially, what they do
is they make this tonically high.
And when it's tonically high and not pulsatile,
the pituitary will not make FSH and LH,
which means you won't make estrogen or testosterone.
If you remove the drug,
which is either a depo injection or a subcutaneous implant,
that pulsatile nature comes back,
and indogenous puberty proceeds.
So in that sense, puberty blockers are reversible.
And most clinicians think of them as a way
to buy adolescents more time to decide
whether or not they want to go on to the next step
of gender-affirming hormones like estrogen
or testosterone, without developing
irreversible secondary sex characteristics,
which are irreversible, right?
So by not doing a puberty blocker,
you're putting something in process that is irreversible.
Whereas the puberty blocker itself,
you can reverse by stopping it.
These medications have been used
since at least the 70s for precocious puberty,
that is their original pediatric indication.
They do not have an indication
for gender-affirming medical care,
mostly because that's clinical trials to be very expensive,
and there's not a great incentive
for pharma companies to do them.
However, they started being used off label in Amsterdam.
Amsterdam is very pretty.
This was their landmark case report
that they published in 1998.
It was about a young transmasculine person
who had severe gender dysphoria and suicidality due to it.
They gave this patient pubertal suppression
followed by testosterone treatment
and gender-affirming surgery.
And in adulthood, that person
had very positive mental health outcomes.
We talked about this, these are the different ways
you can give puberty blockers.
Again, either a depo injection or the subcutaneous implant.
The implant is marketed to last a year,
it often last around two years.
And this is the data that we have
about the impact of pubertal suppression.
So you can see there have been a bunch of studies,
most of them are longitudinal cohort studies
that have largely found lower depression
and increases in global functioning, less suicidal ideation,
less internalizing psychopathology,
so that's anxiety and depression kind of composite score.
And there've been two comparative studies,
so one was ours where we looked at people
who ever desired pubertal suppression.
These were adults, and we said okay just
to people who ever wanted puberty blockers.
Let's compare people who got them
to people who couldn't get them.
And people who got them had lower odds
of lifetime suicidal ideation.
There was another study from the Netherlands
where they compared people who had gotten puberty blockers
to people who were presenting
for the first time asking for them.
And they found that those who had gotten them
had lower rates of anxiety and depression.
Again, no like randomized controlled trials,
and it's probably not something that's going to happen
given that we have so much data showing that
from these longitudinal studies,
that it seems mental health improves.
The most (indistinct) is considered unethical
to randomize people to a control (indistinct).
One thing that someone could do,
is there any budding researchers?
Is there a waitlist control?
So the unfortunate reality is that a lot
of clinics have very long waitlists,
so you can compare people who are on the waitlist
to people who are receiving treatment,
and that might be a better comparative study.
These are things I'm gonna save for the questions.
Next is gender-affirming hormones.
So traditionally in the old endocrine society guidelines,
these were not a possibility until age 16.
So that's the age when adolescents might consider starting
estrogen or testosterone to induce physical changes
that align with their gender identity.
However, the new under consignee guidelines say
you could consider these as early as 13 and a half,
and generally, that's not to be in cases
that are relatively straightforward.
Often kids who socially transitioned very young
had been on puberty blockers for a long time.
Well, it makes sense to keep them on a puberty blocker
for a long time, that risk is, risks bone health.
Also, a lot of adolescents will say
that they don't like that all their peers are going
through puberty, and they're not,
that can be socially stigmatizing and uncomfortable.
But the 13 and a half age is interpreted different ways
by different clinics.
Main things to think about are that estrogen increases
your blood clot risk from the studies we have,
and they're not great.
It doesn't seem there's a huge increase in blood clot risk
for people who are taking estrogen
for gender-affirming medical care
at the doses that are generally prescribed.
However, always counsel patients on the potential risk.
And you may encounter a lot of patients
because like I was saying, the waitlists are so long
and it's so hard to access care
that many patients may get the hormones off the internet
or the black market,
and they may be taking doses that are higher
than one would generally take.
They may not be monitoring their levels,
so they may be at a very high risk of PE, DVT stroke,
particularly if they're smoking.
Testosterone can increase your red blood cell count.
And I put on these tables of the general physical effects
that you get from estrogen and testosterone,
but these are in the endocrine society guidelines
that you can look up if you want to read them
in more detail.
Once again, the data.
So again, we have a lot of longitudinal cohort studies
that generally show an improvement in mental health,
decreasing suicidality, improved quality of life,
decreases in anxiety and depression, et cetera.
There have not been any comparative studies published,
so comparing people who access for months
to people who haven't.
We have a paper under review now,
where similar to that people's depression study.
We looked at people who ever desired gender-free hormones,
and then looked at people who got them
versus people who weren't able to access them.
And people who were able to access them had lower odds
of past-year suicidal ideation,
and past-month severe psychological distress.
This was true, whether they access them as adults
during the age group
from the old Endocrine Society guidelines of 16 to 17.
Also, the expanded age group
in the new Endocrine Society guidelines, 14 to 15.
And then put it on this slide,
but we also compared people who access hormones
during adolescents to people who weren't able
to access them until adulthood.
And people who access them during adolescents had lower odds
of suicidality and severe psychological distress.
Well, we did well on time, unexpected.
Okay, so we have a little bit of time
for talking about dynamic gender identities.
So what you will probably hear in your psychology class is
that gender identity children identify their own gender
at age three.
They can identify that gender doesn't change over time
around age three or five.
(indistinct) these are from small observational studies
of cisgender youth,
and aren't really very quantitatively kind of thing.
And the research for gender diverse youth might end up
being a little bit different.
We talked a little bit about those desistance studies
and the problems with them.
I will say that the studies we have of trans adolescents
who have started, who've presented to clinics asking
for say, pubertal suppression, it seems pretty rare for them
to identify as cisgender in the future.
So a small number of them, like on the order
of one to 2% may choose to stop the puberty blocker
and not go on to gender-affirming hormones.
But it doesn't seem that there are a sizeable number
that come off the hormones or regret the hormones.
And a lot of times,
what is most commonly seen is adolescents may identify
as trans in a binary way,
and then later identify as non-binary,
and then may choose to stop hormones, which again,
won't necessarily be linked to regret about the hormones.
And some kids will say that the hormones
really were necessary for them to consolidate
and understand themselves.
That being said, there are a very small number of patients
who start hormones and do later regret some
of the irreversible physical changes.
And so that's part of the informed consent process
when we talk to families.
But what you're doing is weighing the potential benefits,
providing the therapy with this unlikely potential harm.
And in most cases, the benefits outweigh the risks,
but it's something to talk to families about.
We published this paper in JAACAP about thinking
about dynamic gender presentations,
or dynamic gender identities.
And we talked about if a patient comes to you saying
they wanna stop hormones, or their gender identity
is changing in some way, then you can use this framework
of thinking about internal and external factors.
So internal factors are things like your gender identity
has evolved and changed,
or you're feeling unsure about your gender identity.
External factors are those things we talked about before.
So you're being mistreated at school,
your family's rejecting you,
you're being harassed or discriminated against
in your community, et cetera.
And those external factors could be what's driving
someone's desire to present again as cisgender
or stop medical interventions,
and it's important to counsel them on that
'cause some of those things might be modifiable, right?
That if it's a family problem,
you could do family therapy.
If the school is treating this child
in a way that's not affirming,
you could work with the school
to create a safer environment, et cetera.
To complicate things further,
it's important to keep in mind the external factors,
as we know from the minority,
stress theory can become internal factors.
So when you're sitting with a cat,
it can be hard to tease out,
but worth trying to see that if they're feeling confused
about their gender identity,
how much of that is coming from an internal place
versus how much of it may be that they're internalizing
stigma that they're hearing in the news
or media, families, communities, et cetera.
Just to highlight that this is a study we published
in LGBT health, where we asked
those same 27,000 transgender adults,
"Have you ever de-transitioned at some point
in your life, broadly defined?"
13.1% of them said they had at some point.
So it seems, this is not an uncommon experience
that trans people will de-transition largely
because of some external factor.
So 82% of them said it was one of those external things
like family stigma, societal stigma,
lost health insurance coverage,
military forced them to de-transition, all kinds of things.
So when you're sitting with someone who says
they're transitioning, quote, unquote,
just keeping in mind that that doesn't mean their identity
will evolve for their expression will evolve again
at some point in the future.
This is the table of the reasons
that they gave for why that happened.
And just some of the qualitative quotes, so,
"I live in a very conservative place
and was afraid for my safety."
A lot of people talk about moving,
so they might start hormones in a city where they feel safe.
And then maybe you have to go back and take care
of a family member who's sick or move somewhere for a job,
and then feel that they're forced to de-transition.
Similarly, "The military forced me
to de-transition on service."
Or, "School staff harassed and abused me daily
for my gender expression."
In child psychiatry, you'll see this a lot.
Otherwise, those who may live in a pretty affirming place,
then maybe haven't even experienced
a lot of transphobia per se,
and then you move somewhere or start a new college,
it's a very different social environment
and it can be difficult to manage.
Of course, there are data limitations with this,
so I just wanna clarify these are transgender adults.
So anyone who de-transitioned
and then identified as cisgender would not be in the study.
And there's no published peer review literature
about adolescents who de-transition
and then identify as cisgender,
but based on what we know so far, it seems uncommon,
but it could be that there will be
more emerging literature about that in the future.
This is an interesting read from Slate.
So this is about somebody who transitioned,
had medical interventions and then stopped
those medical interventions and de-transitioned,
and actually became a pretty prominent activist,
arguing that gender-affirming medical intervention
should not be offered to minors.
And then later, came out and wrote this article
and said that they felt that actually they had been
indoctrinated into that idea by a group
of trans exclusionary, radical feminists,
who kind of convinced them that a trans masculine identity
was just a manifestation of internalized misogyny,
and that, you know, they felt that
they got good community there,
firms that worked for them,
that de-transition identity, but then their gender dysphoria
towards their body continued,
and then eventually, they re-transitioned.
So I only bring this up to keep in mind of that interplay
between internal and external factors,
that can be extraordinarily complicated.
It may take time to sort out,
but I think at the end of the day,
when you're working with patients,
you just need to tell them that you are a safe place,
it's the right time to evolve in any way,
and you're gonna support them no matter what.
And there's no like bad outcome from your mind
to like you're gonna be there to support them.
But of course, these de-transition narratives
have been widely politicized.
You may have seen that over 20 bills were introduced
in state legislative sessions last year,
that would have banned gender-affirming medical care
for trans adolescents.
None of them passed, thankfully, except for two.
One was in Tennessee, where they banned
gender-affirming medical interventions
for prepubertal children,
which you now know is not something people do anyway.
So that was largely symbolic
and does not impact care in the state.
However, in Arkansas, the state legislature passed a bill,
the governor vetoed it,
the state legislature actually overrode the veto,
and so it would have become law
if not for the ACLU filing a lawsuit.
And a preliminary injunction was issued,
so that bill is not active.
So right now, there are no active bans
on gender-affirming medical care
for trans adolescents,
but it's likely these bills are gonna come back
in a big way next legislative session,
so that's why I'm glad we were talking about all of this,
so you can know the data, look it up,
and hopefully, advocate as these things start
to come up in state legislature's next session.
This is an article we have in JAMA that provides
a lot of information about why what's contained
in those bills, it's inaccurate.
So take home points, gender identity and expression
are not always static for all people.
De-transition and gender identity evolution
can be understood using this framework
of internal and external factors.
It's important to think about whether
or not external factors are driving internal factors.
And these identities have been highly politicized,
and we need to focus on providing the best care to patients
while advocating for accurate public discourse
about these questions.
Okay, time for questions,
I do have appendix slides about hot topics (chuckles)
people wanna talk about them.
But thank you for dealing with me talking really fast,
I wanna make sure we got everything.
(audience clapping)
(indistinct)
- [Participant] Hi, for the prepuberty blockers or sorry,
puberty blockers, how long, what is the timeframe
for using a puberty blocker before starting
either hormone therapy or reversing
and stopping the puberty blocker?
Like, how long do you have
to use a puberty blocker and wait?
- This is an area of somewhat ongoing controversy.
So what people worry about with prolonged
pubertal suppression is that you need estrogen
or testosterone to induce bone mineralization.
So while you're on the blocker,
you're gonna fall behind on bone age compared
to age matched peers.
The clinical significance of that is somewhat unclear.
So there was a really great perspective published
in pediatrics, where they talked
about a non-binary adolescent
who didn't wanna start hormones,
and they didn't want to come off the blocker.
They calculated, say like the five to 10-year fracture risk,
was really low on the order of one to 2% of doing that,
but they're based on adult calculators
because this isn't something we think
about for adolescent patients,
so it's not hard to figure out.
Most providers will want somebody
to start gender-affirming hormones around age,
like 16 to 18, and won't want people
to be on the blockers for much longer.
That being said, there's interesting science
you could do here.
You could use like a selective estrogen receptor modulator
that would mineralize the bones,
but not induce other secondary sex characteristics.
But that's not something people have done in large numbers,
but maybe something that's coming in the future,
particularly, because more and more,
we're seeing non-binary patients come to clinics.
And like you're saying,
they don't necessarily want to start the hormones.
- [Participant] Hi, so I think a lot
of these research studies to a trans person sort
of feel like pretty obvious, like of course,
like anxiety goes down
when gender-affirming care is available.
Like of course, that, you know, someone's ability
to continue to transition is probably due
mostly to external factors.
So my conversion therapy is bad?
Right, yeah (chuckles).
So I guess I'm curious, like,
how do you balance the need for research that is required
to justify gender-affirming care from like a political
and like a insurance standpoint versus the need for research
that would affect a trans person's visit
to the doctor's office?
- Yeah, I think it's hard,
I think we need both, unfortunately.
Ideally, we would live in a world where we didn't have
to prove things that were obvious.
I totally hear that most of my work is proving things
that are largely obvious (chuckles)
but at the end of the day,
there are powerful politicians and people who are willing
to serve as expert witnesses to go out and say like,
"No, actually, gender-free medical care makes
people's mental health worse."
You know, they'll cite that Jane study,
and plus one, you know,
as a study where they used a registry
of people who got gender-affirming surgery, and they said,
"Look, after the gender-affirming surgery,
these people had higher rates of suicidality
than the general population."
Like, "Gender-affirming medical care should be banned."
It sounds good, right?
Like convincing now.
So their mental health improved actually before
and after the surgery, but you can't use
like cisgender people as the comparison group
for transgender people who have had surgery,
because they're still dealing with all
of the societal stigma that we talked about.
But the problem is, there's so many people trying
to make conversion therapy legal and practice it
and ban medical care that we get stuck doing a lot
of this research that feels obvious,
which is understandably really frustrating
to like the trans community.
Like, why are you wasting your time on this stupid stuff?
But that's the reason, I think the good news is there's more
and more research interests, so there are people
who are doing things that are more useful, if you will,
like they gave out, can we use like SERMs
to prolong pubertal suppression for non-binary kids?
Like what fertility options can we use for people
who do want to have biological children?
How do different, like hormone regimens change
side effects and outcomes?
So luckily, more of that research is being done,
but I hear you totally,
that we do a lot of research that oops, maybe obvious.
- [Participant] Hi there, thank you for coming.
I have a question as all of us, our future positions,
but those of us who are looking to go into family practice
and maybe are from more rural areas,
I'm Keen, moved here from Montana,
which was bright red and one of those maps.
So how, in your research and your work with this population,
how do physicians go about signaling in an area
that might be more rural, more conservative,
that they are someone who can be spoken to,
or kind of how do people, how do you go about starting,
not even starting that conversation,
but just signaling that you're open to that conversation
if you do live in kind of a more conservative location,
that folks might not expect?
- One really easy thing you can do is join
the World Professional Association for Transgender Health.
And they actually have a provider database
that you can put yourself on, so people in your area,
they can go and search like,
"Is there a family medicine doctor who at least
is interested enough in like, my health care
that they put themselves on this database?"
So that's one, and there are a lot of things you can
do in your office, right?
Like, flags posters, try and do a good job
with your medical records to make sure you're not
misgendering people (chuckles) doing a good job
with your letters to not be misgendering people.
It sounds like your question is more
to get them in the door, I think the useful thing is
to be on some of those websites.
And a lot of local places will have referral networks.
So in my area, we have something called Mind the Gap.
That's a consortium, people who work
with gender diverse people.
And so word gets around that you can call this organization
and they'll tell you people in your area.
- [Participant] I think, well, hi,
thank you for coming, right over here.
- I can tell it's coming from there.
(audience laughing)
- [Participant] So I kind of had a more question
in regards to the blockers.
Aside from the bone density, has there been any studies
in regards to like the long-term effects of being,
'cause I know you said they're reversible,
but if we're gonna be providing these services,
and in regards to the informed consent and everything,
has there been any studies in like long-term effects?
And if so, has anything come of it?
- Yeah, so here's what you can say,
they've been used for precocious puberty
since the 70s, and there's been post-marketing surveillance
for pediatric populations in particular since then.
No big red flags have come up.
There have been studies of fertility
after pubertal suppression for people who took them
for central precocious puberty,
and it does not seem their fertility has been impacted.
Another question that's come up is cognitive impact.
The studies we have so far suggest
that it doesn't impact cognition,
at least on executive functioning tasks
in particular for adolescents.
I think the thing that's tough here, right,
is politically, people have asked questions of these drugs
that are not asked about any other drugs, right?
Like, I've never had someone come up to me and say like,
"Can you tell me how Prozac will impair
the Wisconsin card sorting test in 10 years?"
But people ask me that about puberty blockers all the time.
At the end of the day, no medication
is without risks and benefits,
there are certainly gonna be unknowns
about pubertal suppression.
While we know as they've been used since the 70s
for precocious puberty, those people have done well.
Specifically, we've looked at fertility,
executive functioning, and bone density that does seem
you fall behind on bone density,
and that's an important thing to think about.
- [Participant] Awesome, thank you.
- We're gonna peek
through online (indistinct).
Okay (indistinct).
Yeah.
(indistinct)
The questions are here, okay?
- First question from Andy is,
is this meeting accessible by phone?
(audience laughing)
- (laughs) Sorry, I don't know.
Okay, next question is from Nick Lemon,
"How do you approach conversations with hesitant
or non-supportive family members who have not been privy
to the internal experiences trans youth go through
as they determine their gender identity
and decided like, to transition?"
Obviously, a very important question.
What I think is really important is that parents
have a space to process away from their kids.
There are a lot of common things that come up for parents.
And it's usually transient, you know,
they'll have thoughts like,
"Oh, I miss the daughter I thought I was gonna have."
Or, "Oh my God, I put so much thought into that name."
Or like, "I'm really worried about my child's future."
Things that a lot of parents are gonna think.
Also things like, "Is it a phase?"
But not things you want the kids to hear.
Because if that kid does grow up to continue
to identify as trans,
like those small comments are the kinds of things
that stick in someone's head
and impact self-esteem, anxiety,
depression, relationship with parent for a long time.
So I think if you notice that some of that stuff's starting
to bubble to the surface in front of the kid,
see if you can pull the parents aside and be validating.
And be like, "I can understand."
Validating is different than agreeing,
big thing you learn on your psychiatry rotation.
But you can say, "I can understand
why you would have these thoughts and feelings.
I am worried about the impact that can have on your kid.
So I'm not telling you what to think or feel,
but can I please work with you to find a space
where you can explore this in a way
to really make sure you understand your own thoughts
and feelings before expressing them to your child?"
And I think that can, a lot of parents kind of say yes,
as long as you're being validated.
One thing that you sell about puberty blockers
is in many ways, it's, you kind of talk to parents
about delaying a decision, right?
Because if you don't do the puberty blocker,
you're making a decision like you're putting that kid
through indogenous puberty.
That's not reversible, whereas the puberty blockers,
it's to me, more time to decide.
There's a book that's a good example about this,
we reviewed it for JAACAP called "Found in Transition".
And it's written by a mom who's like a liberal pediatrician
in LA, but liberal pediatricians
in LA can have like transphobic thoughts, right?
This is not something unique to like social conservatives.
And she talks about a lot of these ideas
that she went through.
And I think it's a great book to give to parents,
'cause they can kind of go through that journey with her,
and at the same time, not a great book to give to kids.
'Cause they're ideas that will stick in their minds,
it kind of impacts them.
Parents' support groups can be really great.
A lot of areas have them 'cause there'll be parents
at different stages
of their kids coming out and transitioning.
It could be helpful just to have another parent who's gone
through something you've gone through.
Maybe has had the same thoughts you've had,
who can validate and help you understand
how things evolved for them at least.
(indistinct)
- Trying to decide then the best one.
So none of these are short ones.
Okay, let's just do maybe this one,
"How do you feel about people who choose to raise their baby
with a non-binary gender identity from birth?"
It's a thing we do in the Bay Area sometimes.
(audience laughing)
- So I think this gender neutral parenting idea,
I don't see any inherent harm in it.
Obviously, the nice part about it is you're not forcing
any gender norms on the child.
I don't think it's so much that you're like raising
a non-binary child from birth, so much as you're creating
a space where you don't force anything on the kid.
Let your kid, if your kid goes and wants to buy the unicorn
and you know it's a reasonable time
to buy a unicorn you can afford, buy a unicorn.
So I don't think it's so much about creating,
you're not forcing a non-binary identity,
you're not forcing the kid of a certain identity,
but just letting the child explore.
There's this other question of some technicalities
where you have to do things,
so some parents will choose to use pronouns
that are thought of as non-binary,
may use the them pronouns for their child
until their child says, "I wanna use these pronouns,"
I see no inherent harm in that.
I think what you'll hear people concerned about
is that they're worried that
if you affirm a young person's nonsense identity,
that you're like making them more likely to grow up
to be trans, a lot to unpack there.
Number one, it's not a bad thing to grow up
to be trans, don't be a jerk.
Number two, that's not true scientifically.
So Christina Olson from Princeton ran a study
where she looked at prepubertal children
who socially transitioned to see if their degree
of gender and congruence between self and gender identity
was more after a social transition,
and she found it was not.
So it doesn't seem that affirming someone changes
their gender identity, at least in that study.
She even did measures of implicit gender association.
So I don't know if you've seen those implicit association
tasks to see what your subconscious is thinking basically,
but she did that with self in gender,
and it didn't seem that social transition
made that more dramatic, but rather,
the people who go on to socially transition to begin with,
had a greater degree of incongruence
between their sex assigned at birth
and their gender identity.
So I hope that answers the question.
(indistinct)
- [Participant] Yeah, thank you.
Thank you so much for your talk,
I was wondering, in bringing up legislation that happen
to block evidence-based practice,
I was wondering if you had any advice for physicians
interesting in advocating for evidence-based medicine,
especially if it's politically charged,
not just in the clinic, but in the greater political sphere,
as well as to either counter these attempts
or right protections for these into law.
- Sorry, could you repeat the last part?
- [Participant] If you could trying to advocate
for evidence-based medicine,
especially if it's politically charged,
not just in the clinic,
but in the greater political sphere to either counter
the legislation or to also try to write protections
for these into law.
- Where you plant it, this is like my shtick.
(audience laughing)
- There are so many things you can do,
and we are not trained to do them as physicians,
but I think it's so important.
One thing that I actually learned when I like felt
I was too young to decide I wanted to be a doctor.
So when I was a pharma consultant for a year,
that was awful, don't do it.
(audience laughing)
- But I learned that doctors are the weakest lobby
of all of the lobbies, and we don't have a lot
of political power and we're not trained
to change the political system at all,
but there are a lot of things you can learn to do.
So I've done a lot of opinion writing.
If you wanna learn more about op-ed writing,
you can school with the OpEd Project,
they'll assign you a mentor,
they'll teach you how to pitch newspapers,
and you can write op-eds detailing the science
around what a policy should be.
So I wrote one for the New York Times when this first bill
was introduced, allied gender-affirming medical care,
just going through all the things they said in the bill
that weren't true, and showing the data
about why doctors consider these interventions for kids.
And there's strategic ways to do that, right?
You see where bills are being introduced
and where people need to hear the data
and then kind of send it to local newspapers,
things like that.
I'm also a huge advocate for social media involvement
if you want training on that, like bias does a psychiatrist,
the American Psychiatric Association has training
on how to do that.
But a lot of problems come from misinformation spreading
online, not just through major media outlets,
where that happens, but also on things like Twitter,
Instagram, TikTok, et cetera.
So those, I think in medicine traditionally,
we're taught like, that's always the time, like, go learn
the Krebs cycle.
(audience laughing)
- (chuckles) I'm sorry.
But you can make a huge impact
through that advocacy and spreading information,
and there's a lot of power on the other side
of people sending messages that are false.
But nonetheless, drive policy.
- Dr. Tandoh, I think Dr. Imbasciani actually would like
to, he has his hand raised and would like to ask a question,
so we're just gonna pull him back up.
(indistinct)
- Dr. Jack, it's Dr. Vito in Los Angeles.
Hey, you're probably aware of efforts
from your local state Senator up there in Sacramento
to create legislation in California,
and it's probably gonna be mimicked in other states,
that would disallow surgeons like myself
from doing gender-affirming surgery at infancy
or shortly thereafter?
I'm thinking children with congenital adrenal hyperplasia.
So what advice would you give somebody like me
as to what age, how old does the child have
to be to give consent?
- Well, this is gonna be the last question.
(audience laughing)
- So this is not my area, I think you're kind of referring
to differences of sexual development,
which has a broad range
of what were previously called intersex conditions.
And historically, there's been a practice of trying
to predict what gender identity the person's gonna have
in the future, and then performing some sort
of genital surgery in line with that prediction.
This has been a controversial practice
because a lot of adults have later come out
and said that there was a presumption
about what their gender identity would be,
surgery was done, and they wish that surgery had not been.
I will say that that's totally outside my area,
I don't think I can appropriately answer the question
with the expertise that would be needed
for gender-affirming genital surgery for trans adolescents.
All current guidelines say that no person has to be 18.
So age of majority and the country where they are
in contrast to gender-affirming top surgery.
So things for transmasculine patients like masculinizing
chest reconstruction, that is sometimes done earlier
on a case by case basis, and it's really up
to the mental health professional
and the surgeon to weigh the risks and benefits of that.
Surgery data we have so far
on top surgery for transmasculine adolescents is reassuring,
it seems that it improves chest dysphoria
and in general, functioning,
but it's an area where the research is still developing.
And again, the kids don't give the consent,
this is something that I think people get confused about.
This is a big problem, in the Belle versus Tavistock case
in the UK, they probably don't have time for.
But right, except for a few very specific areas of medicine
in the United States, minors don't give consent
for their medical interventions,
their parents give consent, they give us,
and that alone is usually not sufficient
for a doctor to prescribe the medication.
There are exceptions, right?
Like reproductive health care, things like that.
But I just wanna be clear about that
'cause it comes up a lot
in the political debates in particular.
But I'm sorry, that was not an answer
to your question.
- [Dr. Vito] Thanks.
- [Dr. Tandoh] Thank you, very, very much.
- Thank you.
(audience clapping)
- I wanna thank you all for joining us today online
and also the classes here in person.
I also wanna thank Dr. Imbasciani
and Mr. George DiSalvo, again for the generous support,
which made this lecture possible.
And also I'd like to thank Dean Page
for his ongoing leadership in the College of Medicine
and the pursuit of equity and training of future physicians,
better prepared to care for all their patients.
This lecture was very informative for me,
and I think it will help me as I take care
of my patients even as a trauma surgeon.
So again, thank you all, and stay safe
and have a wonderful evening, everyone.
(audience clapping)