Norman Spack: How I help transgender teens become who they want to be
Summary
TLDRThe speaker, a pediatric endocrinologist, discusses the complexities of gender identity, sexual orientation, and medical care for transgender individuals. They explain the difference between gender identity and sexual orientation, sharing personal experiences with patients navigating these issues. The talk highlights the importance of providing medical support to transgender adolescents through puberty blockers and hormone treatments, as well as the emotional and societal challenges faced by transgender individuals. The speaker advocates for a more inclusive society, urging better healthcare, anti-discrimination laws, and the removal of transgender identity from psychiatric disease classifications.
Takeaways
- 👶 The third word ever said about a person at birth often describes their sex, based on external anatomy.
- 🔄 Gender identity and sexual orientation are different. Gender identity is who you go to bed as, while sexual orientation is who you go to bed with.
- 💉 Early interventions like puberty blockers give time for adolescents to explore their gender identity before irreversible physical changes occur.
- 📊 Studies show that children who express cross-gender behaviors often do not persist in identifying as the opposite gender at puberty, but those who do are likely transgender.
- 🚸 Affirming gender identity in youth is critical to their mental health, as untreated transgender individuals face high risks of suicide.
- 🇳🇱 The Dutch pioneered a model of care for transgender youth, starting with puberty blockers at age 12, hormone therapy at 16, and surgery eligibility at 18.
- 💡 Endocrinologists like the speaker help facilitate gender transitions by managing hormone treatments that align with the patient's affirmed gender.
- 🏥 A pediatric program for treating transgender youth began in Boston in 2007, based on the Dutch model, allowing for safe, early treatment.
- 👨👩👧 Family and societal acceptance is a challenge, with many transgender individuals facing rejection from loved ones, which underscores the need for better support.
- 🌍 Discrimination laws are still lacking in many places. Only 17 U.S. states have anti-discrimination laws for housing, employment, and public accommodation for transgender people.
Q & A
What is the significance of the 'third word' mentioned in the script?
-The 'third word' refers to the description of a newborn's sex, usually based on their external genitalia, following the statement 'It's a...'. This is a key moment when society begins to categorize individuals based on their anatomical sex.
Why is the mixed audience response of 'boy' or 'girl' significant?
-The mixed response highlights the uncertainty or complexity of assigning sex at birth, especially in cases where anatomical differences or intersex conditions are present. The speaker uses this to introduce the idea that sex and gender are not always straightforward.
What is the difference between sexual orientation and gender identity as explained by the speaker?
-Sexual orientation refers to 'who you go to bed with', meaning the gender of the people you are attracted to, while gender identity refers to 'who you go to bed as', meaning your internal sense of your own gender, regardless of your anatomical sex.
At what age do feelings of being transgender become more likely to persist, according to the speaker?
-Feelings of being in the 'wrong body' become almost certain to persist during puberty, typically around ages 10 to 14, when physical changes solidify one’s sense of gender. These feelings are unlikely to change, regardless of any attempts at reparative therapy.
What challenges did the speaker face when treating transgender adults?
-The speaker found it painful that many transgender adults had to give up relationships with parents, siblings, children, and spouses. These adults transitioned later in life because they felt they had to affirm their gender identity to avoid the risk of suicide.
What treatment approach did the speaker learn about in the Netherlands for transgender adolescents?
-In the Netherlands, adolescents with gender dysphoria undergo psychometric testing and then receive puberty blockers, delaying the onset of puberty. This prevents unwanted physical changes while allowing time for further evaluation and affirmation of their gender identity.
What are the implications of using puberty blockers in transgender adolescents?
-Puberty blockers temporarily halt the physical changes of puberty, providing time for the adolescent to explore their gender identity without their body changing in ways that might feel distressing. The effects are reversible, but the use of opposite-sex hormones later can have permanent effects.
What did the speaker mean by the 12-16-18 program in transgender care?
-The 12-16-18 program refers to a timeline where puberty blockers are given around age 12, cross-sex hormones may be administered around age 16 after retesting, and gender-affirming surgeries can be performed around age 18. This gradual approach allows for informed, safe transitions.
How does the speaker describe the outcomes for transgender adolescents who receive treatment?
-The speaker reports that transgender adolescents who receive puberty blockers and then hormone treatments have normal heights and body development for their affirmed gender. They blend in with their peers and live fulfilling lives without the distress caused by undergoing the 'wrong' puberty.
What are the broader social and legal issues that the speaker identifies regarding transgender rights?
-The speaker emphasizes the need for anti-discrimination laws to protect transgender people in housing, employment, and public accommodations. They also argue for the removal of transgender identity from the Diagnostic and Statistical Manual of Mental Disorders (DSM), as it should not be classified as a psychiatric condition.
Outlines
👶 The Third Word: Defining Sex at Birth
The speaker invites the audience to recall the third word ever spoken about them, likely related to their sex at birth, such as 'boy' or 'girl.' They highlight the ambiguity that sometimes arises in defining sex, especially when dealing with intersex cases. While sex is typically determined by visible genitalia, sexual orientation and gender identity cannot be defined at birth. The speaker explains how gender identity, distinct from biological sex, emerges over time and often solidifies during puberty, while cross-gender behaviors in childhood are not necessarily indicative of future gender identity.
🤔 Gender Identity vs. Sexual Orientation
The speaker shares their experience treating a transgender patient and how the patient clarified the difference between sexual orientation (who you are attracted to) and gender identity (who you are). Through this experience, the speaker learned that gender identity and sexual orientation are unrelated. They recount the difficulties many transgender individuals face, including rejection from family and society, leading some to transition later in life to avoid the risk of suicide. The speaker emphasizes that understanding gender identity is key to providing proper care and support.
🧪 A New Approach: Puberty Blockers and Gender Affirmation
The speaker describes a groundbreaking approach they encountered in the Netherlands, where puberty blockers are used to pause puberty in transgender adolescents. This method allows young people to delay unwanted physical changes, providing time for further psychological evaluation and personal decision-making. By blocking puberty, these adolescents avoid the distress of developing physical traits inconsistent with their gender identity, buying them time until they are old enough to decide on hormone therapy and possible surgeries. The speaker highlights the importance of starting treatment at the right time to ensure better outcomes for the individual.
🏥 The Rise of Pediatric Endocrinology for Transgender Youth
The speaker discusses their decision to adopt the Dutch model of transgender care, focusing on children and adolescents. They explain how the approach has become the standard of care at Boston Children’s Hospital since 2007, with an increasing number of patients seeking help. The speaker shares a story of a British transgender girl who avoided extreme height and other unwanted male physical traits thanks to early intervention. This patient, who later went on to become a model, exemplifies the success of using puberty blockers and hormone therapy at the right time.
🏛️ Advocacy and Legal Challenges for Transgender Rights
The speaker recounts how a family, including a transgender girl named Nicole, fought against a discriminatory law in Maine that would have restricted transgender people's rights to use public bathrooms. Through personal advocacy, Nicole helped overturn the bill, showing the power of visibility and education. The speaker then highlights the broader legal and societal challenges faced by transgender individuals, including the need for anti-discrimination laws in more states and the removal of gender dysphoria from the DSM. The speaker emphasizes the importance of societal inclusion and supporting transgender individuals to prevent tragic outcomes like suicide.
Mindmap
Keywords
💡Gender Identity
💡Sexual Orientation
💡Puberty Blockers
💡Transgender
💡Endocrinology
💡DSM (Diagnostic and Statistical Manual of Mental Disorders)
💡Gender Dysphoria
💡Surgery
💡Psychometric Testing
💡Discrimination
Highlights
The third word used to describe a newborn is typically a reference to their sex based on their genitals, but it doesn't define their gender identity or sexual orientation.
Sexual orientation doesn't define itself until adolescence, while gender identity may appear in early childhood but can be fluid until later stages.
Cross-gender behavior in children is often normative, and studies show that many children who exhibit this behavior do not persist in wanting to be the opposite gender by puberty.
Children who express a strong feeling of being in the wrong body during puberty are likely to be transgender and unlikely to change those feelings later.
The speaker highlights the importance of puberty blockers to give adolescents time to explore their gender identity without the irreversible effects of puberty.
Hormones given to affirm gender at an early age can result in physical appearances that align more closely with the affirmed gender, making it harder to distinguish transgender individuals in adulthood.
The speaker shares a story of confusion between sexual orientation and gender identity, clarifying that sexual orientation refers to who you go to bed with, and gender identity is who you go to bed as.
Untreated transgender individuals are at a high risk for suicide, emphasizing the life-saving importance of gender-affirming treatment.
A program from the Netherlands focuses on treating adolescents with puberty blockers to delay unwanted puberty and provide more time for gender identity development.
Estrogen can be used at an early age to stop growth in transgender girls, leading to more aligned physical development without stunted height.
The case of identical twin boys highlights the stark differences puberty creates when one twin undergoes male puberty and the other is on pubertal blockers.
Nicole, a transgender girl, successfully lobbied against anti-transgender bathroom legislation in Maine by sharing her personal story with lawmakers.
The speaker discusses the cost of hormone treatments and the need to make these drugs more affordable to support more transgender individuals.
The speaker advocates for removing transgender identity from the DSM (Diagnostic and Statistical Manual of Mental Disorders), just as homosexuality was removed in 1973.
Transgender treatment isn't a widespread practice, but the risks of not treating these individuals, including high suicide rates, make it crucial for a truly inclusive society.
Transcripts
I want you all to think
about the third word that was ever said about you --
or, if you were delivering,
about the person you were delivering.
And you can all mouth it if you want or say it out loud.
It was -- the first two were, "It's a ..."
Audience: (Mixed reply) Girl. Boy.
(Laughter)
Well, it shows you that --
I also deal with issues where there's not certainty
of whether it's a girl or a boy,
so the mixed answer was very appropriate.
Of course, now the answer often comes not at birth but at the ultrasound,
unless the prospective parents choose to be surprised,
like we all were.
But I want you to think about what it is that leads to that statement
on the third word,
because the third word
is a description of your sex.
And by that I mean,
made by a description of your genitals.
Now, as a pediatric endocrinologist,
I used to be very, very involved and still somewhat am, in cases
in which there are mismatches in the externals
or between the externals and the internals,
and we literally have to figure out
what is the description of your sex.
But there is nothing that is definable at the time of birth
that would define you.
And when I talk about definition,
I'm talking about your sexual orientation.
We don't say, "It's a ... gay boy!"
"A lesbian girl!"
Those situations don't really define themselves
more until the second decade of life.
Nor do they define your gender,
which, as different from your anatomic sex,
describes your self-concept:
Do you see yourself as a male or female,
or somewhere in the spectrum in between?
That sometimes shows up
in the first decade of life,
but it can be very confusing for parents,
because it is quite normative for children
to act in a cross-gender play and way,
and, in fact, there are studies that show
that even 80 percent of children who act in that fashion
will not persist in wanting to be the opposite gender
at the time when puberty begins.
But, at the time that puberty begins --
that means between about age 10 to 12 in girls, 12 to 14 in boys --
with breast budding,
or two to three times' increase in the gonads
in the case of genetic males,
by that particular point,
the child who says they are in the absolute wrong body
is almost certain to be transgender
and is extremely unlikely to change those feelings,
no matter how anybody tries reparative therapy
or any other noxious things.
Now, this is relatively rare,
so I had relatively little personal experience with this.
And my experience was more typical,
only because I had an adolescent practice.
And I saw someone age 24,
genetically female, went through Harvard with three male roommates
who knew the whole story,
a registrar who always listed his name on course lists as a male name,
and came to me after graduating,
saying, "Help me. I know you know a lot of endocrinology."
And indeed, I've treated a lot of people who were born without gonads.
This wasn't rocket science.
But I made a deal with him:
"I'll treat you if you teach me."
And so he did.
And what an education I got
from taking care of all the members of his support group.
And then I got really confused,
because I thought it was relatively easy at that age
to just give people the hormones
of the gender in which they were affirming.
But then my patient married,
and he married a woman who had been born as a male,
had married as a male, had two children,
then went through a transition into female.
And now this delightful female
was attached to my male patient -- in fact, got legally married,
because they showed up as a man and a woman, and who knew, right?
(Laughter)
And I was confused --
"Does this make so-and-so gay?
Does this make so-and-so straight?"
I was getting sexual orientation confused with gender identity.
And my patient said to me,
"Look, look, look.
If you just think of the following, you'll get it right:
Sexual orientation is who you go to bed with.
Gender identity is who you go to bed as."
(Laughter)
And I subsequently learned from the many adults --
I took care of about 200 adults --
I learned from them
that if I didn't peek as to who their partner was in the waiting room,
I would never be able to guess better than chance,
whether they were gay, straight, bi or asexual
in their affirmed gender.
In other words,
one thing has absolutely nothing to do with the other.
And the data show it.
Now, as I took care of the 200 adults,
I found it extremely painful.
These people -- many of them --
had to give up so much of their lives.
Sometimes their parents would reject them,
siblings, their own children,
and then their divorcing spouse
would forbid them from seeing their children.
It was so awful,
but why did they do it at 40 and 50?
Because they felt they had to affirm themselves
before they would kill themselves.
And indeed, the rate of suicide among untreated transgendered people
is among the highest in the world.
So, what to do?
I was intrigued, in going to a conference in Holland,
where they are experts in this,
and saw the most remarkable thing.
They were treating young adolescents
after giving them the most intense psychometric testing of gender,
and they were treating them by blocking the puberty that they didn't want.
Because basically, kids look about the same,
each sex, until they go through puberty,
at which point, if you feel you're in the wrong sex,
you feel like Pinocchio becoming a donkey.
The fantasy that you had that your body will change
to be who you want it to be, with puberty,
actually is nullified by the puberty you get.
And they fall apart.
So that's why putting the puberty on hold -- why on hold?
You can't just give them the opposite hormones that young.
They'll end up stunted in growth,
and you think you can have a meaningful conversation
about the fertility effects of such treatment
with a 10-year-old girl, a 12-year-old boy?
So this buys time in the diagnostic process
for four or five years,
so that they can work it out.
They can have more and more testing,
they can live without feeling their bodies are running away from them.
And then, in a program they call 12-16-18,
around age 12 is when they give the blocking hormones,
and then at age 16, with retesting,
they re-qualify to receive --
now remember, the blocking hormones are reversible,
but when you give the hormones of the opposite sex,
you now start spouting breasts and facial hair and voice change,
depending on what you're using,
and those effects are permanent,
or require surgery to remove,
or electrolysis,
and you can never really affect the voice.
So this is serious, and this is 15-, 16-year-old stuff.
And then at 18, they're eligible for surgery.
And while there's no good surgery for females to males genitally,
the male-to-female surgery has fooled gynecologists.
That's how good it can be.
So I looked at how the patients were doing,
and I looked at patients who just looked like everybody else,
except they were pubertally delayed.
But once they gave them the hormones
consistent with the gender they affirm,
they look beautiful.
They look normal.
They had normal heights.
You would never be able to pick them out in a crowd.
So at that point, I decided I'm going to do this.
This is really where the pediatric endocrine realm comes in,
because, in fact, if you're going to deal with it in kids aged 10 to 14,
that's pediatric endocrinology.
So I brought some kids in,
and this now became the standard of care,
and the [Boston] Children's Hospital was behind it.
By my showing them the kids before and after,
people who never got treated and people who wished to be treated,
and pictures of the Dutch --
they came to me and said,
"You've got to do something for these kids."
Well, where were these kids before?
They were out there suffering, is where they were.
So we started a program in 2007.
It became the first program of its kind --
but it's really of the Dutch kind --
in North America.
And since then, we have 160 patients.
Did they come from Afghanistan? No.
75 percent of them came from within 150 miles of Boston.
And some came from England.
Jackie had been abused in the Midlands, in England.
She's 12 years old there,
she was living as a girl,
but she was being beaten up.
It was a horror show, they had to homeschool her.
And the reason the British were coming
was because they would not treat anybody with anything under age 16,
which means they were consigning them to an adult body
no matter what happened,
even if they tested them well.
Jackie, on top of it, was, by virtue of skeletal markings,
destined to be six feet five.
And yet, she had just begun a male puberty.
Well, I did something a little bit innovative,
because I do know hormones,
and that estrogen is much more potent
in closing epiphyses, the growth plates,
and stopping growth, than testosterone is.
So we blocked her testosterone with a blocking hormone,
but we added estrogen, not at 16, but at 13.
And so here she is at 16, on the left.
And on her 16th birthday, she went to Thailand,
where they would do a genital plastic surgery.
They will do it at 18 now.
And she ended up 5'11".
But more than that, she has normal breast size,
because by blocking testosterone,
every one of our patients has normal breast size
if they get to us at the appropriate age,
not too late.
And on the far right, there she is.
She went public -- semifinalist in the Miss England competition.
The judges debated as to, can they do this?
And one of them quipped, I'm told,
"But she has more natural self than half the other contestants."
(Laughter)
And some of them have been rearranged a little bit,
but it's all her DNA.
And she's become a remarkable spokeswoman.
And she was offered contracts as a model,
at which point she teased me, when she said,
"You know, I might have had a better chance as a model
if you'd made me six feet one."
(Laughter)
Go figure.
So this picture, I think, says it all.
It really says it all.
These are Nicole and brother Jonas,
identical twin boys,
and proven to be identical.
Nicole had affirmed herself as a girl as early as age three.
At age seven, they changed her name,
and came to me at the very beginnings of a male puberty.
Now you can imagine looking at Jonas at only 14,
that male puberty is early in this family,
because he looks more like a 16-year-old.
But it makes the point all the more,
of why you have to be conscious of where the patient is.
Nicole is on pubertal blockade in here,
and Jonas is just going -- biologic control.
This is what Nicole would look like
if we weren't doing what we were doing.
He's got a prominent Adam's apple.
He's got angular bones to the face, a mustache,
and you can see there's a height difference,
because he's gone through a growth spurt that she won't get.
Now Nicole is on estrogen.
She has a bit of a form to her.
This family went to the White House last spring,
because of their work in overturning an anti-discrimination --
there was a bill that would block
the right of transgender people in Maine to use public bathrooms,
and it looked like the bill was going to pass,
and that would have been a problem,
but Nicole went personally to every legislator in Maine
and said, "I can do this.
If they see me, they'll understand
why I'm no threat in the ladies' room,
but I can be threatened in the men's room."
And then they finally got it.
So where do we go from here?
Well, we still have a ways to go in terms of anti-discrimination.
There are only 17 states that have an anti-discrimination law
against discrimination in housing,
employment, public accommodation --
only 17 states, and five of them are in New England.
We need less expensive drugs.
They cost a fortune.
And we need to get this condition out of the DSM.
It is as much a psychiatric disease as being gay and lesbian,
and that went out the window in 1973,
and the whole world changed.
And this isn't going to break anybody's budget.
This is not that common.
But the risks of not doing anything for them
not only puts all of them at risk of losing their lives to suicide,
but it also says something about whether we are a truly inclusive society.
Thank you.
(Applause)
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