Norman Spack: How I help transgender teens become who they want to be

Summary

The 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

00:00

👶 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.

05:01

🤔 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.

10:04

🧪 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.

15:05

🏥 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.

Keywords

💡Gender Identity

Gender identity refers to a person's internal sense of their own gender, whether male, female, or somewhere along the gender spectrum. In the video, the speaker emphasizes the distinction between gender identity and biological sex, explaining that gender identity relates to 'who you go to bed as,' rather than 'who you go to bed with.' This concept is central to understanding how individuals, including transgender people, perceive and affirm their gender, regardless of their anatomy at birth.

💡Sexual Orientation

Sexual orientation describes a person's emotional, romantic, or sexual attraction to others. It is separate from gender identity and refers to 'who you go to bed with,' as explained in the video. The speaker clarifies that sexual orientation (e.g., gay, straight, bisexual) is distinct from gender identity, and one cannot predict someone's sexual orientation based on their gender identity.

💡Puberty Blockers

Puberty blockers are medications used to delay the onset of puberty in children, particularly those who experience gender dysphoria. In the video, the speaker explains how these blockers are used in transgender adolescents to prevent unwanted physical changes and buy time for them to explore their gender identity without the pressure of irreversible puberty changes. The blockers are described as reversible and part of a Dutch treatment protocol for transgender youth.

💡Transgender

A transgender person is someone whose gender identity does not align with the sex they were assigned at birth. The speaker talks about their experience as a pediatric endocrinologist working with transgender patients, emphasizing the emotional and physical challenges faced by individuals who feel they are in the 'wrong body.' The speaker also discusses the medical interventions available for transgender youth, including puberty blockers and hormone therapy.

💡Endocrinology

Endocrinology is the branch of medicine that deals with hormones and their effects on the body. The speaker, as a pediatric endocrinologist, plays a critical role in helping transgender individuals navigate their physical transition, particularly during puberty. The discussion focuses on the use of hormones to align a person's physical characteristics with their gender identity, underscoring the medical complexity of such treatments.

💡DSM (Diagnostic and Statistical Manual of Mental Disorders)

The DSM is a manual used by mental health professionals to diagnose psychological disorders. In the video, the speaker argues that being transgender should no longer be classified as a psychiatric disorder, similar to how being gay or lesbian was removed from the DSM in 1973. This classification affects societal perception and legal policies regarding transgender rights.

💡Gender Dysphoria

Gender dysphoria is the distress a person experiences when their gender identity does not match their sex assigned at birth. The speaker references this condition when discussing the emotional pain transgender individuals feel, especially during puberty when their bodies may develop in ways that feel wrong to them. The use of puberty blockers is described as a way to alleviate gender dysphoria in transgender youth.

💡Surgery

Surgery in the context of the video refers to gender confirmation surgeries (also known as gender reassignment surgeries) that some transgender individuals may undergo to align their physical body with their gender identity. The speaker discusses how such surgeries are available for transgender individuals, particularly male-to-female surgeries, which can be so effective that even gynecologists may not notice the difference.

💡Psychometric Testing

Psychometric testing involves the use of psychological assessments to evaluate an individual's cognitive and emotional functioning. In the video, the speaker mentions that before administering puberty blockers, transgender youth undergo intense psychometric testing to confirm their gender identity. This testing is critical in ensuring that the child truly identifies with a gender different from their assigned sex before medical intervention is offered.

💡Discrimination

Discrimination refers to the unfair treatment of individuals based on their gender identity or sexual orientation. The speaker highlights the legal and societal challenges faced by transgender individuals, such as being denied access to public restrooms and facing rejection by family members. The fight against discrimination is a major theme, with the speaker advocating for anti-discrimination laws and better societal acceptance of transgender people.

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)