0:00:00.763,0:00:04.579 I want you all to think 0:00:04.603,0:00:10.295 about the third word[br]that was ever said about you -- 0:00:11.582,0:00:14.614 or, if you were delivering, 0:00:14.638,0:00:18.344 about the person you were delivering. 0:00:19.864,0:00:23.705 And you can all mouth it[br]if you want or say it out loud. 0:00:23.729,0:00:29.286 It was -- the first two were, "It's a ..." 0:00:29.310,0:00:31.331 Audience: (Mixed reply) Girl. Boy. 0:00:31.355,0:00:32.356 (Laughter) 0:00:32.380,0:00:33.982 Well, it shows you that -- 0:00:34.006,0:00:37.085 I also deal with issues[br]where there's not certainty 0:00:37.109,0:00:38.684 of whether it's a girl or a boy, 0:00:38.708,0:00:41.989 so the mixed answer was very appropriate. 0:00:42.336,0:00:46.970 Of course, now the answer often comes[br]not at birth but at the ultrasound, 0:00:46.994,0:00:50.948 unless the prospective parents[br]choose to be surprised, 0:00:50.972,0:00:52.576 like we all were. 0:00:53.835,0:01:00.835 But I want you to think about what it is[br]that leads to that statement 0:01:00.859,0:01:02.875 on the third word, 0:01:02.899,0:01:05.376 because the third word 0:01:05.400,0:01:10.238 is a description of your sex. 0:01:13.159,0:01:15.548 And by that I mean, 0:01:15.572,0:01:19.071 made by a description of your genitals. 0:01:20.436,0:01:23.480 Now, as a pediatric endocrinologist, 0:01:23.504,0:01:28.981 I used to be very, very involved[br]and still somewhat am, in cases 0:01:29.005,0:01:35.269 in which there are mismatches[br]in the externals 0:01:35.293,0:01:39.307 or between the externals[br]and the internals, 0:01:39.331,0:01:44.144 and we literally have to figure out 0:01:44.168,0:01:47.286 what is the description of your sex. 0:01:48.502,0:01:53.784 But there is nothing[br]that is definable at the time of birth 0:01:53.808,0:01:57.053 that would define you. 0:01:58.101,0:02:00.244 And when I talk about definition, 0:02:00.268,0:02:05.029 I'm talking about your sexual orientation. 0:02:06.274,0:02:10.143 We don't say, "It's a ... gay boy!" 0:02:11.668,0:02:12.957 "A lesbian girl!" 0:02:14.449,0:02:17.958 Those situations don't[br]really define themselves 0:02:17.982,0:02:20.171 more until the second decade of life. 0:02:21.971,0:02:26.928 Nor do they define your gender, 0:02:26.952,0:02:30.540 which, as different[br]from your anatomic sex, 0:02:30.564,0:02:33.814 describes your self-concept: 0:02:33.838,0:02:39.346 Do you see yourself as a male or female, 0:02:39.370,0:02:43.326 or somewhere in the spectrum in between? 0:02:44.593,0:02:49.872 That sometimes shows up 0:02:49.896,0:02:52.856 in the first decade of life, 0:02:52.880,0:02:56.502 but it can be very confusing for parents, 0:02:56.526,0:03:01.233 because it is quite normative for children 0:03:01.257,0:03:05.610 to act in a cross-gender play and way, 0:03:05.634,0:03:07.944 and, in fact, there are studies that show 0:03:07.968,0:03:13.796 that even 80 percent of children[br]who act in that fashion 0:03:13.820,0:03:20.738 will not persist in wanting[br]to be the opposite gender 0:03:20.762,0:03:23.458 at the time when puberty begins. 0:03:24.746,0:03:29.278 But, at the time that puberty begins -- 0:03:30.206,0:03:35.835 that means between about age 10 to 12[br]in girls, 12 to 14 in boys -- 0:03:37.239,0:03:38.946 with breast budding, 0:03:38.970,0:03:42.843 or two to three times'[br]increase in the gonads 0:03:42.867,0:03:45.712 in the case of genetic males, 0:03:45.736,0:03:47.362 by that particular point, 0:03:47.386,0:03:52.318 the child who says[br]they are in the absolute wrong body 0:03:53.504,0:03:56.034 is almost certain to be transgender 0:03:57.291,0:04:04.279 and is extremely unlikely[br]to change those feelings, 0:04:04.303,0:04:08.838 no matter how anybody tries[br]reparative therapy 0:04:08.862,0:04:11.036 or any other noxious things. 0:04:12.742,0:04:15.189 Now, this is relatively rare, 0:04:15.213,0:04:18.109 so I had relatively little[br]personal experience with this. 0:04:18.929,0:04:21.583 And my experience was more typical, 0:04:21.607,0:04:23.647 only because I had an adolescent practice. 0:04:23.671,0:04:25.339 And I saw someone age 24, 0:04:25.363,0:04:29.930 genetically female, went through Harvard[br]with three male roommates 0:04:29.954,0:04:31.290 who knew the whole story, 0:04:31.314,0:04:37.331 a registrar who always listed his name[br]on course lists as a male name, 0:04:37.355,0:04:40.306 and came to me after graduating, 0:04:40.330,0:04:44.324 saying, "Help me. I know you know[br]a lot of endocrinology." 0:04:44.348,0:04:47.656 And indeed, I've treated a lot of people[br]who were born without gonads. 0:04:47.680,0:04:49.324 This wasn't rocket science. 0:04:49.348,0:04:50.951 But I made a deal with him: 0:04:50.975,0:04:52.772 "I'll treat you if you teach me." 0:04:53.900,0:04:55.987 And so he did. 0:04:57.161,0:04:58.971 And what an education I got 0:04:58.995,0:05:01.824 from taking care of all the members[br]of his support group. 0:05:03.647,0:05:06.170 And then I got really confused, 0:05:06.194,0:05:08.727 because I thought it was[br]relatively easy at that age 0:05:08.751,0:05:10.334 to just give people the hormones 0:05:10.358,0:05:13.776 of the gender[br]in which they were affirming. 0:05:14.595,0:05:17.801 But then my patient married, 0:05:17.825,0:05:22.631 and he married a woman[br]who had been born as a male, 0:05:22.655,0:05:25.934 had married as a male, had two children, 0:05:25.958,0:05:30.229 then went through[br]a transition into female. 0:05:31.721,0:05:35.710 And now this delightful female 0:05:36.536,0:05:42.202 was attached to my male patient --[br]in fact, got legally married, 0:05:42.226,0:05:45.478 because they showed up as a man[br]and a woman, and who knew, right? 0:05:45.502,0:05:47.005 (Laughter) 0:05:47.966,0:05:51.003 And I was confused -- 0:05:51.501,0:05:53.898 "Does this make so-and-so gay? 0:05:53.922,0:05:55.672 Does this make so-and-so straight?" 0:05:55.696,0:06:00.522 I was getting sexual orientation[br]confused with gender identity. 0:06:01.609,0:06:03.784 And my patient said to me, 0:06:03.808,0:06:05.276 "Look, look, look. 0:06:05.300,0:06:08.713 If you just think of the following,[br]you'll get it right: 0:06:08.737,0:06:11.980 Sexual orientation[br]is who you go to bed with. 0:06:12.004,0:06:15.344 Gender identity is who you go to bed as." 0:06:15.802,0:06:17.803 (Laughter) 0:06:17.827,0:06:20.619 And I subsequently learned[br]from the many adults -- 0:06:20.643,0:06:23.165 I took care of about 200 adults -- 0:06:23.189,0:06:24.859 I learned from them 0:06:24.883,0:06:29.518 that if I didn't peek as to who[br]their partner was in the waiting room, 0:06:29.542,0:06:33.217 I would never be able to guess[br]better than chance, 0:06:33.241,0:06:37.439 whether they were gay,[br]straight, bi or asexual 0:06:37.463,0:06:39.607 in their affirmed gender. 0:06:39.631,0:06:40.853 In other words, 0:06:40.877,0:06:45.436 one thing has absolutely nothing[br]to do with the other. 0:06:45.460,0:06:48.139 And the data show it. 0:06:50.075,0:06:52.224 Now, as I took care of the 200 adults, 0:06:52.248,0:06:53.843 I found it extremely painful. 0:06:54.814,0:06:57.797 These people -- many of them -- 0:06:57.821,0:07:02.098 had to give up so much of their lives. 0:07:02.122,0:07:04.553 Sometimes their parents would reject them, 0:07:04.577,0:07:06.926 siblings, their own children, 0:07:06.950,0:07:08.697 and then their divorcing spouse 0:07:08.721,0:07:12.232 would forbid them[br]from seeing their children. 0:07:12.724,0:07:14.485 It was so awful, 0:07:14.509,0:07:17.765 but why did they do it at 40 and 50? 0:07:18.289,0:07:23.034 Because they felt[br]they had to affirm themselves 0:07:23.058,0:07:24.840 before they would kill themselves. 0:07:25.316,0:07:31.262 And indeed, the rate of suicide[br]among untreated transgendered people 0:07:31.286,0:07:33.737 is among the highest in the world. 0:07:35.057,0:07:36.210 So, what to do? 0:07:37.020,0:07:40.932 I was intrigued, in going[br]to a conference in Holland, 0:07:40.956,0:07:43.202 where they are experts in this, 0:07:43.226,0:07:45.528 and saw the most remarkable thing. 0:07:46.623,0:07:49.845 They were treating young adolescents 0:07:49.869,0:07:55.839 after giving them the most intense[br]psychometric testing of gender, 0:07:55.863,0:08:00.259 and they were treating them by blocking[br]the puberty that they didn't want. 0:08:00.283,0:08:02.845 Because basically,[br]kids look about the same, 0:08:02.869,0:08:05.864 each sex, until they go through puberty, 0:08:05.888,0:08:08.581 at which point, if you feel[br]you're in the wrong sex, 0:08:08.605,0:08:10.794 you feel like Pinocchio becoming a donkey. 0:08:11.675,0:08:14.216 The fantasy that you had[br]that your body will change 0:08:14.240,0:08:16.891 to be who you want it to be, with puberty, 0:08:16.915,0:08:19.636 actually is nullified[br]by the puberty you get. 0:08:21.779,0:08:23.796 And they fall apart. 0:08:25.328,0:08:28.804 So that's why putting the puberty[br]on hold -- why on hold? 0:08:28.828,0:08:31.878 You can't just give them[br]the opposite hormones that young. 0:08:31.902,0:08:33.737 They'll end up stunted in growth, 0:08:33.761,0:08:36.309 and you think you can have[br]a meaningful conversation 0:08:36.333,0:08:38.823 about the fertility effects[br]of such treatment 0:08:38.847,0:08:42.242 with a 10-year-old girl,[br]a 12-year-old boy? 0:08:42.663,0:08:45.169 So this buys time[br]in the diagnostic process 0:08:45.193,0:08:47.021 for four or five years, 0:08:47.045,0:08:49.343 so that they can work it out. 0:08:49.819,0:08:52.447 They can have more and more testing, 0:08:52.471,0:08:56.440 they can live without feeling their bodies[br]are running away from them. 0:08:56.464,0:09:00.622 And then, in a program they call 12-16-18, 0:09:00.646,0:09:05.495 around age 12 is when they[br]give the blocking hormones, 0:09:05.519,0:09:07.959 and then at age 16, with retesting, 0:09:07.983,0:09:10.265 they re-qualify to receive -- 0:09:10.289,0:09:13.261 now remember, the blocking[br]hormones are reversible, 0:09:13.285,0:09:16.166 but when you give the hormones[br]of the opposite sex, 0:09:16.190,0:09:19.507 you now start spouting breasts[br]and facial hair and voice change, 0:09:19.531,0:09:21.273 depending on what you're using, 0:09:21.297,0:09:23.399 and those effects are permanent, 0:09:23.423,0:09:25.241 or require surgery to remove, 0:09:25.265,0:09:26.496 or electrolysis, 0:09:26.520,0:09:28.646 and you can never really affect the voice. 0:09:29.027,0:09:32.280 So this is serious,[br]and this is 15-, 16-year-old stuff. 0:09:33.184,0:09:35.861 And then at 18,[br]they're eligible for surgery. 0:09:36.772,0:09:40.864 And while there's no good surgery[br]for females to males genitally, 0:09:40.888,0:09:44.188 the male-to-female surgery[br]has fooled gynecologists. 0:09:45.381,0:09:46.833 That's how good it can be. 0:09:48.087,0:09:52.064 So I looked at how[br]the patients were doing, 0:09:52.088,0:09:54.950 and I looked at patients[br]who just looked like everybody else, 0:09:54.974,0:09:57.705 except they were pubertally delayed. 0:09:57.729,0:09:59.642 But once they gave them the hormones 0:09:59.666,0:10:02.275 consistent with the gender they affirm, 0:10:02.299,0:10:03.532 they look beautiful. 0:10:04.229,0:10:05.515 They look normal. 0:10:06.040,0:10:07.395 They had normal heights. 0:10:07.935,0:10:10.737 You would never be able[br]to pick them out in a crowd. 0:10:12.522,0:10:15.079 So at that point, I decided[br]I'm going to do this. 0:10:15.103,0:10:19.587 This is really where the pediatric[br]endocrine realm comes in, 0:10:19.611,0:10:24.428 because, in fact, if you're going to deal[br]with it in kids aged 10 to 14, 0:10:24.452,0:10:26.372 that's pediatric endocrinology. 0:10:27.354,0:10:30.741 So I brought some kids in, 0:10:31.513,0:10:34.074 and this now became the standard of care, 0:10:34.098,0:10:36.903 and the [Boston][br]Children's Hospital was behind it. 0:10:36.927,0:10:41.070 By my showing them[br]the kids before and after, 0:10:41.094,0:10:44.915 people who never got treated[br]and people who wished to be treated, 0:10:44.939,0:10:46.527 and pictures of the Dutch -- 0:10:48.035,0:10:49.256 they came to me and said, 0:10:49.280,0:10:51.487 "You've got to do[br]something for these kids." 0:10:51.511,0:10:53.568 Well, where were these kids before? 0:10:54.774,0:10:57.145 They were out there suffering,[br]is where they were. 0:10:57.894,0:11:04.038 So we started a program in 2007. 0:11:04.062,0:11:06.458 It became the first program of its kind -- 0:11:06.482,0:11:08.839 but it's really of the Dutch kind -- 0:11:08.863,0:11:10.046 in North America. 0:11:10.927,0:11:14.426 And since then, we have 160 patients. 0:11:15.180,0:11:17.831 Did they come from Afghanistan? No. 0:11:18.440,0:11:25.440 75 percent of them came[br]from within 150 miles of Boston. 0:11:26.701,0:11:29.456 And some came from England. 0:11:30.138,0:11:34.181 Jackie had been abused[br]in the Midlands, in England. 0:11:34.205,0:11:36.067 She's 12 years old there, 0:11:36.091,0:11:37.404 she was living as a girl, 0:11:37.428,0:11:39.586 but she was being beaten up. 0:11:39.610,0:11:42.181 It was a horror show,[br]they had to homeschool her. 0:11:42.649,0:11:44.993 And the reason the British were coming 0:11:45.017,0:11:50.717 was because they would not treat[br]anybody with anything under age 16, 0:11:50.741,0:11:54.454 which means they were consigning[br]them to an adult body 0:11:54.478,0:11:55.937 no matter what happened, 0:11:55.961,0:11:57.537 even if they tested them well. 0:11:58.108,0:12:02.786 Jackie, on top of it, was,[br]by virtue of skeletal markings, 0:12:02.810,0:12:04.731 destined to be six feet five. 0:12:07.138,0:12:10.042 And yet, she had just begun[br]a male puberty. 0:12:10.938,0:12:14.513 Well, I did something[br]a little bit innovative, 0:12:14.537,0:12:16.635 because I do know hormones, 0:12:16.659,0:12:18.597 and that estrogen is much more potent 0:12:18.621,0:12:22.411 in closing epiphyses, the growth plates, 0:12:22.435,0:12:25.728 and stopping growth, than testosterone is. 0:12:25.752,0:12:30.481 So we blocked her testosterone[br]with a blocking hormone, 0:12:30.505,0:12:33.964 but we added estrogen,[br]not at 16, but at 13. 0:12:34.909,0:12:37.489 And so here she is at 16, on the left. 0:12:38.093,0:12:40.371 And on her 16th birthday,[br]she went to Thailand, 0:12:40.395,0:12:42.673 where they would do[br]a genital plastic surgery. 0:12:42.697,0:12:44.573 They will do it at 18 now. 0:12:44.597,0:12:46.637 And she ended up 5'11". 0:12:47.312,0:12:50.535 But more than that,[br]she has normal breast size, 0:12:50.559,0:12:52.847 because by blocking testosterone, 0:12:52.871,0:12:56.225 every one of our patients[br]has normal breast size 0:12:56.249,0:12:59.259 if they get to us at the appropriate age, 0:12:59.283,0:13:00.434 not too late. 0:13:01.057,0:13:02.816 And on the far right, there she is. 0:13:02.840,0:13:06.665 She went public -- semifinalist[br]in the Miss England competition. 0:13:09.068,0:13:11.571 The judges debated[br]as to, can they do this? 0:13:12.134,0:13:16.285 And one of them quipped, I'm told, 0:13:16.309,0:13:20.275 "But she has more natural self[br]than half the other contestants." 0:13:20.299,0:13:22.187 (Laughter) 0:13:22.211,0:13:26.458 And some of them[br]have been rearranged a little bit, 0:13:26.482,0:13:28.566 but it's all her DNA. 0:13:29.679,0:13:32.774 And she's become a remarkable spokeswoman. 0:13:33.121,0:13:36.982 And she was offered contracts as a model, 0:13:37.006,0:13:39.131 at which point[br]she teased me, when she said, 0:13:39.155,0:13:41.700 "You know, I might have had[br]a better chance as a model 0:13:41.724,0:13:43.432 if you'd made me six feet one." 0:13:43.456,0:13:45.436 (Laughter) 0:13:45.460,0:13:46.611 Go figure. 0:13:48.038,0:13:50.966 So this picture, I think, says it all. 0:13:51.740,0:13:53.081 It really says it all. 0:13:53.760,0:13:57.384 These are Nicole and brother Jonas, 0:13:57.408,0:13:59.347 identical twin boys, 0:14:00.427,0:14:01.931 and proven to be identical. 0:14:03.978,0:14:07.572 Nicole had affirmed herself[br]as a girl as early as age three. 0:14:07.596,0:14:10.103 At age seven, they changed her name, 0:14:10.127,0:14:14.571 and came to me at the very[br]beginnings of a male puberty. 0:14:14.904,0:14:17.688 Now you can imagine[br]looking at Jonas at only 14, 0:14:17.712,0:14:20.499 that male puberty is early in this family, 0:14:20.523,0:14:22.562 because he looks more like a 16-year-old. 0:14:23.086,0:14:24.896 But it makes the point all the more, 0:14:24.920,0:14:28.205 of why you have to be conscious[br]of where the patient is. 0:14:28.665,0:14:31.371 Nicole is on pubertal blockade in here, 0:14:32.451,0:14:35.562 and Jonas is just going --[br]biologic control. 0:14:36.189,0:14:37.886 This is what Nicole would look like 0:14:37.910,0:14:39.967 if we weren't doing what we were doing. 0:14:39.991,0:14:42.458 He's got a prominent Adam's apple. 0:14:42.482,0:14:46.039 He's got angular bones[br]to the face, a mustache, 0:14:46.063,0:14:48.126 and you can see there's[br]a height difference, 0:14:48.150,0:14:51.029 because he's gone through[br]a growth spurt that she won't get. 0:14:51.053,0:14:52.570 Now Nicole is on estrogen. 0:14:52.594,0:14:55.061 She has a bit of a form to her. 0:14:55.887,0:14:59.502 This family went[br]to the White House last spring, 0:14:59.526,0:15:05.265 because of their work in overturning[br]an anti-discrimination -- 0:15:05.289,0:15:07.671 there was a bill that would block 0:15:07.695,0:15:12.298 the right of transgender people in Maine[br]to use public bathrooms, 0:15:12.322,0:15:15.067 and it looked like the bill[br]was going to pass, 0:15:15.091,0:15:16.798 and that would have been a problem, 0:15:16.822,0:15:20.299 but Nicole went personally[br]to every legislator in Maine 0:15:20.323,0:15:22.311 and said, "I can do this. 0:15:22.335,0:15:24.327 If they see me, they'll understand 0:15:24.351,0:15:26.497 why I'm no threat in the ladies' room, 0:15:26.521,0:15:28.603 but I can be threatened[br]in the men's room." 0:15:28.627,0:15:30.126 And then they finally got it. 0:15:32.038,0:15:33.713 So where do we go from here? 0:15:35.022,0:15:39.091 Well, we still have a ways to go[br]in terms of anti-discrimination. 0:15:39.115,0:15:42.782 There are only 17 states[br]that have an anti-discrimination law 0:15:42.806,0:15:45.382 against discrimination in housing, 0:15:45.406,0:15:48.498 employment, public accommodation -- 0:15:48.522,0:15:51.510 only 17 states, and five of them[br]are in New England. 0:15:51.534,0:15:53.435 We need less expensive drugs. 0:15:53.459,0:15:54.846 They cost a fortune. 0:15:55.164,0:15:59.057 And we need to get[br]this condition out of the DSM. 0:15:59.081,0:16:03.781 It is as much a psychiatric disease[br]as being gay and lesbian, 0:16:03.805,0:16:06.724 and that went out the window in 1973, 0:16:06.748,0:16:08.252 and the whole world changed. 0:16:08.649,0:16:10.994 And this isn't going to break[br]anybody's budget. 0:16:11.018,0:16:12.485 This is not that common. 0:16:13.279,0:16:16.660 But the risks of not[br]doing anything for them 0:16:18.005,0:16:24.477 not only puts all of them at risk[br]of losing their lives to suicide, 0:16:24.501,0:16:30.753 but it also says something about[br]whether we are a truly inclusive society. 0:16:30.777,0:16:31.928 Thank you. 0:16:31.952,0:16:35.928 (Applause)