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00:00:00,763 --> 00:00:04,579
I want you all to think

2
00:00:04,603 --> 00:00:10,295
about the third word
that was ever said about you --

3
00:00:11,582 --> 00:00:14,614
or, if you were delivering,

4
00:00:14,638 --> 00:00:18,344
about the person you were delivering.

5
00:00:19,864 --> 00:00:23,705
And you can all mouth it
if you want or say it out loud.

6
00:00:23,729 --> 00:00:29,286
It was -- the first two were, "It's a ..."

7
00:00:29,310 --> 00:00:31,331
Audience: (Mixed reply) Girl. Boy.

8
00:00:31,355 --> 00:00:32,356
(Laughter)

9
00:00:32,380 --> 00:00:33,982
Well, it shows you that --

10
00:00:34,006 --> 00:00:37,085
I also deal with issues
where there's not certainty

11
00:00:37,109 --> 00:00:38,684
of whether it's a girl or a boy,

12
00:00:38,708 --> 00:00:41,989
so the mixed answer was very appropriate.

13
00:00:42,336 --> 00:00:46,970
Of course, now the answer often comes
not at birth but at the ultrasound,

14
00:00:46,994 --> 00:00:50,948
unless the prospective parents
choose to be surprised,

15
00:00:50,972 --> 00:00:52,576
like we all were.

16
00:00:53,835 --> 00:01:00,835
But I want you to think about what it is
that leads to that statement

17
00:01:00,859 --> 00:01:02,875
on the third word,

18
00:01:02,899 --> 00:01:05,376
because the third word

19
00:01:05,400 --> 00:01:10,238
is a description of your sex.

20
00:01:13,159 --> 00:01:15,548
And by that I mean,

21
00:01:15,572 --> 00:01:19,071
made by a description of your genitals.

22
00:01:20,436 --> 00:01:23,480
Now, as a pediatric endocrinologist,

23
00:01:23,504 --> 00:01:28,981
I used to be very, very involved
and still somewhat am, in cases

24
00:01:29,005 --> 00:01:35,269
in which there are mismatches
in the externals

25
00:01:35,293 --> 00:01:39,307
or between the externals
and the internals,

26
00:01:39,331 --> 00:01:44,144
and we literally have to figure out

27
00:01:44,168 --> 00:01:47,286
what is the description of your sex.

28
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But there is nothing
that is definable at the time of birth

29
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that would define you.

30
00:01:58,101 --> 00:02:00,244
And when I talk about definition,

31
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I'm talking about your sexual orientation.

32
00:02:06,274 --> 00:02:10,143
We don't say, "It's a ... gay boy!"

33
00:02:11,668 --> 00:02:12,957
"A lesbian girl!"

34
00:02:14,449 --> 00:02:17,958
Those situations don't
really define themselves

35
00:02:17,982 --> 00:02:20,171
more until the second decade of life.

36
00:02:21,971 --> 00:02:26,928
Nor do they define your gender,

37
00:02:26,952 --> 00:02:30,540
which, as different
from your anatomic sex,

38
00:02:30,564 --> 00:02:33,814
describes your self-concept:

39
00:02:33,838 --> 00:02:39,346
Do you see yourself as a male or female,

40
00:02:39,370 --> 00:02:43,326
or somewhere in the spectrum in between?

41
00:02:44,593 --> 00:02:49,872
That sometimes shows up

42
00:02:49,896 --> 00:02:52,856
in the first decade of life,

43
00:02:52,880 --> 00:02:56,502
but it can be very confusing for parents,

44
00:02:56,526 --> 00:03:01,233
because it is quite normative for children

45
00:03:01,257 --> 00:03:05,610
to act in a cross-gender play and way,

46
00:03:05,634 --> 00:03:07,944
and, in fact, there are studies that show

47
00:03:07,968 --> 00:03:13,796
that even 80 percent of children
who act in that fashion

48
00:03:13,820 --> 00:03:20,738
will not persist in wanting
to be the opposite gender

49
00:03:20,762 --> 00:03:23,458
at the time when puberty begins.

50
00:03:24,746 --> 00:03:29,278
But, at the time that puberty begins --

51
00:03:30,206 --> 00:03:35,835
that means between about age 10 to 12
in girls, 12 to 14 in boys --

52
00:03:37,239 --> 00:03:38,946
with breast budding,

53
00:03:38,970 --> 00:03:42,843
or two to three times'
increase in the gonads

54
00:03:42,867 --> 00:03:45,712
in the case of genetic males,

55
00:03:45,736 --> 00:03:47,362
by that particular point,

56
00:03:47,386 --> 00:03:52,318
the child who says
they are in the absolute wrong body

57
00:03:53,504 --> 00:03:56,034
is almost certain to be transgender

58
00:03:57,291 --> 00:04:04,279
and is extremely unlikely
to change those feelings,

59
00:04:04,303 --> 00:04:08,838
no matter how anybody tries
reparative therapy

60
00:04:08,862 --> 00:04:11,036
or any other noxious things.

61
00:04:12,742 --> 00:04:15,189
Now, this is relatively rare,

62
00:04:15,213 --> 00:04:18,109
so I had relatively little
personal experience with this.

63
00:04:18,929 --> 00:04:21,583
And my experience was more typical,

64
00:04:21,607 --> 00:04:23,647
only because I had an adolescent practice.

65
00:04:23,671 --> 00:04:25,339
And I saw someone age 24,

66
00:04:25,363 --> 00:04:29,930
genetically female, went through Harvard
with three male roommates

67
00:04:29,954 --> 00:04:31,290
who knew the whole story,

68
00:04:31,314 --> 00:04:37,331
a registrar who always listed his name
on course lists as a male name,

69
00:04:37,355 --> 00:04:40,306
and came to me after graduating,

70
00:04:40,330 --> 00:04:44,324
saying, "Help me. I know you know
a lot of endocrinology."

71
00:04:44,348 --> 00:04:47,656
And indeed, I've treated a lot of people
who were born without gonads.

72
00:04:47,680 --> 00:04:49,324
This wasn't rocket science.

73
00:04:49,348 --> 00:04:50,951
But I made a deal with him:

74
00:04:50,975 --> 00:04:52,772
"I'll treat you if you teach me."

75
00:04:53,900 --> 00:04:55,987
And so he did.

76
00:04:57,161 --> 00:04:58,971
And what an education I got

77
00:04:58,995 --> 00:05:01,824
from taking care of all the members
of his support group.

78
00:05:03,647 --> 00:05:06,170
And then I got really confused,

79
00:05:06,194 --> 00:05:08,727
because I thought it was
relatively easy at that age

80
00:05:08,751 --> 00:05:10,334
to just give people the hormones

81
00:05:10,358 --> 00:05:13,776
of the gender
in which they were affirming.

82
00:05:14,595 --> 00:05:17,801
But then my patient married,

83
00:05:17,825 --> 00:05:22,631
and he married a woman
who had been born as a male,

84
00:05:22,655 --> 00:05:25,934
had married as a male, had two children,

85
00:05:25,958 --> 00:05:30,229
then went through
a transition into female.

86
00:05:31,721 --> 00:05:35,710
And now this delightful female

87
00:05:36,536 --> 00:05:42,202
was attached to my male patient --
in fact, got legally married,

88
00:05:42,226 --> 00:05:45,478
because they showed up as a man
and a woman, and who knew, right?

89
00:05:45,502 --> 00:05:47,005
(Laughter)

90
00:05:47,966 --> 00:05:51,003
And I was confused --

91
00:05:51,501 --> 00:05:53,898
"Does this make so-and-so gay?

92
00:05:53,922 --> 00:05:55,672
Does this make so-and-so straight?"

93
00:05:55,696 --> 00:06:00,522
I was getting sexual orientation
confused with gender identity.

94
00:06:01,609 --> 00:06:03,784
And my patient said to me,

95
00:06:03,808 --> 00:06:05,276
"Look, look, look.

96
00:06:05,300 --> 00:06:08,713
If you just think of the following,
you'll get it right:

97
00:06:08,737 --> 00:06:11,980
Sexual orientation
is who you go to bed with.

98
00:06:12,004 --> 00:06:15,344
Gender identity is who you go to bed as."

99
00:06:15,802 --> 00:06:17,803
(Laughter)

100
00:06:17,827 --> 00:06:20,619
And I subsequently learned
from the many adults --

101
00:06:20,643 --> 00:06:23,165
I took care of about 200 adults --

102
00:06:23,189 --> 00:06:24,859
I learned from them

103
00:06:24,883 --> 00:06:29,518
that if I didn't peek as to who
their partner was in the waiting room,

104
00:06:29,542 --> 00:06:33,217
I would never be able to guess
better than chance,

105
00:06:33,241 --> 00:06:37,439
whether they were gay,
straight, bi or asexual

106
00:06:37,463 --> 00:06:39,607
in their affirmed gender.

107
00:06:39,631 --> 00:06:40,853
In other words,

108
00:06:40,877 --> 00:06:45,436
one thing has absolutely nothing
to do with the other.

109
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And the data show it.

110
00:06:50,075 --> 00:06:52,224
Now, as I took care of the 200 adults,

111
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I found it extremely painful.

112
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These people -- many of them --

113
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had to give up so much of their lives.

114
00:07:02,122 --> 00:07:04,553
Sometimes their parents would reject them,

115
00:07:04,577 --> 00:07:06,926
siblings, their own children,

116
00:07:06,950 --> 00:07:08,697
and then their divorcing spouse

117
00:07:08,721 --> 00:07:12,232
would forbid them
from seeing their children.

118
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It was so awful,

119
00:07:14,509 --> 00:07:17,765
but why did they do it at 40 and 50?

120
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Because they felt
they had to affirm themselves

121
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before they would kill themselves.

122
00:07:25,316 --> 00:07:31,262
And indeed, the rate of suicide
among untreated transgendered people

123
00:07:31,286 --> 00:07:33,737
is among the highest in the world.

124
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So, what to do?

125
00:07:37,020 --> 00:07:40,932
I was intrigued, in going
to a conference in Holland,

126
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where they are experts in this,

127
00:07:43,226 --> 00:07:45,528
and saw the most remarkable thing.

128
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They were treating young adolescents

129
00:07:49,869 --> 00:07:55,839
after giving them the most intense
psychometric testing of gender,

130
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and they were treating them by blocking
the puberty that they didn't want.

131
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Because basically,
kids look about the same,

132
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each sex, until they go through puberty,

133
00:08:05,888 --> 00:08:08,581
at which point, if you feel
you're in the wrong sex,

134
00:08:08,605 --> 00:08:10,794
you feel like Pinocchio becoming a donkey.

135
00:08:11,675 --> 00:08:14,216
The fantasy that you had
that your body will change

136
00:08:14,240 --> 00:08:16,891
to be who you want it to be, with puberty,

137
00:08:16,915 --> 00:08:19,636
actually is nullified
by the puberty you get.

138
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And they fall apart.

139
00:08:25,328 --> 00:08:28,804
So that's why putting the puberty
on hold -- why on hold?

140
00:08:28,828 --> 00:08:31,878
You can't just give them
the opposite hormones that young.

141
00:08:31,902 --> 00:08:33,737
They'll end up stunted in growth,

142
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and you think you can have
a meaningful conversation

143
00:08:36,333 --> 00:08:38,823
about the fertility effects
of such treatment

144
00:08:38,847 --> 00:08:42,242
with a 10-year-old girl,
a 12-year-old boy?

145
00:08:42,663 --> 00:08:45,169
So this buys time
in the diagnostic process

146
00:08:45,193 --> 00:08:47,021
for four or five years,

147
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so that they can work it out.

148
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They can have more and more testing,

149
00:08:52,471 --> 00:08:56,440
they can live without feeling their bodies
are running away from them.

150
00:08:56,464 --> 00:09:00,622
And then, in a program they call 12-16-18,

151
00:09:00,646 --> 00:09:05,495
around age 12 is when they
give the blocking hormones,

152
00:09:05,519 --> 00:09:07,959
and then at age 16, with retesting,

153
00:09:07,983 --> 00:09:10,265
they re-qualify to receive --

154
00:09:10,289 --> 00:09:13,261
now remember, the blocking
hormones are reversible,

155
00:09:13,285 --> 00:09:16,166
but when you give the hormones
of the opposite sex,

156
00:09:16,190 --> 00:09:19,507
you now start spouting breasts
and facial hair and voice change,

157
00:09:19,531 --> 00:09:21,273
depending on what you're using,

158
00:09:21,297 --> 00:09:23,399
and those effects are permanent,

159
00:09:23,423 --> 00:09:25,241
or require surgery to remove,

160
00:09:25,265 --> 00:09:26,496
or electrolysis,

161
00:09:26,520 --> 00:09:28,646
and you can never really affect the voice.

162
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So this is serious,
and this is 15-, 16-year-old stuff.

163
00:09:33,184 --> 00:09:35,861
And then at 18,
they're eligible for surgery.

164
00:09:36,772 --> 00:09:40,864
And while there's no good surgery
for females to males genitally,

165
00:09:40,888 --> 00:09:44,188
the male-to-female surgery
has fooled gynecologists.

166
00:09:45,381 --> 00:09:46,833
That's how good it can be.

167
00:09:48,087 --> 00:09:52,064
So I looked at how
the patients were doing,

168
00:09:52,088 --> 00:09:54,950
and I looked at patients
who just looked like everybody else,

169
00:09:54,974 --> 00:09:57,705
except they were pubertally delayed.

170
00:09:57,729 --> 00:09:59,642
But once they gave them the hormones

171
00:09:59,666 --> 00:10:02,275
consistent with the gender they affirm,

172
00:10:02,299 --> 00:10:03,532
they look beautiful.

173
00:10:04,229 --> 00:10:05,515
They look normal.

174
00:10:06,040 --> 00:10:07,395
They had normal heights.

175
00:10:07,935 --> 00:10:10,737
You would never be able
to pick them out in a crowd.

176
00:10:12,522 --> 00:10:15,079
So at that point, I decided
I'm going to do this.

177
00:10:15,103 --> 00:10:19,587
This is really where the pediatric
endocrine realm comes in,

178
00:10:19,611 --> 00:10:24,428
because, in fact, if you're going to deal
with it in kids aged 10 to 14,

179
00:10:24,452 --> 00:10:26,372
that's pediatric endocrinology.

180
00:10:27,354 --> 00:10:30,741
So I brought some kids in,

181
00:10:31,513 --> 00:10:34,074
and this now became the standard of care,

182
00:10:34,098 --> 00:10:36,903
and the [Boston]
Children's Hospital was behind it.

183
00:10:36,927 --> 00:10:41,070
By my showing them
the kids before and after,

184
00:10:41,094 --> 00:10:44,915
people who never got treated
and people who wished to be treated,

185
00:10:44,939 --> 00:10:46,527
and pictures of the Dutch --

186
00:10:48,035 --> 00:10:49,256
they came to me and said,

187
00:10:49,280 --> 00:10:51,487
"You've got to do
something for these kids."

188
00:10:51,511 --> 00:10:53,568
Well, where were these kids before?

189
00:10:54,774 --> 00:10:57,145
They were out there suffering,
is where they were.

190
00:10:57,894 --> 00:11:04,038
So we started a program in 2007.

191
00:11:04,062 --> 00:11:06,458
It became the first program of its kind --

192
00:11:06,482 --> 00:11:08,839
but it's really of the Dutch kind --

193
00:11:08,863 --> 00:11:10,046
in North America.

194
00:11:10,927 --> 00:11:14,426
And since then, we have 160 patients.

195
00:11:15,180 --> 00:11:17,831
Did they come from Afghanistan? No.

196
00:11:18,440 --> 00:11:25,440
75 percent of them came
from within 150 miles of Boston.

197
00:11:26,701 --> 00:11:29,456
And some came from England.

198
00:11:30,138 --> 00:11:34,181
Jackie had been abused
in the Midlands, in England.

199
00:11:34,205 --> 00:11:36,067
She's 12 years old there,

200
00:11:36,091 --> 00:11:37,404
she was living as a girl,

201
00:11:37,428 --> 00:11:39,586
but she was being beaten up.

202
00:11:39,610 --> 00:11:42,181
It was a horror show,
they had to homeschool her.

203
00:11:42,649 --> 00:11:44,993
And the reason the British were coming

204
00:11:45,017 --> 00:11:50,717
was because they would not treat
anybody with anything under age 16,

205
00:11:50,741 --> 00:11:54,454
which means they were consigning
them to an adult body

206
00:11:54,478 --> 00:11:55,937
no matter what happened,

207
00:11:55,961 --> 00:11:57,537
even if they tested them well.

208
00:11:58,108 --> 00:12:02,786
Jackie, on top of it, was,
by virtue of skeletal markings,

209
00:12:02,810 --> 00:12:04,731
destined to be six feet five.

210
00:12:07,138 --> 00:12:10,042
And yet, she had just begun
a male puberty.

211
00:12:10,938 --> 00:12:14,513
Well, I did something
a little bit innovative,

212
00:12:14,537 --> 00:12:16,635
because I do know hormones,

213
00:12:16,659 --> 00:12:18,597
and that estrogen is much more potent

214
00:12:18,621 --> 00:12:22,411
in closing epiphyses, the growth plates,

215
00:12:22,435 --> 00:12:25,728
and stopping growth, than testosterone is.

216
00:12:25,752 --> 00:12:30,481
So we blocked her testosterone
with a blocking hormone,

217
00:12:30,505 --> 00:12:33,964
but we added estrogen,
not at 16, but at 13.

218
00:12:34,909 --> 00:12:37,489
And so here she is at 16, on the left.

219
00:12:38,093 --> 00:12:40,371
And on her 16th birthday,
she went to Thailand,

220
00:12:40,395 --> 00:12:42,673
where they would do
a genital plastic surgery.

221
00:12:42,697 --> 00:12:44,573
They will do it at 18 now.

222
00:12:44,597 --> 00:12:46,637
And she ended up 5'11".

223
00:12:47,312 --> 00:12:50,535
But more than that,
she has normal breast size,

224
00:12:50,559 --> 00:12:52,847
because by blocking testosterone,

225
00:12:52,871 --> 00:12:56,225
every one of our patients
has normal breast size

226
00:12:56,249 --> 00:12:59,259
if they get to us at the appropriate age,

227
00:12:59,283 --> 00:13:00,434
not too late.

228
00:13:01,057 --> 00:13:02,816
And on the far right, there she is.

229
00:13:02,840 --> 00:13:06,665
She went public -- semifinalist
in the Miss England competition.

230
00:13:09,068 --> 00:13:11,571
The judges debated
as to, can they do this?

231
00:13:12,134 --> 00:13:16,285
And one of them quipped, I'm told,

232
00:13:16,309 --> 00:13:20,275
"But she has more natural self
than half the other contestants."

233
00:13:20,299 --> 00:13:22,187
(Laughter)

234
00:13:22,211 --> 00:13:26,458
And some of them
have been rearranged a little bit,

235
00:13:26,482 --> 00:13:28,566
but it's all her DNA.

236
00:13:29,679 --> 00:13:32,774
And she's become a remarkable spokeswoman.

237
00:13:33,121 --> 00:13:36,982
And she was offered contracts as a model,

238
00:13:37,006 --> 00:13:39,131
at which point
she teased me, when she said,

239
00:13:39,155 --> 00:13:41,700
"You know, I might have had
a better chance as a model

240
00:13:41,724 --> 00:13:43,432
if you'd made me six feet one."

241
00:13:43,456 --> 00:13:45,436
(Laughter)

242
00:13:45,460 --> 00:13:46,611
Go figure.

243
00:13:48,038 --> 00:13:50,966
So this picture, I think, says it all.

244
00:13:51,740 --> 00:13:53,081
It really says it all.

245
00:13:53,760 --> 00:13:57,384
These are Nicole and brother Jonas,

246
00:13:57,408 --> 00:13:59,347
identical twin boys,

247
00:14:00,427 --> 00:14:01,931
and proven to be identical.

248
00:14:03,978 --> 00:14:07,572
Nicole had affirmed herself
as a girl as early as age three.

249
00:14:07,596 --> 00:14:10,103
At age seven, they changed her name,

250
00:14:10,127 --> 00:14:14,571
and came to me at the very
beginnings of a male puberty.

251
00:14:14,904 --> 00:14:17,688
Now you can imagine
looking at Jonas at only 14,

252
00:14:17,712 --> 00:14:20,499
that male puberty is early in this family,

253
00:14:20,523 --> 00:14:22,562
because he looks more like a 16-year-old.

254
00:14:23,086 --> 00:14:24,896
But it makes the point all the more,

255
00:14:24,920 --> 00:14:28,205
of why you have to be conscious
of where the patient is.

256
00:14:28,665 --> 00:14:31,371
Nicole is on pubertal blockade in here,

257
00:14:32,451 --> 00:14:35,562
and Jonas is just going --
biologic control.

258
00:14:36,189 --> 00:14:37,886
This is what Nicole would look like

259
00:14:37,910 --> 00:14:39,967
if we weren't doing what we were doing.

260
00:14:39,991 --> 00:14:42,458
He's got a prominent Adam's apple.

261
00:14:42,482 --> 00:14:46,039
He's got angular bones
to the face, a mustache,

262
00:14:46,063 --> 00:14:48,126
and you can see there's
a height difference,

263
00:14:48,150 --> 00:14:51,029
because he's gone through
a growth spurt that she won't get.

264
00:14:51,053 --> 00:14:52,570
Now Nicole is on estrogen.

265
00:14:52,594 --> 00:14:55,061
She has a bit of a form to her.

266
00:14:55,887 --> 00:14:59,502
This family went
to the White House last spring,

267
00:14:59,526 --> 00:15:05,265
because of their work in overturning
an anti-discrimination --

268
00:15:05,289 --> 00:15:07,671
there was a bill that would block

269
00:15:07,695 --> 00:15:12,298
the right of transgender people in Maine
to use public bathrooms,

270
00:15:12,322 --> 00:15:15,067
and it looked like the bill
was going to pass,

271
00:15:15,091 --> 00:15:16,798
and that would have been a problem,

272
00:15:16,822 --> 00:15:20,299
but Nicole went personally
to every legislator in Maine

273
00:15:20,323 --> 00:15:22,311
and said, "I can do this.

274
00:15:22,335 --> 00:15:24,327
If they see me, they'll understand

275
00:15:24,351 --> 00:15:26,497
why I'm no threat in the ladies' room,

276
00:15:26,521 --> 00:15:28,603
but I can be threatened
in the men's room."

277
00:15:28,627 --> 00:15:30,126
And then they finally got it.

278
00:15:32,038 --> 00:15:33,713
So where do we go from here?

279
00:15:35,022 --> 00:15:39,091
Well, we still have a ways to go
in terms of anti-discrimination.

280
00:15:39,115 --> 00:15:42,782
There are only 17 states
that have an anti-discrimination law

281
00:15:42,806 --> 00:15:45,382
against discrimination in housing,

282
00:15:45,406 --> 00:15:48,498
employment, public accommodation --

283
00:15:48,522 --> 00:15:51,510
only 17 states, and five of them
are in New England.

284
00:15:51,534 --> 00:15:53,435
We need less expensive drugs.

285
00:15:53,459 --> 00:15:54,846
They cost a fortune.

286
00:15:55,164 --> 00:15:59,057
And we need to get
this condition out of the DSM.

287
00:15:59,081 --> 00:16:03,781
It is as much a psychiatric disease
as being gay and lesbian,

288
00:16:03,805 --> 00:16:06,724
and that went out the window in 1973,

289
00:16:06,748 --> 00:16:08,252
and the whole world changed.

290
00:16:08,649 --> 00:16:10,994
And this isn't going to break
anybody's budget.

291
00:16:11,018 --> 00:16:12,485
This is not that common.

292
00:16:13,279 --> 00:16:16,660
But the risks of not
doing anything for them

293
00:16:18,005 --> 00:16:24,477
not only puts all of them at risk
of losing their lives to suicide,

294
00:16:24,501 --> 00:16:30,753
but it also says something about
whether we are a truly inclusive society.

295
00:16:30,777 --> 00:16:31,928
Thank you.

296
00:16:31,952 --> 00:16:35,928
(Applause)