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