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..."
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 that 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 have 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,
went through Harvard 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 them:
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 while I was confused about,
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."
And subsequently I learned from the many adults
— I took care of about 200 adults —
I learned from them
that if I didn't look, 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 were, 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 requalify.
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, 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 look like everybody else.
They look, 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 age 10-12, 10-14,
that's pediatric endocrinology.
So I brought some kids in,
and this now became the standard of care,
and 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 gotta 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.
They came, 75 percent of them came
from within 150 miles of Boston.
And some came from England.
Jackie had been abused in Midlands, 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 home school 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, okay?
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 Ms. England competition.
Okay?
The judges debates as to, can they do this?
Can they make her—?
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, where she said,
"You know, I might have had a better chance
as a model if you'd made me six feet one."
Go figure. (Laughter)
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,
in which 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
why you have to be conscious
of where the patient is.
Nicole has done pubetal blockade in here,
and Jonas has 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 lady's 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)