0:00:00.763,0:00:04.411
I want you all to think

0:00:04.411,0:00:08.740
about the third word that was ever said

0:00:08.740,0:00:11.582
about you,

0:00:11.582,0:00:14.638
or if you were delivering,

0:00:14.638,0:00:19.796
about the person you were delivering.

0:00:19.796,0:00:22.077
And you can all mouth it if you want

0:00:22.077,0:00:23.647
or say it out loud.

0:00:23.647,0:00:29.595
It was, the first two were, "It's a ..."

0:00:32.268,0:00:34.005
Well, it shows you that

0:00:34.005,0:00:35.935
I also deal with issues where there's

0:00:35.935,0:00:38.708
not certainty of whether it's a girl or a boy,

0:00:38.708,0:00:42.013
so the mixed answer was very appropriate.

0:00:42.013,0:00:44.457
Of course, now the answer often comes

0:00:44.457,0:00:46.863
not at birth but at the ultrasound,

0:00:46.863,0:00:49.801
unless the prospective parents choose

0:00:49.801,0:00:53.508
to be surprised like we all were.

0:00:53.508,0:00:56.468
But I want you to think about what it is

0:00:56.468,0:01:00.922
that leads to that statement

0:01:00.922,0:01:02.599
on the third word,

0:01:02.599,0:01:05.100
because the third word

0:01:05.100,0:01:12.859
is a description of your sex,

0:01:12.859,0:01:15.434
and by that I mean,

0:01:15.434,0:01:20.341
made by a description of your genitals.

0:01:20.341,0:01:23.204
Now, as a pediatric endocrinologist,

0:01:23.204,0:01:25.594
I used to be very, very involved,

0:01:25.594,0:01:27.475
and still somewhat am,

0:01:27.475,0:01:30.292
in cases in which

0:01:30.292,0:01:32.875
there are mismatches

0:01:32.875,0:01:35.315
in the externals

0:01:35.315,0:01:39.308
or between the externals and the internals,

0:01:39.308,0:01:44.108
and we literally have to figure out

0:01:44.108,0:01:48.202
what is the description of your sex.

0:01:48.202,0:01:50.680
But there is nothing that is definable

0:01:50.680,0:01:53.925
at the time of birth

0:01:53.925,0:01:57.922
that would define you,

0:01:57.922,0:01:59.968
and when I talk about definition,

0:01:59.968,0:02:06.271
I'm talking about your sexual orientation.

0:02:06.271,0:02:11.721
We don't say, "It's a gay boy."

0:02:11.721,0:02:14.371
"A lesbian girl."

0:02:14.371,0:02:17.980
Those situations don't really define themselves

0:02:17.980,0:02:21.671
more until the second decade of life.

0:02:21.671,0:02:26.652
Nor do they define your gender,

0:02:26.652,0:02:30.264
which, as different from your anatomic sex,

0:02:30.264,0:02:33.644
describes your self-concept.

0:02:33.644,0:02:35.582
Do you see yourself

0:02:35.582,0:02:39.070
as a male or female

0:02:39.070,0:02:44.687
or somewhere in the spectrum in between?

0:02:44.687,0:02:49.668
That sometimes shows up

0:02:49.668,0:02:52.748
in the first decade of life,

0:02:52.748,0:02:56.305
but it can be very confusing for parents

0:02:56.305,0:02:59.443
because it is quite normative

0:02:59.443,0:03:05.506
for children to act in a cross-gender play and way,

0:03:05.506,0:03:07.668
and that in fact there are studies that show

0:03:07.668,0:03:10.715
that even 80 percent of children

0:03:10.715,0:03:13.199
who act in that fashion

0:03:13.199,0:03:18.229
will not persist in wanting to be

0:03:18.229,0:03:20.462
the opposite gender

0:03:20.462,0:03:24.394
at the time when puberty begins.

0:03:24.394,0:03:30.107
But at the time that puberty begins,

0:03:30.107,0:03:33.674
that means between about age 10 to 12 in girls,

0:03:33.674,0:03:37.056
12 to 14 in boys,

0:03:37.056,0:03:38.700
with breast budding

0:03:38.700,0:03:42.598
or two to three times increase in the gonads

0:03:42.598,0:03:45.510
in the case of genetic males,

0:03:45.510,0:03:48.892
by that particular point, the child who says

0:03:48.892,0:03:53.300
they are in the absolute wrong body

0:03:53.300,0:03:57.012
is almost certain to be transgender

0:03:57.012,0:04:04.003
and is extremely unlikely to change those feelings,

0:04:04.003,0:04:08.670
no matter how anybody tries reparative therapy

0:04:08.670,0:04:12.660
or any other noxious things.

0:04:12.660,0:04:15.104
Now this is relatively rare,

0:04:15.104,0:04:18.629
so I had relatively little[br]personal experience with this,

0:04:18.629,0:04:21.204
and my experience was more typical

0:04:21.204,0:04:23.606
only because I had an adolescent practice.

0:04:23.606,0:04:25.469
And I saw someone age 24,

0:04:25.469,0:04:27.940
went through Harvard, genetically female,

0:04:27.940,0:04:29.654
went through Harvard with three male roommates

0:04:29.654,0:04:31.189
who knew the whole story,

0:04:31.189,0:04:34.882
a registrar who always listed his name

0:04:34.882,0:04:36.990
on course lists as a male name,

0:04:36.990,0:04:41.710
and came to me after graduating saying, "Help me.

0:04:41.710,0:04:43.801
I know you know a lot of endocrinology."

0:04:43.801,0:04:45.945
And indeed I've treated a lot of people

0:04:45.945,0:04:47.338
who were born without gonads.

0:04:47.338,0:04:49.048
This wasn't rocket science.

0:04:49.048,0:04:50.792
But I made a deal with him:

0:04:50.792,0:04:53.600
I'll treat you if you teach me.

0:04:53.600,0:04:56.960
And so he did.

0:04:56.960,0:04:58.771
And what an education I got

0:04:58.771,0:05:00.450
from taking care of all the members

0:05:00.450,0:05:03.262
of his support group.

0:05:03.262,0:05:05.884
And then I got really confused,

0:05:05.884,0:05:08.492
because I thought it was relatively easy at that age

0:05:08.492,0:05:10.122
to just give people the hormones

0:05:10.122,0:05:14.421
of the gender in which they were affirming,

0:05:14.421,0:05:17.631
but then my patient married,

0:05:17.631,0:05:20.399
and he married a woman

0:05:20.399,0:05:22.095
who had been born as a male,

0:05:22.095,0:05:25.793
had married as a male, had two children,

0:05:25.793,0:05:31.183
then went through a transition into female,

0:05:31.183,0:05:36.460
and now this delightful female

0:05:36.460,0:05:40.247
was attached to my male patient,

0:05:40.247,0:05:42.984
in fact got legally married because they showed up

0:05:42.984,0:05:44.560
as a man and a woman, and who knew?

0:05:44.560,0:05:47.666
Right? (Laughter)

0:05:47.666,0:05:51.380
And while I was confused about,

0:05:51.380,0:05:53.796
does this make so-and-so gay?

0:05:53.796,0:05:55.684
Does this make so-and-so straight?

0:05:55.684,0:05:58.147
I was getting sexual orientation

0:05:58.147,0:06:01.182
confused with gender identity.

0:06:01.182,0:06:03.669
And my patient said to me,

0:06:03.669,0:06:05.334
"Look, look, look.

0:06:05.334,0:06:08.563
If you just think of the following, you'll get it right:

0:06:08.563,0:06:11.829
Sexual orientation is who you go to bed with;

0:06:11.829,0:06:17.657
gender identity is who you go to bed as."

0:06:17.657,0:06:20.343
And I subsequently learned from the many adults --

0:06:20.343,0:06:22.889
I took care of about 200 adults —

0:06:22.889,0:06:24.948
I learned from them

0:06:24.948,0:06:27.053
that if I didn't look, peek as to who

0:06:27.053,0:06:29.363
their partner was in the waiting room,

0:06:29.363,0:06:31.575
I would never be able to guess

0:06:31.575,0:06:33.045
better than chance

0:06:33.045,0:06:35.973
whether they were gay, straight, bi,

0:06:35.973,0:06:39.661
or asexual in their affirmed gender.

0:06:39.661,0:06:40.976
In other words,

0:06:40.976,0:06:43.760
one thing has absolutely nothing to do

0:06:43.760,0:06:45.361
with the other.

0:06:45.361,0:06:47.706
And the data show it.

0:06:47.706,0:06:52.240
Now, as I took care of the 200 adults,

0:06:52.240,0:06:54.585
I found it extremely painful.

0:06:54.585,0:06:57.615
These people were -- many of them

0:06:57.615,0:07:01.822
had to give up so much of their lives.

0:07:01.822,0:07:04.474
Sometimes their parents would reject them,

0:07:04.474,0:07:06.796
siblings, their own children,

0:07:06.796,0:07:08.577
and then their divorcing spouse

0:07:08.577,0:07:12.554
would forbid them from seeing their children.

0:07:12.554,0:07:15.894
It was so awful, but why did they do it

0:07:15.894,0:07:18.302
at 40 and 50?

0:07:18.302,0:07:22.822
Because they felt they had to affirm themselves

0:07:22.822,0:07:25.178
before they would kill themselves.

0:07:25.178,0:07:27.782
And indeed, the rate of suicide

0:07:27.782,0:07:31.323
among untreated transgendered people

0:07:31.323,0:07:34.757
is among the highest in the world.

0:07:34.757,0:07:37.100
So what to do?

0:07:37.100,0:07:40.170
I was intrigued in going to a conference

0:07:40.170,0:07:42.775
in Holland, where they are experts in this,

0:07:42.775,0:07:46.563
and saw the most remarkable thing.

0:07:46.563,0:07:49.915
They were treating young adolescents

0:07:49.915,0:07:52.528
after giving them the most intense

0:07:52.528,0:07:55.606
psychometric testing of gender,

0:07:55.606,0:07:57.423
and they were treating them by blocking

0:07:57.423,0:07:59.983
the puberty that they didn't want.

0:07:59.983,0:08:02.837
Because basically, kids look about the same,

0:08:02.837,0:08:05.486
each sex, until they go through puberty,

0:08:05.486,0:08:08.458
at which point, if you feel you're in the wrong sex,

0:08:08.458,0:08:11.500
you feel like Pinocchio becoming a donkey.

0:08:11.500,0:08:14.123
The fantasy that you had that your body will change

0:08:14.123,0:08:16.816
to be who you want it to be with puberty

0:08:16.816,0:08:21.555
actually is nullified by the puberty you get.

0:08:21.555,0:08:24.880
And they fall apart.

0:08:24.880,0:08:27.465
So that's why putting the puberty on hold—

0:08:27.465,0:08:29.869
Why on hold? You can't just give them

0:08:29.869,0:08:31.602
the opposite hormones that young.

0:08:31.602,0:08:33.619
They'll end up stunted in growth,

0:08:33.619,0:08:36.207
and you think you can have[br]a meaningful conversation

0:08:36.207,0:08:38.547
about the fertility effects of such treatment

0:08:38.547,0:08:42.584
with a 10-year-old girl, a 12-year-old boy?

0:08:42.584,0:08:44.893
So this buys time in the diagnostic process

0:08:44.893,0:08:46.745
for four or five years

0:08:46.745,0:08:49.803
so that they can work it out,

0:08:49.803,0:08:52.480
they can have more and more testing,

0:08:52.480,0:08:54.530
they can live without feeling their bodies

0:08:54.530,0:08:56.164
are running away from them.

0:08:56.164,0:09:00.346
And then, in a program they call 12-16-18,

0:09:00.346,0:09:05.219
around age 12 is when they[br]give the blocking hormones,

0:09:05.219,0:09:07.877
and then at age 16 with retesting,

0:09:07.877,0:09:09.989
they requalify.

0:09:09.989,0:09:13.194
Now remember, the blocking[br]hormones are reversible,

0:09:13.194,0:09:16.117
but when you give the hormones of the opposite sex,

0:09:16.117,0:09:18.750
you now start spouting breasts and facial hair

0:09:18.750,0:09:20.852
and voice, depending on what you're using,

0:09:20.852,0:09:23.122
and those effects are permanent

0:09:23.122,0:09:25.200
or require surgery to remove

0:09:25.200,0:09:26.421
or electrolysis,

0:09:26.421,0:09:28.791
and you can never really affect the voice.

0:09:28.791,0:09:33.090
So this is serious, and this is 15-, 16-year-old stuff.

0:09:33.090,0:09:36.253
And then at 18, they're eligible for surgery,

0:09:36.253,0:09:40.588
and while there's no good surgery[br]for females to males genitally,

0:09:40.588,0:09:45.359
the male-to-female surgery[br]has fooled gynecologists.

0:09:45.359,0:09:48.120
That's how good it can be.

0:09:48.120,0:09:51.980
So I looked at how the patients were doing,

0:09:51.980,0:09:54.990
and I looked at patients who[br]just looked like everybody else,

0:09:54.990,0:09:57.429
except they were pubertally delayed.

0:09:57.429,0:09:59.488
But once they gave them the hormones

0:09:59.488,0:10:01.999
consistent with the gender they affirm,

0:10:01.999,0:10:03.977
they look beautiful.

0:10:03.977,0:10:07.743
They look normal. They had normal heights.

0:10:07.743,0:10:09.976
You would never be able to pick them out

0:10:09.976,0:10:12.571
in a crowd.

0:10:12.571,0:10:14.927
So at that point, I decided I'm going to do this.

0:10:14.927,0:10:17.502
This is really where the pediatric

0:10:17.502,0:10:19.490
endocrine realm comes in,

0:10:19.490,0:10:21.471
because in fact, if you're going to deal with it

0:10:21.471,0:10:24.152
in kids age 10-12, 10-14,

0:10:24.152,0:10:27.434
that's pediatric endocrinology.

0:10:27.434,0:10:31.213
So I brought some kids in,

0:10:31.213,0:10:33.870
and this now became the standard of care,

0:10:33.870,0:10:36.627
and Children's Hospital was behind it.

0:10:36.627,0:10:41.068
By my showing them the kids before and after,

0:10:41.068,0:10:42.417
people who never got treated

0:10:42.417,0:10:44.945
and people who wished to be treated,

0:10:44.945,0:10:48.091
and pictures of the Dutch,

0:10:48.091,0:10:49.220
they came to me and said,

0:10:49.220,0:10:51.211
"You've got to do something for these kids."

0:10:51.211,0:10:54.518
Well, where were these kids before?

0:10:54.518,0:10:57.672
They were out there suffering, is where they were.

0:10:57.672,0:11:03.983
So we started a program in 2007.

0:11:03.983,0:11:06.135
It became the first program of its kind --

0:11:06.135,0:11:08.733
but it's really of the Dutch kind --

0:11:08.733,0:11:10.874
in North America.

0:11:10.874,0:11:15.071
And since then, we have 160 patients.

0:11:15.071,0:11:18.348
Did they come from Afghanistan? No.

0:11:18.348,0:11:21.621
They came, 75 percent of them came

0:11:21.621,0:11:26.689
from within 150 miles of Boston.

0:11:26.689,0:11:30.086
And some came from England.

0:11:30.086,0:11:33.905
Jackie had been abused in the Midlands, in England.

0:11:33.905,0:11:35.920
She's 12 years old there,

0:11:35.920,0:11:37.273
she was living as a girl

0:11:37.273,0:11:39.425
but she was being beaten up.

0:11:39.425,0:11:40.478
It was a horror show.

0:11:40.478,0:11:42.474
They had to homeschool her.

0:11:42.474,0:11:45.223
And the reason the British were coming was

0:11:45.223,0:11:48.588
because they would not treat anybody

0:11:48.588,0:11:50.528
with anything under age 16,

0:11:50.528,0:11:52.316
which means they were consigning them

0:11:52.316,0:11:55.784
to an adult body, no matter what happened,

0:11:55.784,0:11:57.808
even if they tested them well.

0:11:57.808,0:12:00.176
Jackie, on top of it, was,

0:12:00.176,0:12:02.751
by virtue of skeletal markings,

0:12:02.751,0:12:06.838
destined to be six feet five.

0:12:06.838,0:12:08.809
And yet, she had just begun

0:12:08.809,0:12:10.964
a male puberty.

0:12:10.964,0:12:14.409
Well, I did something a little bit innovative,

0:12:14.409,0:12:16.359
because I do know hormones,

0:12:16.359,0:12:18.429
and that estrogen is much more potent

0:12:18.429,0:12:22.135
in closing epiphyses, the growth plates,

0:12:22.135,0:12:25.452
and stopping growth, than testosterone is.

0:12:25.452,0:12:27.838
So we blocked her testosterone

0:12:27.838,0:12:30.396
with a blocking hormone,

0:12:30.396,0:12:34.735
but we added estrogen, not at 16, but at 13.

0:12:34.735,0:12:38.253
And so here she is at 16, on the left.

0:12:38.253,0:12:40.254
And on her 16th birthday, she went to Thailand,

0:12:40.254,0:12:42.397
where they would do a genital plastic surgery.

0:12:42.397,0:12:44.297
They will do it at 18 now.

0:12:44.297,0:12:47.161
And she ended up 5'11"

0:12:47.161,0:12:50.468
but more than that, she has normal breast size,

0:12:50.468,0:12:52.731
because by blocking testosterone,

0:12:52.731,0:12:54.361
every one of our patients

0:12:54.361,0:12:56.236
has normal breast size

0:12:56.236,0:13:00.411
if they get to us at the appropriate age, not too late.

0:13:00.411,0:13:02.691
And on the far right, there she is.

0:13:02.691,0:13:04.406
She went public,

0:13:04.406,0:13:07.488
semifinalist in the Miss England competition.

0:13:08.768,0:13:12.000
The judges debated as to, can they do this?

0:13:12.000,0:13:13.868
Can they make her —

0:13:13.868,0:13:16.159
And one of them quipped, I'm told,

0:13:16.159,0:13:18.214
"But she has more natural self

0:13:18.214,0:13:20.139
than half the other contestants."

0:13:20.139,0:13:22.106
(Laughter)

0:13:22.106,0:13:26.322
And some of them have been rearranged a little bit,

0:13:26.322,0:13:29.634
but it's all her DNA.

0:13:29.634,0:13:32.947
And she's become a remarkable spokeswoman.

0:13:32.947,0:13:36.957
And she was offered contracts as a model,

0:13:36.957,0:13:38.800
at which point she teased me, where she said,

0:13:38.800,0:13:40.880
"You know, I might have had a better chance

0:13:40.880,0:13:43.607
as a model if you'd made me six feet one."

0:13:43.607,0:13:48.060
Go figure. (Laughter)

0:13:48.060,0:13:51.713
So this picture, I think, says it all.

0:13:51.713,0:13:53.460
It really says it all.

0:13:53.460,0:13:57.311
These are Nicole and brother Jonas,

0:13:57.311,0:14:00.127
identical twin boys,

0:14:00.127,0:14:02.696
and proven to be identical,

0:14:02.696,0:14:05.186
in which Nicole had affirmed herself

0:14:05.186,0:14:07.416
as a girl as early as age three.

0:14:07.416,0:14:09.917
At age seven, they changed her name,

0:14:09.917,0:14:13.130
and came to me at the very beginnings

0:14:13.130,0:14:14.776
of a male puberty.

0:14:14.776,0:14:16.344
Now you can imagine looking at Jonas

0:14:16.344,0:14:18.102
at only 14 that male puberty

0:14:18.102,0:14:20.619
is early in this family,

0:14:20.619,0:14:22.870
because he looks more like a 16-year-old,

0:14:22.870,0:14:24.710
but it makes the point all the more

0:14:24.710,0:14:26.367
why you have to be conscious

0:14:26.367,0:14:28.319
of where the patient is.

0:14:28.319,0:14:32.279
Nicole has done pubertal blockade in here,

0:14:32.279,0:14:36.072
and Jonas is just going -- biologic control.

0:14:36.072,0:14:37.610
This is what Nicole would look like

0:14:37.610,0:14:39.790
if we weren't doing what we were doing.

0:14:39.790,0:14:42.182
He's got a prominent Adam's apple.

0:14:42.182,0:14:45.889
He's got angular bones to the face, a mustache,

0:14:45.889,0:14:47.409
and you can see there's a height difference

0:14:47.409,0:14:48.709
because he's gone through

0:14:48.709,0:14:50.749
a growth spurt that she won't get.

0:14:50.749,0:14:52.630
Now Nicole is on estrogen.

0:14:52.630,0:14:55.919
She has a bit of a form to her.

0:14:55.919,0:14:59.226
This family went to the White House last spring

0:14:59.226,0:15:01.847
because of their work

0:15:01.847,0:15:05.245
in overturning an anti-discrimination,

0:15:05.245,0:15:08.086
there was a bill that would block

0:15:08.086,0:15:10.343
the right of transgender people in Maine

0:15:10.343,0:15:12.022
to use public bathrooms,

0:15:12.022,0:15:15.145
and it looked like the bill was going to pass,

0:15:15.145,0:15:16.522
and that would have been a problem,

0:15:16.522,0:15:20.133
but Nicole went personally[br]to every legislator in Maine

0:15:20.133,0:15:22.207
and said, "I can do this.

0:15:22.207,0:15:24.158
If they see me, they'll understand

0:15:24.158,0:15:26.221
why I'm no threat in the lady's room,

0:15:26.221,0:15:28.558
but I can be threatened in the men's room."

0:15:28.558,0:15:31.996
And then they finally got it.

0:15:31.996,0:15:35.016
So where do we go from here?

0:15:35.016,0:15:37.406
Well, we still have a ways to go

0:15:37.406,0:15:39.029
in terms of anti-discrimination.

0:15:39.029,0:15:40.444
There are only 17 states that have

0:15:40.444,0:15:42.506
an anti-discrimination law

0:15:42.506,0:15:45.456
against discrimination in housing,

0:15:45.456,0:15:48.269
employment, public accommodation,

0:15:48.269,0:15:51.563
only 17 states, and five of them are in New England.

0:15:51.563,0:15:53.354
We need less expensive drugs.

0:15:53.354,0:15:54.787
They cost a fortune.

0:15:54.787,0:15:56.963
And we need to get this condition

0:15:56.963,0:15:59.000
out of the DSM.

0:15:59.000,0:16:01.609
It is as much a psychiatric disease

0:16:01.609,0:16:03.414
as being gay and lesbian,

0:16:03.414,0:16:06.375
and that went out the window in 1973,

0:16:06.375,0:16:08.217
and the whole world changed.

0:16:08.217,0:16:10.951
And this isn't going to break anybody's budget.

0:16:10.951,0:16:13.067
This is not that common.

0:16:13.067,0:16:17.705
But the risks of not doing anything for them

0:16:17.705,0:16:21.916
not only puts all of them at risk

0:16:21.916,0:16:24.373
of losing their lives to suicide,

0:16:24.373,0:16:27.070
but it also says something about

0:16:27.070,0:16:30.861
whether we are a truly inclusive society.

0:16:30.861,0:16:33.430
Thank you.

0:16:33.430,0:16:35.996
(Applause)