-
I want you all to think
-
about the third word that was ever said
-
about you,
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or if you were delivering,
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about the person you were delivering.
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And you can all mouth it if you want
-
or say it out loud.
-
It was, the first two were, "It's a..."
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Well, it shows you that
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I also deal with issues where there's
-
not certainty of whether it's a girl or a boy,
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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."
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"A lesbian girl."
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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,
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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.
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But at the time that puberty begins,
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that means between about age 10 to 12 in girls,
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12 to 14 in boys,
-
with breast-budding
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or two to three times increase in the gonads
-
in the case of genetic males,
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by that particular point, the child who says
-
they are in the absolute wrong body
-
is almost certain to be transgender
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and is extremely unlikely to change those feelings,
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no matter how anybody tries reparative therapy
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or any other noxious things.
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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,
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went through Harvard genetically female,
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went through Harvard with three male roommates
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who knew the whole story,
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a registrar who always listed his name
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on course lists as a male name,
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and came to me after graduating saying, "Help me.
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I know you know a lot of endocrinology,
-
and indeed I've treated a lot of people
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who were born without gonads.
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This wasn't rocket science,
-
but I made a deal with them:
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I'll treat you if you teach me.
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And so he did.
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And what an education I got
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from taking care of all the members
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of his support group.
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And then I got really confused,
-
because I thought it was relatively easy at that age
-
to just give people the hormones
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of the gender in which they were affirming,
-
but then my patient married,
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and he married a woman
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who had been born as a male,
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had married as a male, had two children,
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then went through a transition into female,
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and now this delightful female
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was attached to my male patient,
-
in fact got legally married because they showed up
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as a man and a woman, and who knew?
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Right? (Laughter)
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And while I was confused about,
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I was confused, does this make so-and-so gay?
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Does this make so-and-so straight?
-
I was getting sexual orientation
-
confused with gender identity.
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And my patient said to me,
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"Look, look, look.
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If you just think of the following, you'll get it right.
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Sexual orientation is who you go to bed with.
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Gender identity is who you go to bed as."
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And subsequently I learned from the many adults
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— I took care of about 200 adults —
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I learned from them
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that if I didn't look, peek as to who
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their partner was in the waiting room,
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I would never be able to guess
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better than chance
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whether they were gay, straight, bi,
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or asexual in their affirmed gender.
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In other words,
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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.
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Sometimes their parents would reject them,
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siblings, their own children,
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and then their divorcing spouse
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would forbid them from seeing their children.
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It was so awful, but why did they do it
-
at 40 and 50?
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Because they felt they had to affirm themselves
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before they would kill themselves.
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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
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in Holland, where they are experts in this,
-
and saw the most remarkable thing.
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They were treating young adolescents
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after giving them the most intense
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psychometric testing of gender,
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and they were treating them by blocking
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the puberty that they didn't want.
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Because basically, kids look about the same,
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each sex, until they go through puberty,
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at which point, if you feel you're in the wrong sex,
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you feel like Pinocchio becoming a donkey.
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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.
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And they fall apart.
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So that's why putting the puberty on hold—
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Why on hold? You can't just give them
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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
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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,
-
to 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)
Adrian Dobroiu
15:24 lady's room -> ladies' room
Krystian Aparta
The English transcript was updated on 12/7/2015. At 10:34, "and Children's Hospital was behind it" was changed to "the [Boston] Children's Hospital was behind it."