How I help transgender teens become who they want to be

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 had 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 him:

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,

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 I subsequently 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 looked like everybody else,

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've got to 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 the Midlands, in 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 homeschool 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.

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, 18 or not.

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 Miss England competition.

The judges debated 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 pubertal blockade in here,

and Jonas is 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)