Pleasantville: How the “Myth of Binary” Harms Our (Trans) Children

March 28, 2022

Information

March 23, 2022

D. Micah Hester, PhD

Chair, Department of Medical Humanities & Bioethics

Clinical Ethicist (UAMS & Arkansas Children’s Hospital)

ID7617

To CiteDCA Citation Guide

00:05OK, my friends welcome.
00:07Welcome to the Yale Pediatric Ethics
00:10Program Evening Ethics seminar series.
00:13And tonight we have an old friend of mine,
00:17Doctor Micah Hester.
00:20Mica mica is the chair and professor
00:22of medical, humanities, and bioethics,
00:24and he's also professor of Pediatrics at the
00:27University of Arkansas for Medical Sciences,
00:30and he's a clinical ethicist there
00:32and at Arkansas Children's Hospital.
00:35When asked Micah to send me a bio,
00:38he sends me a thing.
00:38He said that and then he
00:40says here's Michael story.
00:41He writes stuff,
00:42teaches students and has known to
00:44sing to Spotify in his car.
00:46Otherwise, it isn't entirely clear what
00:48qualifies him to give a talk for an
00:50audience associated with Yale University,
00:52so that's Mike's biography.
00:54OK, so this of course,
00:55let's me tell you why Michael
00:57has to his qualified,
00:58even though he doesn't believe it,
01:00I'm so I would tell you that
01:01that I have been in pediatric
01:03ethics circles for some time now.
01:05And anybody who in the United
01:08States who who studies pediatric
01:09ethics and speaks about it is very
01:12familiar with Mike and his work.
01:14I we've used his book here on
01:17ethics committees for some time.
01:19He has been insightful speaker and
01:22writer and is certainly one of the
01:24shining lights in pediatric ethics
01:26in the United States and so Yale
01:28University is quite honored to have
01:30Professor Hester here with us.
01:33I'd also point out something interesting,
01:34which is that most of the folks in
01:36pediatric ethics who are leaders
01:38in this field.
01:38Most of the folks really are
01:40other physicians or nurses,
01:42and Mike has a PhD in philosophy.
01:44It's really important to have the
01:46clinicians perspective on these matters.
01:48It's also as I think,
01:49most on this call realized,
01:51really important,
01:52really beneficial to have the non
01:54clinicians perspective on these things.
01:56Sometimes we need to hear from folks
01:58who aren't as deep into the trenches
02:00as the physicians and nurses are.
02:02Though I have to say because
02:03of Mike's position there,
02:04Mike is pretty deep into the trenches as
02:06well in a different in a different manner.
02:08Perhaps he got his PhD in philosophy
02:10as well as an MA in philosophy from
02:13Vanderbilt University and his bachelor's
02:15degree was from Pomona College.
02:17Mike has been at Arkansas for many years,
02:19and as I said,
02:20he is the chairman there it is
02:22my pleasure to introduce Doctor
02:24Micah Hester who is going to
02:26speak to us on the Pleasantville.
02:29The myth of the normal and how
02:31this harms our trans children.
02:33Doctor Michael Hester.
02:34Welcome to Yale and thank you
02:36Sir very much thank you now,
02:38wait Michael before you start talking.
02:40I forgot to tell everybody I told
02:42you just for those folks who are new
02:45to our series, it's going to work.
02:46This way,
02:47which is to say that Mike is
02:49going to speak for 45 minutes to
02:51an hour in that range,
02:52and afterward we will have questions,
02:56and I'll invite you folks to
02:58submit questions through chat
02:59or Q&amp;A. Com Chat is fine,
03:00and I'll ask Michael the questions that
03:02you submit and we'll have a bit of a
03:04conversation as best we can under zoom.
03:06These things tend to work pretty well,
03:08and then we'll go until 6:30,
03:10at which point I'll say thank you to you.
03:13Well, and I'll apologize not
03:14to whoever questions I didn't
03:16get to when we hit the 6:30.
03:17Right, thank you all very much.
03:19You're going to hear about.
03:20I think from Karen you may already.
03:21I'll just check my chat here.
03:23You already heard about this.
03:24DM me and you're gonna put in
03:27their touch the texting code.
03:28You know what I send them the
03:30number they need to text that to
03:31Karen so we can do that as well.
03:33And then folks will have that.
03:34And I'm done talking.
03:35I'm very happily turn this over to my
03:38friend and colleague Micah Hester,
03:39Professor Hester.
03:41Thank you, I appreciate that mark very much.
03:43That from Curiel is far too kind to me.
03:47I'm I've been doing this for quite
03:49awhile and I'm a philosopher and never
03:52no one should ever trust a philosopher.
03:55But having said that, you're going to
03:57just have to listen to me now anyway.
03:59And I'm very glad to be here.
04:01Quite honored, in fact,
04:03to give a talk at, well,
04:05the Pomona College of the East,
04:07quite frankly so.
04:10Let's get going.
04:12I was asked to talk about the
04:15issues in care of transgender youth
04:18and this is a quite timely topic.
04:23I mean, it would have been timely a
04:25year ago or two years ago, but it is.
04:29It is that on a hot plate now,
04:31as it were given so much that's going on so.
04:37Here's the objectives these you put
04:39in for CE credits and who knows
04:41if I'll actually get to them.
04:43But disclosures are important.
04:45I'll let those run in the background
04:47while I explain that when I
04:50was asked to give this talk.
04:53What kept going through my head
04:55is I'm just not sure why it is we
04:59hate transgender people as much
05:01as we do in this society.
05:06And I kept going round and round about
05:10this idea and it's what gave me kind of
05:14the jumping off point that jumping off
05:16point is the movie Pleasantville from 1998.
05:21If you don't know the movie
05:23The movie Pleasantville is.
05:27About well, it's about a teenager
05:31and his family in the 1990s,
05:34and his mother had.
05:36He lives with his mother.
05:37His parents are divorced and he in
05:41part in order to kind of deal with his
05:45frustrating and complex life gets.
05:50Gets obsessed with the television
05:52show Pleasantville,
05:53which is a pseudo fake 1950s black and white.
06:00Yeah, family show right.
06:02Ala Ozzie and Harriet or Father
06:05knows best or the Donna Reed show,
06:07or any of those kinds of things.
06:09And Tobey Maguire plays character.
06:14David, who gets sucked into the show.
06:17And so he goes from the 1990s
06:20and gets sucked back into this
06:23television show in some magical way,
06:26but who also gets sucked in is his sister,
06:29who thinks he's a geek and she
06:31thinks everybody like him.
06:32He's kind of a nerd and but she
06:35gets sucked back into this very.
06:38This very two dimensional,
06:40literally and figuratively life
06:43of of Pleasantville,
06:45and this idea and the whole idea of
06:49Pleasantville is that everything that
06:53everything is quite black and white.
06:56Think there is good and there is bad
06:58and there is the nuclear family,
07:01that is that is well oiled and
07:04seasoned and everybody has this
07:07error of getting along and that.
07:09You know this is the Voltaire candied
07:13myth of the best of all possible
07:16worlds kind of thing going on.
07:19But something happens, what happens is?
07:24You might say truth is is.
07:29Is inserted into this life because
07:31of the existence of Tobey Maguire
07:34and Reese Witherspoon's character
07:35is coming from the 1990s at into
07:39this two dimensional 1950s sitcom.
07:42And because of those, because of that,
07:47insertion of reality really
07:49usually coming through either
07:52sex or love as the show has it,
07:55color starts to happen,
07:57complexity happens,
07:58but this is a scary thing
08:00for all the characters,
08:02and in fact the mother of of Bud.
08:08Has these deep feelings
08:10for another character,
08:12not her husband and and because
08:15of that she herself changes into
08:18color from black and white,
08:21but now she's scared because
08:24she's something other.
08:25She's showing her real self,
08:27but in a world that's not ready for it.
08:30And frankly she isn't ready for it either.
08:34And.
08:35This foundational myth is a myth
08:37that the United States and others,
08:40but I mean, certainly we'll
08:42talk in the United States terms.
08:43This foundational myth is our myth,
08:47and it's of course exacerbated
08:49and and kind of amplified.
08:50In a movie like this,
08:52the idea that there really that that
08:54the world really is a very simple space
08:57and that and that it's better that way.
08:59And this simplicity makes
09:02everything run well and and and.
09:06No one should want out of
09:09this space until they taste.
09:11Reality and then they start to realize
09:14that maybe in fact there's something more.
09:17That challenging reality happens
09:19and we make Macy's character.
09:21Who's the father here looks at his wife,
09:24who's changed color, right?
09:26And says and it'll go away.
09:27It it it? I'll it'll go away, right?
09:30I mean, don't don't worry, this is.
09:32This is some weird kind of virus
09:34so much that's that's hit and and
09:37she comes to realize John Allen's
09:40character comes to realize that that.
09:42She doesn't want to change.
09:44This really is who she is and with
09:46all the challenges that it brings up.
09:50She wants to say this way, well,
09:52the other part of the complexity here is,
09:54of course this is happening within this very
09:57insular community of Pleasantville on TV,
09:59and within that insular
10:01community the the people.
10:04The whole community is scared and frustrated,
10:07and the town leaders.
10:10The town leaders themselves are concerned
10:13and they call Tobey Maguire's character
10:16kind of into a town meeting about this.
10:19Trying to stop this scourge
10:22of of colourising as it were.
10:25And and main character Big Bob
10:27says this behavior must stop at
10:30once to be turns to and says.
10:32But see, this is just the point.
10:34It can't stop it once because it's in you.
10:37And you can't stop something
10:39that's inside you.
10:41And.
10:41As it all goes through,
10:43eventually color actually comes
10:45to this whole universe by the
10:48end of by the end of the movie.
10:51And in in A twist in it, spoiler.
10:55Tobey Maguire actually is able to get
10:57back to his own timeline of the 1990s,
10:59but Reese Witherspoon actually stays.
11:02She's she's kind of the one that
11:04jumpstarts this whole thing,
11:05because she doesn't understand this.
11:07Crazy is crazy 2 dimensionality,
11:11but she decides to stay and and figure
11:14out how to get her life in order.
11:18But obviously this is a parable about a
11:22great many things in our in our world.
11:26I think you can see already how this
11:30speaks to our our situation in the
11:34United States regarding transgender persons,
11:37whether they be adult or youths.
11:41And it's because we live in this idea
11:44of of a myth of binary and it's not
11:48exclusive to issues of gender at all.
11:51We see the myth of binary in
11:54many different modes, right?
11:55Fact and value.
11:56There's facts and there's values.
11:58But in fact,
12:00as it were.
12:03Facts themselves are already infused with
12:06values and values themselves are part of the
12:09real world and not something on top of it.
12:12It's not something that transcends the world,
12:15they're part of it, and so this
12:17distinction between fact and value.
12:18And all of these distinctions can be
12:20analytically useful for certain purposes.
12:23But they're myths when we reify them
12:26into kind of metaphysical conditions.
12:29Or sometimes we fosters,
12:31called ontologically different conditions.
12:33Same is true of good and evil.
12:37That there's some pure good and some pure
12:39evil and and near the twain shall meet.
12:42And the reality is,
12:44it's a weird mixture of all of this.
12:46And what makes things good and evil
12:49can be purposeful as much as anything.
12:52Free and enslaved.
12:56Are we all completely free?
12:57Is there something situations
12:59and complete enslavement again?
13:01These are myths of a of a certain kind of
13:05binary or dyad, substance and accidents,
13:08order and chaos, spirit matter, mind body.
13:14Right or Diet Coke and Diet Pepsi?
13:17OK, that's really not a myth.
13:19'cause everybody knows Diet Coke is the
13:21real thing and diet Pepsi is just a sad,
13:24sad, sad imitation.
13:27But in all seriousness that this
13:30idea of binary is is a way we help
13:34order our world and make a very
13:38complex world much easier to handle.
13:40And again, for certain analytic
13:42purposes, we absolutely should.
13:46Continue to to recognize these
13:49kinds of distinctions, but we can't.
13:53Then we shouldn't then.
13:55Determine that those distinctions map onto.
14:01Map onto a certain trueness of complete.
14:06And utter difference in the real world.
14:13And of course we see this.
14:14Then in the myth of gender binary as well,
14:17and you can read these quotes as I
14:19go through, but right we we talk
14:21about male and female men and women,
14:25boys and girls, masculine and feminine,
14:30as if these are distinctions that
14:34connect and only distinctions to be made,
14:38that there is no middle ground. No other.
14:42There are only male and female and
14:45you can see in quotes and this these
14:49quotes are being pulled from the.
14:51Not just recent controversies of of
14:54the recent NCA swim championships
14:59with Lea Thompson,
15:00but but other kinds of situations
15:03that we've been talking about,
15:05but the in our culture.
15:07But these these quotes kind of bring
15:10up this same idea and myth that
15:13ideology is trans women or women.
15:16But then there's the biological part.
15:18The idea, the idea ideology is not fact.
15:22Is not a fact that the idea,
15:25the ideology is not a fact.
15:26It is not a fact that trans women are women.
15:30The fact is,
15:31biological man is a biological man.
15:33A biological woman is a biological woman.
15:35Little thing called science and DNA.
15:38See, but here's the thing.
15:40And philosophers know this.
15:42And the rest of us should.
15:45And that is when we talk about things
15:48like biological woman and biological man.
15:51We're already.
15:53Talking about conceptions about
15:56impressions and not observations,
15:59the observation might be the DNA
16:02or the chromosomes or whatever.
16:04And and the fact that we map these
16:08onto distinct categories we call
16:10men and women is a thing that we
16:13do as human beings as a community.
16:16As a social consensus,
16:19it is not necessarily mapped onto
16:22the whole of reality.
16:24Because in point of fact,
16:25since the dawn of the human race,
16:28there hasn't always just been ** and XY.
16:31There have been X,
16:32XY and other kinds of chromosome conditions,
16:37and it's not as if those people
16:41aren't people and human.
16:43But we call them aberrations or
16:46abnormal or something like that rather
16:50than recognizing that they may be variants.
16:54Within the normal range of
16:56what it means to be human?
16:59And of course means love to bring up this
17:01myth right in the world of social media.
17:03And I thought them hippie.
17:04Big baby boomers were were bad, right?
17:08They at least knew the gender
17:09was gender and all that stuff.
17:11But they didn't.
17:12We never did and you can go back
17:15through history and you can see the
17:18many times in which history shows us
17:21that human beings all along have lived
17:24trying to understand what it meant
17:27for them to live their lives under
17:29certain social morays of 1 gender
17:33or another or some fluidity therein.
17:37And and the fact that we continue
17:41to reify this reify this binary.
17:46It is troubling when you look at reality.
17:50So why do I call this a myth?
17:52I call this a myth because because
17:55let's let me be quite transparent here.
17:59I call this a myth because.
18:03It's I have a particular worldview what
18:06the Germans call a Weltanschauung.
18:09I have a particular worldview in my
18:12worldview differs from other people,
18:14those the the worldview of the myth of
18:17the the worldview of Pleasantville right?
18:20And whether I from my standpoint,
18:23Pleasantville is a myth
18:25from the Pleasantville IANS.
18:27They didn't see it that way,
18:28at least not initially.
18:30Now, of course,
18:31neither of our will do is live in a vacuum.
18:34Our worldviews deal with one another.
18:38And so part of the challenge is
18:40always going to be that different
18:42human beings will hold different
18:44worldviews and at some point I can't
18:46necessarily argue someone else
18:48out of their own worldview, but.
18:52As long as we live together,
18:54we must account for each others worldviews.
18:57We must talk about them.
18:58We must deal with them when they
19:01come into conflict.
19:02My worldview comes from my study
19:06of folks like American philosopher
19:08William James who talked about the
19:12idea that experience is like a stream.
19:15Everflowing and contiguous
19:17continuous and in fact,
19:20when we carve up experience,
19:23we do so for analytic purposes when there is,
19:26when it hits a rock and splits,
19:29it's the irritation of doubt
19:31that comes up and says how do
19:34we reroute and go around this?
19:36It creates a question for us,
19:38and thus we may analyze our
19:40world in various ways,
19:41but it's still a flowing continuous stream.
19:44It is artificial.
19:45You might say that we break up
19:47experience in different ways in order
19:49for us to live our lives successfully,
19:52so we must do it.
19:54But any particular cut or break
19:57in the stream of experience is
19:59for particular purpose. It isn't.
20:03It isn't any.
20:05One particular cut is not necessarily
20:08a necessary cut,
20:09it is one that we use in order to move on.
20:12And that's my worldview.
20:14And so in that worldview.
20:16These ideas of true binary Ness of of
20:22complete complete separation between
20:25concepts or genders or whatever.
20:29Whatever the issue is.
20:32That kind of split actually is
20:35that just doesn't doesn't fit well
20:38with my worldview and I want to be
20:41transparent about that up front.
20:43Well up front ish.
20:45I've been talking for awhile already so.
20:48So for me,
20:49the idea that there is an existence
20:52of a non binary fluidity in life is
20:55part and parcel of what it means to
20:57see the world as a continuous streams
21:01of experience and that even biology.
21:03Again as I said,
21:04historically we know biologically
21:08human beings haven't just been
21:11one or two different sets of
21:14biological maps of genetic maps.
21:17They just haven't.
21:18And and just because most people fit
21:22into one of two genetic mappings doesn't
21:25mean that those are the only two that matter,
21:29and that's how we've done done
21:30this in our world is.
21:32We've turned it into what matters is.
21:37Men or.
21:38Right or XY and women ** right,
21:42and that's what matters.
21:43And again,
21:44is that what matters?
21:45It's interesting when you have
21:47these discussions because
21:49at some point people will talk about well,
21:51what matters is, say, genitalia.
21:54Or maybe it matters how
21:56we're perceived by others.
21:57Or maybe it matters about genetics.
21:59So what do we even mapping
22:01onto when we map onto these?
22:03When we try to map our conceptual
22:06categories onto something we think is more?
22:09Solid in meal,
22:10more scientific as that quote had it.
22:15Something to recognize as we
22:17kind of move closer to than some.
22:20Some of the further comments as opposed
22:22to the background here is that there
22:25is a reality to gender diversity.
22:28We may only say look,
22:30you may only turn to me and say
22:33what you call the reality of gender
22:36diversity are different expressions
22:38of experiences that that person have,
22:41but in fact that's not the
22:42reality of the diversity.
22:43'cause the diversity either comes
22:45in the genetics or it doesn't.
22:47And what's very interesting about
22:49that is even as we get into in a
22:53second some state laws and stuff
22:55that are that are designed to.
22:58To curb or or eliminate
23:02transgender care for children.
23:05For teenagers,
23:07even those even some of those laws
23:11within their definitions define gender
23:13as as a cultural experiential category,
23:18not as not necessarily as
23:21a category of genetics.
23:24So there is still the rest recognition.
23:26The gender is this cultural.
23:28Category and if that's true,
23:30then we need to recognize that culturally
23:34people are telling us something.
23:37And what we are learning is that.
23:41Teenagers, people you know,
23:45even younger than teenagers,
23:47but at least teenagers,
23:48when they're when they're
23:50surveyed at a clip of almost 10%,
23:52are willing to tell us that they experience
23:55themselves as gender diverse, right?
23:59Or within the gender diverse universe.
24:02And. If 10% of them are willing to
24:06tell us that within a culture that
24:08lives primarily by this myth of the
24:11binary and the frustration and and
24:14struggles that such a culture creates,
24:17you have to imagine that it's
24:19actually higher than that.
24:20Because it would be hard for those,
24:24it would be hard for many people
24:25to be able to say that even
24:27in an anonymous survey.
24:31So that gets us to the current legal
24:34landscape, and I fear that the next
24:36button I'm going to hit is going
24:37to screw up and not look nearly as
24:39pretty as it should, so I'll get.
24:41I'll hop into this slide very quickly,
24:43but the legal landscape is very
24:45important because in the last few
24:47years in particular in my state is
24:49paradigmatic in this state of Arkansas.
24:51And so we'll get to that in a second.
24:53But in the last few years,
24:54the legal landscape has changed greatly when
24:56it comes to transgender care for minors.
25:00So in just the last few years,
25:04three States and I have passed different
25:08kinds of laws that limit or eliminate.
25:15Care transgender care,
25:18medical or surgical for minors,
25:23and all of these states.
25:25Sorry for how how this all pumped up today.
25:27All of these states have are attempting
25:30in this year in 2022 to do the same.
25:33Some haven't made it.
25:34I've already been withdrawn or
25:36died in committee or didn't pass,
25:38but many of them are still working their
25:41way through their state legislatures.
25:43Some will not.
25:43Some of these on this list won't pass.
25:46Some of these were.
25:47And so more and more states are doing this.
25:50What we know is that since 2018,
25:53about 670 anti LGBTQ bills were
25:56filed by state legislators.
25:59And just in this year alone, 240 were filed.
26:03And roughly 50,000 teens
26:06could lose medical care.
26:09We could use medical care for their
26:12for their concerns about transgender
26:15experience and and considerations.
26:20If all these states actually passed laws,
26:22and that's a that's a conservative
26:24estimate on how many really are affected.
26:26In fact, in the state of Arkansas,
26:28the numbers roughly about 1500 that have been
26:34seeking care in the last couple of years.
26:37So like I said, unfortunately my
26:39state is paradigmatic in this move,
26:42and they passed what
26:43they called the SAFE Act.
26:45I'm not so sure about that.
26:47Save adolescents from experimentation,
26:50which is also another terrible,
26:53clever rhetorical device,
26:55politically used.
26:57But unfortunately I think inaccurate.
27:00And that law and several other states
27:02have taken this as the paradigm law.
27:04So they are trying to pass
27:06this same law in other states,
27:08physician or health care professional
27:10shall not provide gender transition
27:12procedures to any individual under
27:1318 a physician or health care
27:15professional shall not refer any shall
27:17not refer any individual under 18.
27:21To any health care professional
27:23for gender transition procedures,
27:24and by the way,
27:26that's that also means referral
27:28to out-of-state places.
27:31Gender transition procedures mean and.
27:33So what does this all mean?
27:35It means alter or remove physical
27:39anatomical characteristics.
27:40Instill or create physiological
27:42or anatomical characteristics
27:43that resemble a sex different from
27:46the individuals biological sex,
27:47including, without limitation,
27:49medical services that provide
27:51puberty blocking drugs,
27:52cross sex hormones,
27:54or other mechanisms to promote
27:56the development of feminizing
27:58or masculinizing masculinizing
28:00features in the opposite biological
28:02sets or genital or non genital
28:05gender reassignment surgery.
28:06That's our law. It was passed in 2011.
28:11It was fairly quickly.
28:15The ACLU brought suit and it
28:17was suspended by the courts,
28:18and it is currently under suspension.
28:22However, it is most of our
28:25legal experts around the state.
28:28Believe that in fact it will.
28:32The courts will go ahead and allow it to.
28:36Allow it to.
28:39Go back well unsuspended and I
28:41allow it to be the law of the state.
28:44Of course, more students may come thereafter,
28:47but the moment it does we we would
28:51have to stop all all transgender
28:55based care for anyone under 18,
28:59even if parents if parents
29:02are supportive of it.
29:04And as such, we've ended up.
29:08We've ended up limiting our
29:10gender or gender clinic at our
29:13Children's Hospital so that it
29:15only it's only seeing patients
29:18that it's already been seeing.
29:19It is not taking any new
29:21patients and and it's trying to.
29:25It's trying as best as possible to refer
29:28while the law still is not implant.
29:34Other states have tried different things.
29:35Texas was unable to pass such
29:37a law through its legislature,
29:39so the Attorney General and the governor
29:42of the state decided to render an opinion
29:47on child maltreatment and determined
29:50that there the child maltreatment
29:53that that Jan Stander care should be.
29:57Should be interpreted as child
30:02maltreatment and so that that too
30:05has gone under suit in that state,
30:08but that's the opinion.
30:09Now, of course it's a nonbinding opinion,
30:12but having said that, it it means that the.
30:16The state based prosecution Attorney
30:18Generals Office is willing to try
30:21prosecute anyone who provides or refers
30:24for transgender care in the state of Texas.
30:27Other states are now trying to write
30:29legislation that puts that in as well.
30:31I think Idaho,
30:33or if I'm not mistaken,
30:34is a state using that kind of
30:36language in there.
30:37But what few states are trying to do?
30:40All of this is very interesting because
30:42when you do a public opinion poll,
30:44what you learn is that in
30:46fact majority of Americans,
30:48regardless of their political
30:50stripe majority of Americans,
30:53actually believe that states shouldn't
30:55pass laws in relationship to this.
30:59That the government should should not step
31:01in and let medicine take care of itself,
31:05so I think that's an important
31:07context to keep in mind.
31:13That leads us then to this question.
31:17States are stepping in and
31:20saying medicine and health care
31:23providers shouldn't be doing this.
31:25And part of this is raised because of
31:28a view that says that this shouldn't
31:31even be a medical issue then.
31:33In fact, when you call it child
31:35abuse or something like that,
31:37it would render it a non medical.
31:42Non medical condition and any medical
31:45response would be inappropriate in such case.
31:48So the question is,
31:49does it fall under the umbrella medicine?
31:51Does transgender care fall
31:53under the umbrella medicine?
31:54And I think what I want to do is follow
31:57me carefully here because this can be a
31:59little bit challenging but I wanna I wanna.
32:01See if we can do this.
32:05What is medicine?
32:07I think it could be defined
32:09a number of different ways.
32:10Some people define quite broadly,
32:12it's just well being.
32:13Medicine is about well being,
32:15but then that starts to bring in things
32:17like self help is self help and self help.
32:19Books and stuff.
32:20Is that medical care maybe not.
32:22So that starts to undermine
32:25that broad sense.
32:29Some people defined it as living
32:32healthily or healthy living or
32:34helping people live healthily.
32:35By the way, I've defined it that
32:38way in some of my own work,
32:40but it does raise the question.
32:41So then what is health
32:43and how does how do we?
32:45What do we mean by health in
32:47relationship to living healthfully?
32:48Is it just well being
32:50or is it something else?
32:53But we could get more narrow
32:54and we could say no.
32:55Medicine is really just about
32:57dealing with illness and injury.
32:59That's probably as narrow as we probably get.
33:02But then you start to ask about things
33:04like what about primary preventative
33:06care or OB care or something?
33:08Those aren't illnesses or
33:10injuries that we're dealing with,
33:12and we say it's under the umbrella medicine.
33:14So is it?
33:16Is illness and injury really the correct
33:18way to think about what medicine is?
33:21So let's broaden it a little bit more.
33:23Again,
33:23remember I'm kind of on record for a a
33:25broader definition like living healthfully,
33:27but I'm trying to play this through
33:30to to see how narrow can we go
33:34with this definition and given
33:36how narrow we go if if we get it.
33:40In a narrow enough definition that we
33:42that that most people can agree to,
33:45would transgender care fall
33:47under that umbrella?
33:48And so if we said it's about illness,
33:50injuries, injury, and the prevention thereof.
33:54The psychiatry count in
33:57that is cosmetic surgery.
33:59Count in that if we do that,
34:01but let's go ahead,
34:03and I mean there's still questions about
34:06this narrow definition as the definition,
34:09but let's hold on to that for
34:11a second and then think about.
34:14Does trans you know where does
34:16transgender care fall in that?
34:18Is it in it is transgender
34:21identity and illness?
34:22Well,
34:23I think that's I think that's
34:25a problem that's a problematic
34:27way to think of it in general.
34:28So if we held that medicine is about illness,
34:32injury, and prevention thereof,
34:34it's a little hard.
34:35I think it's does a disservice to
34:38transgender identity to call it an illness,
34:41though it does have physiologic,
34:43psychological,
34:44and existential elements to it and.
34:49It may, it may have effects on all of this,
34:52so it may then have something
34:55to do with prevention, right?
34:57Does it result in injury and illness?
35:00Does does transgender identity in
35:03our universe and and world does it?
35:06Create
35:10a scope of of of conditions
35:13that fall under medicine.
35:15I think there's no question about that.
35:19And it's within that sphere that
35:21even the more narrow definition
35:23has to start acknowledging that
35:25transgender care matters, right?
35:29And so can health care as what
35:32they do in their physiologic and
35:35psychological conditions of health care?
35:37Can we help patients live healthfully?
35:40Can we help patients?
35:43Using the tools of healthcare
35:46transgender patients,
35:47and I think the answer is clearly yes,
35:49but I'm not the only one, right?
35:52Different professional societies
35:54certainly think so right?
35:57Child and analysts, psychiatry,
36:00Pediatrics,
36:01endocrine society all recognize that
36:04translator youths are at risk of various
36:08of various conditions that they're
36:11identifying their their identity.
36:13Requires a response from health care
36:16that's affirming and supportive so,
36:19so in all of this professional societies
36:23within medicine are saying yes,
36:26this is right. Go on, there's.
36:29These are just three examples.
36:30There are many professional
36:31societies that that do this.
36:35And look, even if we just narrowly,
36:38and I'm not saying by any means we should.
36:40But even if we just narrowly looked
36:42at the issue of mental health.
36:45For you seeking transgender care.
36:49This is what we know. We know that.
36:53Transgender youths have high rates
36:55of depression, anxiety, self harm,
36:58and suicidality and multiple studies
37:00have done this and just showing you
37:02a couple but multiple studies have
37:04shown this right and you can see that
37:07versus the the rate among all teens.
37:12And the other thing we know is that
37:15that good gender affirming care
37:17actually helps reduce this aspect of of.
37:21Of kids lives that it helps
37:24reduce their depression,
37:26anxiety, anxiety and suicidal
37:29suicidal ideations that seems.
37:32Central to the mission of medicine is to
37:37help reduce these kinds of bad outcomes,
37:41right? And that leads us then too.
37:46Not just to the question of whether
37:48or not transgender care falls
37:50under the umbrella of medicine,
37:51but what should we do in
37:54the clinical encounter?
37:55And how should clinicians respond to
37:58transgender children or children who
38:01are are gender diverse and and trying
38:04to think through and their experiences
38:06or work through their experience?
38:09So let's get this out of the way.
38:12Well, not up front,
38:13but up front for this particular
38:14part of the talk,
38:15let's get this out of the way and
38:17as an individual practitioner with
38:18laws and licensure guidelines allow
38:20you to opt out of providing direct
38:22patient care for transgender persons,
38:24adults or children.
38:26OK,
38:26as an individual practitioner you
38:28can say I don't want to do that
38:31and you are protected to do so.
38:33It is within your legal and
38:35licensure rights to do that.
38:37There's no question about that.
38:39In fact,
38:39in Arkansas we passed yet another
38:41law in the same year that we passed
38:43the quote UN quote Safe Act passed
38:46another law that expanded the idea
38:48of protection of the individual
38:50practitioner to refuse to provide such care.
38:54But please don't.
38:55Don't these patients need the expertise
38:57in medical and mental health professionals?
39:00They need it.
39:01Whatever your particular
39:03values and worldviews are.
39:06Actual individuals are suffering.
39:08Because of the conditions they're under,
39:12the experiences they're having,
39:14and you have an ability to help with that.
39:17Whether you help it directly or.
39:20Or get them help from other experts
39:23who may be better positioned to do it,
39:26but walking away please don't.
39:29And why shouldn't you walk away?
39:31Because the nature of medical relationships
39:33is the right healing action for this patient.
39:36That's what it's about.
39:38It's about helping them reconnect
39:39with their community,
39:41their everydayness so that they
39:43can live their lives connected,
39:44not disconnected and.
39:47It's about trust.
39:49Every patient that shows up at our door,
39:51unless they're unconscious,
39:52demonstrates even a little bit of trust.
39:54Even if they tell us they don't trust us,
39:56the fact that they show up at the
39:58door shows they have some trust that
40:00the parents of these use as well
40:03as these children are showing some
40:05trust and and it's fundamental to
40:07the relationship that you work on a
40:10healing action for this patient in
40:13order to help them reconnect with
40:14the community that they're part of
40:16our communities that they're part of.
40:18And that you do trust.
40:20So we must show them respect
40:22and trustworthiness,
40:23that our actions are trustworthy.
40:24These are just the basic moral
40:27norms of medicine.
40:28This isn't specific or
40:31unique to transgender care.
40:33This is these are the moral
40:35Lawrence you buy into
40:37when you go into medicine.
40:38When you become a health care professional,
40:41you respect and show test marilena's
40:44through caring through truth, telling
40:46through confidentiality through fidelity.
40:49These are the kinds of moral
40:51norms that you should hold on to.
40:54And your goals of medicine
40:56that aren't to cure.
40:58Because many of your patients
41:01like transgender immunes.
41:03Aren't in a situation where they need cure,
41:07they are.
41:08Your goal should help them live healthfully
41:11through the conditions that they live in.
41:14Think of disabled persons and say there are
41:17certain disabilities that never go away.
41:19So is medicine not supposed to do anything?
41:22No medicine provides the conditions
41:25in which with those disabilities,
41:28humans can live their best lives, right?
41:32And transgender youths as trender youth,
41:35transgender youth,
41:36should be able to live their best lives.
41:39But you may still resist, right?
41:41And you might say look healing action
41:43is one thing, but gender firm care?
41:46Not so sure.
41:47So what about D'assistance
41:50medical versus surgical responses?
41:52Long term effects of treatments?
41:54Or when parents and children disagree
41:56and this will finish out my talk as we go
41:59through these kind of what if scenarios?
42:01What do you do if you're still
42:03not sure about these kinds of
42:06situations and conditions?
42:07Distance is this.
42:08It's controversial 'cause it has
42:10a couple of different missions.
42:12We don't really know about it and the and
42:14the research on it is is questionable,
42:17but persistence is essentially children who
42:20don't persist in an interest to transition.
42:23So the how common is it for a child to
42:27change their mind to change their insight to,
42:32to rethink their identity as they move along?
42:37And some research.
42:39These three are examples of research
42:42that argues that distance is very common,
42:46as high as 80% of children as they
42:49move through puberty will change,
42:51will change their mind,
42:53and decide that they really don't
42:56want to transition.
42:57However,
42:58there's been careful work on this
43:00research that has questioned it,
43:02and if you read these particular
43:05articles by Newhook and Carrington,
43:07you'll see some significant flaws
43:09in the research on persistence.
43:11Now,
43:11let's be honest.
43:16There may be significant
43:17flaws in maybe 80%, isn't it?
43:19What if it turned out it was
43:21still 50% and the question is,
43:22does that mean we should not help and not
43:26provide medical care for these children?
43:28I think the answer is no,
43:30it doesn't mean that because
43:31the focus is wrong.
43:32If you're worried about
43:33persistence versus d'assistance.
43:37What you should look at is that
43:39children are coming to you.
43:42And what you were support as a health
43:45care provider and the question is how
43:47do we support them best in doing that?
43:50We get them good.
43:52We get them good mental health.
43:55Mental health support and.
43:57We may provide them some
44:00good medical support as well.
44:03Some of the treatments you know
44:06about medicinal responses,
44:07like puberty blocking treatments or hormones.
44:10Right now there's some challenges with that.
44:12They're not benign right?
44:14Bone density, fertility in our development,
44:17hypertension are all kind of question
44:20marks because we don't know all of
44:22the long term effects yet of starting
44:24this early in early in someone's
44:27life and and continuing through.
44:29We don't have the data yet.
44:31At the other side, there are some concerns,
44:33but they're also not so high that
44:35we don't think we can correct for
44:38them with other medical options,
44:40but we do, but we shouldn't.
44:44They're like puberty.
44:46Blocking is something that's
44:47reversible later,
44:48so we could start that in whatever.
44:50But let's not we have we have to
44:52be clear with families and with
44:54the children themselves,
44:55but this is not a benign process
44:58and there's no risk or no possible
45:01negative outcomes.
45:02However,
45:02extent of those negative outcomes is unclear,
45:06and frankly,
45:07not very high from what little data we have.
45:10Mental health responses.
45:12Counseling is extraordinarily important,
45:15and it's counseling to help support
45:17people who are challenged with what
45:19they're thinking and experiencing
45:21in their lives,
45:22and especially in a culture that
45:24lives under the myth of binding.
45:27How do,
45:27how do I exist as a person who
45:30seems to be counter culture and
45:33not by my own choosing,
45:34at least not as it's experienced.
45:36It's not experienced by these children,
45:38is as it's not their own.
45:40Choosing challenge is good therapists
45:44as we lack good therapists for
45:47children in general and then talk
45:49talk about a topic this specific
45:52really hard to find good therapy.
45:55Social responses providers should
45:57use desired names and pronouns and
46:00sometimes parents will ask you not to,
46:02and in the face of that I think you have to.
46:06I think you I think you have to look
46:09at your patient and say my patient is
46:11asking me for this and this is not.
46:14But let's be really clear.
46:15This is not something where you
46:19are affecting.
46:20You're affecting their long
46:22term Physiology or something,
46:24so calling them with their names and
46:26pronouns isn't somehow violating
46:28the rights of the parents in
46:30these kinds of cases,
46:32this is supportive of
46:34the children themselves.
46:36There are, of course,
46:38surgical responses for
46:39the most part in ethics.
46:41We have argued that at Sept.
46:44In very unusual cases,
46:45for the most part we would avoid
46:48surgical options until somebody
46:49reaches the age of majority to be
46:52able to make that decision for
46:54him or herself or themselves,
46:56and so that's that's where we've
46:59come down on that, and so frankly.
47:03Like a lot of the legislators who passed
47:05the quote UN quote Safe Act in Arkansas
47:08really believed what they were doing
47:11was stopping surgical interventions.
47:13But in the state of Arkansas,
47:14we weren't doing surgical interventions.
47:16We were offering hormones and and
47:19puberty suppression. But we were.
47:21We weren't doing any surgeries
47:23here and most of most of the
47:26rhetoric was about was about.
47:29Doing surgery to genitalia,
47:30which just simply wasn't happening and
47:33so part of this also comes down to what's
47:35really happening and what are the facts.
47:41One of the well last things I want
47:43to talk about are conflicts between
47:46parents and child when parents stay.
47:48They when the child wants to
47:51move forward with say puberty
47:54suppression and parents do not.
47:57We have to we have to recognize that our
48:01society accepts and and supports parental
48:03authority over their own children, right?
48:06That it's a social and legal standard that.
48:10That we then turn to parents and expect
48:13them to be governed normatively.
48:15Ethically by the best interest
48:18standard and their decisions,
48:20or would be limited by the harm principle,
48:23that is, if their decisions are art
48:25imminently, harmful to the child,
48:27their decisions should be limited
48:29in the state should step in,
48:31but what do we?
48:32What do we think about the child's authority
48:35over their own experiences and bodies?
48:38And some have argued because the
48:41benefits of the treatment are
48:44such that it reduces dysmorphic
48:46experiences and depression because it
48:49improves quality of life indicators.
48:51Those benefits are so great that
48:53the child should have authority
48:55regardless of what the parent says.
48:58And.
48:59And others have argued that children
49:02actually have rights to be able
49:05to express their own developing
49:07autonomy and not to be harmed by.
49:12By the avoidance of these
49:14kinds of treatments,
49:15but should be allowed to make these
49:17treatment decisions for themselves.
49:18So in just the last few years,
49:20several people have been publishing on
49:24arguments that say children should be able
49:25to make this decision for themselves,
49:27at least when they hit the age of.
49:2913 fourteen 15.
49:33So where do I stand on all this?
49:35And we'll finish up with this and then we
49:38can have conversations on what you think.
49:41First, I say gender is a substantive
49:44if not fundamental aspect of the
49:46self and the self is a situated and
49:49mutable aspect of human beings.
49:51As such, gender is not something fixed.
49:53The certainly affected by by
49:56biology or genetics or nature,
49:59and may demand attention and
50:01consideration throughout the lifespan.
50:04Children are early developing selves,
50:07physiologically, psychologically,
50:08socially and cognitively.
50:11As such, they will experience their
50:13developing selves and work and are working
50:16on understanding who they are becoming.
50:19Further,
50:19they may lack the ability to act as
50:22fully a ton of individuals with regard
50:24to translating care individuals because
50:26they are still in those developmental
50:28in the throes of development.
50:30Parents are tasked with helping
50:32their children become the best
50:33versions of themselves by helping
50:35author their life stories,
50:36and as such they're entitled to
50:38operate within their own values,
50:39but also must listen to the developing
50:42interests and values of their children,
50:43providing support for those experiences.
50:47Health care providers are under the
50:50ethical norm of helping persons live
50:52healthily using means at their disposal.
50:55To the disposal.
50:56Medicine to do so.
50:58As such,
50:58they should stand at the ready to
51:01provide or refer those who can provide
51:03gender affirming care were appropriate.
51:05Kansas State the state should
51:07recognize parental authority while
51:09also protecting vulnerable individuals
51:11from undue and identifiable harm,
51:14and as such,
51:15it should allow families to work through
51:17the conflicts about about starting
51:19medical interventions in transgender care.
51:22I have to admit,
51:23I'm still thinking about that one in terms
51:25of where I'm ultimately going to come down.
51:27That's kind of where I stand right now,
51:29but also they should step in to
51:32protect children whose families
51:33turn abusive or negligent or.
51:36Or or harmful towards their
51:40transgender children.
51:42And further,
51:42the state should not should not
51:45interfere with access to trender
51:47affirming care that it's not
51:49the states rule to do that.
51:51'cause gender affirming care doesn't
51:54meet the does it meet the conditions
51:58to blink to bring the police
52:00power of the state on board so.
52:03It was a whirlwind of information
52:06and and presentation.
52:07I thank you so much for your
52:09attention and time and I look
52:11forward to the conversation.
52:14Thank you Michael.
52:15That was an exceptional presentation.
52:17Very, very interesting.
52:18Lots of great ideas to talk about.
52:21I'm friends. I invite you to
52:23submit your questions through
52:24chat questions or comments.
52:28So I I learned a lot from this talk, Michael.
52:30So let me let me just touch base
52:32on a couple of things one had to
52:35do with the with the SAFE Act.
52:38And it that that even bans referrals,
52:42which essentially, I guess,
52:45bans speech among physicians, yes.
52:50This has been part of the argument
52:52that's been raised to the courts.
52:55Yes, yes, that it becomes a first.
52:58It becomes a a form of First
53:01Amendment violation, yes, but yeah,
53:02at this point we don't know where that's
53:04going to go until the courts you know,
53:06until it runs its course in the courts.
53:09We've got a number of people who
53:10have things they want to ask and say,
53:11so I'm gonna I'm gonna get to it.
53:141st I have. I'm not clear
53:16whether speaker is saying
53:18nonbinary identity is biological,
53:21just like male and female,
53:22or is it a cultural overlay
53:24on male and female biology?
53:27I don't think it's clear that you
53:30can separate those two neatly.
53:33We don't know the full biological
53:36conditions under which.
53:40Non binary identity arises, right?
53:43I mean I've got.
53:45So I've got genetics colleagues that will
53:47tell me everything is genetics and so should.
53:50So would also John Non binary identity
53:52have some sort of genetic component
53:54which we just haven't found? Now?
53:56Look, I don't know if that's true or not.
53:58My point is that I don't think
54:01you can neatly define these
54:04things such that you can say ah
54:07priority that there is no.
54:09Biological.
54:13No biological connection with
54:16these these concepts, but yes,
54:19the concepts are primarily cultural social.
54:25Social concepts and categories and
54:28whether or not they they map on to
54:33biology is less important to me than
54:37it than we have talked about it.
54:41In the past, as part of our culture.
54:44So perhaps with your
54:46suggestion is if if we Child says I
54:50am I am a I am a boy even though I
54:53look like a girl I'm a I am a boy.
54:56In fact that the fact that the child
55:00perceives as such is more important than
55:03whether or not you can find a gene that
55:06dictates that this that this channel
55:07who is an ** chromosome who identifies.
55:12Now I look like this.
55:16Maybe absolutely nothing to
55:18be careful of. This is Mike
55:22Mike. I don't know. I don't know if
55:24I'm gonna ask Sam to chime in here.
55:26The sound is coming out. Very strange.
55:28I don't know if that's just my computer.
55:30If Sam are you hearing that as well?
55:32Yeah, I'm hearing it as well.
55:33I would just try to meeting but I can
55:35re coming back in real fast, yeah?
55:40Let's let's try it again.
55:41If you could do better,
55:42like about 15 seconds to answer
55:44the question that I raised.
55:47Yeah, can you hear me better?
55:49Yes, this sounds fine right?
55:51Sorry yeah I don't know right?
55:53I'm in my office.
55:53Who knows what happens, right?
55:56No, I think I think the answer is that
56:00that children look children may say,
56:05let me let me be careful when children
56:09say something about their experience.
56:11I am not saying that that is
56:14definitive about who they are.
56:16Or even should who they should be
56:18or even who they are at this moment.
56:20But we should take it seriously right?
56:23And and and take it seriously to
56:25the extent that it doesn't matter
56:27to me so much what their what
56:30their chromosomes are telling me.
56:32I'm more concerned about what their
56:34experience is telling me and and I
56:37want to work through that because
56:39that's going to tell me more about
56:41how they're going to be able to
56:43live their lives going forward.
56:45And again, it may be that.
56:4750% of these children
56:51quote UN quote flip back or whatever,
56:53right and and no longer have any can.
56:56Gender, gender differentiation,
56:57or gender dysphoria or whatever kind
56:59of term you want to use now, is it?
57:02It doesn't matter to me at the moment
57:05that they're experiencing this. This.
57:10This way of viewing themselves,
57:12it matters, and then we have to work on it.
57:15It doesn't mean that I'm going to stick
57:17puberty suppression drugs in that moment,
57:18right? I mean, nor should we.
57:21But it does mean that I now need
57:24to be thinking medically and
57:27socially about how how the next,
57:30how the, how the next steps will be,
57:32and how we're going to help this child
57:35work through this and live their lives,
57:36right? So
57:38so I think one of the one of the
57:40fears that many informations.
57:41Have or some physicians may have is that
57:43we will, unless fears we live there,
57:45there is that we will make a mistake.
57:46And of course the biggest mistakes
57:48that we make as physicians are
57:51mistakes that can't be reversed.
57:53So, so I've often told my trainees
57:55or students that you know if you
57:56come to a fork in the road and
57:58you're really not sure which path to
58:00take and you're completely stumped.
58:02And one seems equally good or equally
58:04bad to the other and you have to
58:06make a choice in that situation.
58:07You're probably well advised to
58:09make the choice that's most easily
58:11reversed in case you get it wrong.
58:13This gets to I'm fascinated by a
58:15significant disparity in when you
58:16talked about the assistance when
58:18you said it could be as high as 80%,
58:20but even if we say it was lower,
58:21it was 50% right there was that.
58:24And yet,
58:25adults who had gender affirming treatment,
58:28you give us a number that's less than 1%.
58:30Yes, yes.
58:31How do you reconcile these two very
58:33different pieces of information?
58:35Well, I mean, hey, we're capturing that
58:37data at very different times, right?
58:39And so the the adult is an adult and
58:43their neurobiological development is is
58:46such that it's probably a more complete.
58:51That you know then the child and and
58:53their experiences in life are more solid,
58:55so that they're that that.
58:58They probably are also able to situate.
59:04Their transgender identity.
59:05Within the full scope of a larger range
59:09of experiences that they've had in life
59:12and think through that and thus come to.
59:15A certain comfort and and
59:18and solidity with that idea,
59:20children are still working through it.
59:22And again I think to to the
59:24point of of right the the least,
59:27the the the most reversible
59:30or the least impactful.
59:32Yeah, I think that's why
59:34you start with things like.
59:36Mental health support then maybe
59:39puberty suppression right?
59:41And so?
59:42Because these go reversible you don't
59:44go straight to surgery and it's why
59:47we argue in most ethics cases you
59:49know we wouldn't do surgery until
59:52they're able to make decisions
59:54for themselves by law and by and
59:56hopefully by neuro development, right?
59:58So, so that's it's not that.
01:00:01It's entirely up to date,
01:00:02but most for most minors it is
01:00:05because of that.
01:00:07And for that very reason,
01:00:08for the very reason that you give work,
01:00:10thank
01:00:10you. Thank you. So next question.
01:00:12The wording of the safe law was interesting
01:00:15because how how do they determine the
01:00:18child's biological gender to decide
01:00:20what procedures go against that gender,
01:00:22especially for intersex children,
01:00:24would this also prevent us from safe
01:00:27prescribing spironolactone to SIS males,
01:00:29which we do because it could cause
01:00:31a side effect of breast growth?
01:00:34Yeah, it's an egg.
01:00:35It's an excellent question,
01:00:36and of course it's a law.
01:00:37Written by people who don't necessarily
01:00:40have all the all the medical and
01:00:42scientific background and so right it it.
01:00:45It loses all the nuances so so the moment
01:00:49you, you're absolutely right, the law,
01:00:51if I remember correctly and forgive me,
01:00:52I don't have it right up in front
01:00:53of me right now, but a lot just
01:00:55just talks about the difference.
01:00:57The difference being
01:00:58gender and biological sex.
01:01:00And those are and biological sex is is
01:01:04defined as of as your as your sex at birth.
01:01:08Right, it doesn't get into ** XY,
01:01:11XXY, it does right?
01:01:12It doesn't get into all of that,
01:01:14and so it it lacks that ability
01:01:17to recognize that there are.
01:01:19There's right,
01:01:20there's all shades of color, right?
01:01:22It's not just black and white,
01:01:23and and and so the law, I think,
01:01:26is is unable to speak to that clearly.
01:01:28And so then, what do you get into that?
01:01:30The implication in this question, right?
01:01:32Is you get into interpretations that are
01:01:34going to have to be made at the court level.
01:01:37And now you're, you know.
01:01:38Now you're going to court for all
01:01:40these other kinds of conditions.
01:01:42Because of that,
01:01:43that could become questionable, right?
01:01:46I mean,
01:01:46that's the challenge.
01:01:48Whenever you turn these kinds of
01:01:49things into laws and regulations.
01:01:52Thank you next a comment and then.
01:01:56Question so the comment was it sounds
01:01:57a lot like how we view pregnancy.
01:01:59This was regard, I think to not not an
01:02:03illness or injury but and and then the.
01:02:06The questioner says Doctor Dan Aaron
01:02:08staffed writes the GID should have
01:02:11been referred to as GE D because all
01:02:14that was needed was incongruent.
01:02:15Gender expression.
01:02:16For example, femininity and boys,
01:02:19the 85% of disasters with the flawed
01:02:23diagnostic criteria were proto Gay.
01:02:25How does this align with your thoughts?
01:02:27On the diagnostic criteria,
01:02:28maybe you can help explain
01:02:30some of this as well.
01:02:32I probably cannot so.
01:02:36So the problem. So let me I'm going
01:02:38to step back 'cause I'm not sure I
01:02:40can answer this question directly.
01:02:42I'm not sure I'm smart enough,
01:02:43but but let me step back and say this and and
01:02:46maybe it'll get out a little bit of this.
01:02:48The issue with the desistance research
01:02:51is just this issue of definition.
01:02:54What counts as what counts as the
01:02:57the condition of what condition
01:03:00are we wondering about persisting?
01:03:03And and what would it mean, then,
01:03:05to desist right? So if the so.
01:03:09So if we are talking about a
01:03:11wide range of conditions,
01:03:13not all of which are the identity of of.
01:03:18Of say, assist female identifying
01:03:22then as trans male, right?
01:03:26And just does kind of set of
01:03:28conditions and and one might think
01:03:30quote UN quote vice versa right if
01:03:32that's the set of conditions only
01:03:34and then ask does that persist?
01:03:36That's a different question
01:03:38than do people have.
01:03:40Do people do kids have a wide
01:03:43range of non gender conforming?
01:03:47Quotes right non gender conforming
01:03:49experiences and do those persist overtime?
01:03:52Because the answer is.
01:03:54A lot of kids have non gender
01:03:57conforming experiences that
01:03:59don't persist overtime right?
01:04:01And so then the number gets really big 8587%.
01:04:05Those kinds of things if
01:04:06that's what this is part of,
01:04:07what the arguments were in those who don't,
01:04:10who think the research was
01:04:12bad is the definitions,
01:04:13and all the things that fell under it don't
01:04:17really capture the set of conditions that.
01:04:21That matter to most of us,
01:04:22because most of us actually have
01:04:25those kinds of experiences.
01:04:26One sort or another, and then,
01:04:27depending on what you're capturing.
01:04:29Of course they don't persist,
01:04:31but if you're if you're wondering
01:04:34more about do transgender experiences
01:04:36and identity persist?
01:04:38And that's narrowly defined,
01:04:40it probably does persist much more.
01:04:42This then gets back to your other
01:04:44to your other point.
01:04:45Mark that that if that persists
01:04:50more overtime.
01:04:51It probably also helps explain why
01:04:54those who do fully transition later
01:04:57in life aren't comfortable with that
01:05:00comfortable with that move right
01:05:02now. Thank you.
01:05:04So this is a bit of a story,
01:05:06but one one I'll share here.
01:05:08I found it and share the HMS Center for
01:05:11Bioethics Community Ethics Committee.
01:05:13I assume that's Harvard Medical School.
01:05:15We have prepared a report on medical
01:05:18management of pediatric gender dysphoria,
01:05:20and I would be glad to
01:05:21make it available to you.
01:05:22We had several questions,
01:05:23but two come to mind in this context.
01:05:26First gender dysphoria services should
01:05:28provide a quote offramp End Quote.
01:05:32When patients are uncertain rather than
01:05:34finding themselves in a program with a
01:05:37strong bias or pressure to continue.
01:05:392nd, we agree with the Arkansas
01:05:42conclusion that surgery should be made
01:05:44available after the patient reaches
01:05:4618 to acknowledge and protect real
01:05:49quote informed consent and quote.
01:05:51We conclude it.
01:05:52Yeah, I mean, yeah,
01:05:53we concluded that every patient
01:05:56receiving gender management
01:05:57services is in participating,
01:05:58is participating in an experiment.
01:06:02Is in participating.
01:06:03I assume that meant is
01:06:04participating in an experiment.
01:06:05We agreed to take on this topic
01:06:07after I spent several hours
01:06:09with a mom who shared with me.
01:06:11She never set out to be a chance.
01:06:12Denver advocate,
01:06:13but she concluded she would
01:06:14either need to advocate for her
01:06:16daughter or grieve her dead son.
01:06:19Thank you.
01:06:21So I appreciate this Karelitz.
01:06:23Thank you for the for the question or story.
01:06:28Look, I so I agree with the off
01:06:30ramp and I agree that we do have
01:06:33to be careful of bias and whatever
01:06:35that you know it's it's hard to be.
01:06:37There's no such thing as kind of pure non
01:06:39bias or pure nondirective medical care,
01:06:42but but to the extent that we can be
01:06:44open to allowing children to share with
01:06:47us their experiences to support them
01:06:50in that and supportive as that changes
01:06:53overtime and if it changes to give them
01:06:56the support too as it offering it as it were.
01:06:59I think that's really important
01:07:00and that becomes something that you
01:07:02have to build not just in policy,
01:07:04but also part of your culture, right?
01:07:06I mean, you just got it.
01:07:07You got to keep doing that. Now.
01:07:08Of course we should do that in all care,
01:07:10but it's it is particularly heightened.
01:07:13And and concerning in these cases,
01:07:15so fair enough.
01:07:17Again, I ethically,
01:07:19I think because the surgery is is.
01:07:26I essentially irreversible.
01:07:27I mean, you can reverse in weird ways,
01:07:30but but it wouldn't be.
01:07:31Then you wouldn't be going back to baseline,
01:07:33as it were right with reverse
01:07:35ability because it's that because
01:07:36that's true in the surgery.
01:07:38Yes, I think for the most part
01:07:40we we should wait now Chris,
01:07:41remember it's not like informed
01:07:43consent becomes something great.
01:07:44At 18 years old and and so I
01:07:47wouldn't make that.
01:07:48The reason I think what we have
01:07:50to acknowledge and Laney Ross is
01:07:52good about this at the University
01:07:54of Chicago we acknowledge that
01:07:5518 is is the socially accepted.
01:07:57Legal fact of when people become
01:07:59adults in most states except
01:08:01Nebraska where it's 19 right and
01:08:03and and because that's the social
01:08:05consensus we're gonna ride with it.
01:08:08But we shouldn't fool ourselves into
01:08:10thinking that somehow informed consents
01:08:11better at 18 than it was at 17,
01:08:13and it just it just has more legal weight.
01:08:17And OK.
01:08:18So be it.
01:08:19I mean, at some point we do again have
01:08:20to make distinctions for purposes.
01:08:22This is a legal purpose.
01:08:23Then we make that distinction.
01:08:25That's fair enough.
01:08:27And then, uh. So I don't agree.
01:08:32However, I'm not sure that.
01:08:34I I don't agree that we're
01:08:37participating in experiment.
01:08:40Or at least, I don't think rhetorically,
01:08:42that's the way to to describe it,
01:08:44because I think it's misleading.
01:08:46Weird, we're doing things we know.
01:08:50We know their effects in
01:08:52their outcomes in many ways,
01:08:53and certainly as well as we do in
01:08:56many other aspects of pediatric
01:08:58standard medical care.
01:08:59The thing that makes it experiment
01:09:01as it were, is is that.
01:09:06The children themselves do change
01:09:07over time and we don't know
01:09:09where that's leading us, right?
01:09:10That?
01:09:11That development means that if
01:09:13we start this at 10 or 12 and
01:09:17start doing some support there,
01:09:19it may not end where,
01:09:20where,
01:09:21where we think the natural
01:09:23trajectory would take us
01:09:24right? Which is we start?
01:09:27We start transgender care at at 11 or 12.
01:09:30We do some support that
01:09:33mental health support.
01:09:34We give them pretty suppression.
01:09:36Maybe some hormones laid in their
01:09:39teens and all of that's on a
01:09:41trajectory that they will eventually
01:09:43continue and maybe fully transition
01:09:45when they become adults, right?
01:09:48That's the trajectory and the
01:09:50experiment is insofar as maybe they
01:09:52may be a number of them off ramp.
01:09:54And don't go that way, right?
01:09:57That's the experiment,
01:09:58but that's not unusual in any
01:10:00pedia in many pediatric cases,
01:10:02'cause kids are always developing,
01:10:03and they're always developing
01:10:04in all sorts of ways.
01:10:05And and we try this in.
01:10:07It in all sorts of different
01:10:09aspects of kids lives,
01:10:10and it doesn't go the way
01:10:12we think it's going to.
01:10:13That's the only way I would use
01:10:15the term experiment otherwise.
01:10:17I mean,
01:10:17we know how puberty spreadsheet works.
01:10:19We know how the hormones work.
01:10:21I mean, we're not.
01:10:22We're not just throwing things at
01:10:23a wall and seeing if it sticks,
01:10:24so I, I and I just fear the
01:10:26rhetoric of experimentation.
01:10:28Has that has that sense.
01:10:29But
01:10:30yeah, I I think that it's
01:10:32interesting because experiment is
01:10:33is a word in common English usage,
01:10:35and it means something different.
01:10:36I think the people who actually
01:10:38do experiments for a living.
01:10:39Or who read about experiments
01:10:40and then people say, well,
01:10:42this is experimental,
01:10:42so I think it's helpful whenever
01:10:44someone says something like that to
01:10:46actually define what is meant when
01:10:48they say something is experimental,
01:10:49what exactly,
01:10:50how exactly they define an experiment?
01:10:54Every treatment that we give a patient,
01:10:56even if it's a well proven treatment,
01:10:58it is for that patient and experiment,
01:11:00which is to say it may or may not
01:11:02work for that particular patient.
01:11:03It doesn't necessarily mean the same
01:11:05thing as being part of a clinical trial,
01:11:08that's that's something a bit different.
01:11:12The last point though,
01:11:13that that that that that last comment I made,
01:11:15which was an important one,
01:11:16is something you alluded to in
01:11:17terms of advocating for her daughter
01:11:19or grieving for her dead son.
01:11:20I mean, I thought that that was
01:11:22that parents and then therefore,
01:11:24and therefore this question of Carol powers.
01:11:26I thought those are very powerful
01:11:28words that again make the point that
01:11:31there's such a significant risk of
01:11:33of depression and and suicidal you
01:11:35referred to suicidal ideations.
01:11:37Do you have any data for specifically on
01:11:40suicide suicide numbers for these kids?
01:11:42Suicide numbers I had some and I have to
01:11:45admit I don't have them right off the
01:11:47top of my head right now at the right
01:11:49the ID Asian is in like the 50% range.
01:11:52Suicides themselves is at least I
01:11:54if I remember, it's at least twice,
01:11:57but it may be three times the national
01:12:00average in teens for suicide itself,
01:12:03but but ideations, it's like 4 two.
01:12:06It's it's like three to four
01:12:09times just ideational
01:12:10wow. I mean that's gotta.
01:12:12You would think that that would even
01:12:13the folks who were very skeptical think
01:12:14that would get people to stand up as
01:12:16one of those considerations as we try
01:12:17to make make these kids lives better.
01:12:21You know, as they as they face
01:12:23their lives the next please.
01:12:25Even though the courts have suspended
01:12:27enactment of state statutes,
01:12:28clinical providers including
01:12:29those in Arkansas,
01:12:30have dramatically restricted
01:12:32or suspended access to gender
01:12:34affirming medical treatments,
01:12:35essentially supporting the intent
01:12:37of the legislation.
01:12:38Given some of the arguments
01:12:40you've made this afternoon,
01:12:41can you please comment on the ethical
01:12:44responsibility medical providers may have?
01:12:46To continue or even initiate gender
01:12:48affirming medical treatments in the
01:12:50face of statutes that make it illegal.
01:12:53So I so excellent question.
01:12:56This is something I have been
01:12:58wrestling with a lot because the
01:13:00two institutions I work for have.
01:13:03I have wrestled with this and and asked
01:13:05me an occasion and let me just add in
01:13:08something that's even more interesting.
01:13:10Insofar as, right, Arkansas has the law,
01:13:12and though it's currently
01:13:13suspended by the courts,
01:13:15it it does stand on our books so you
01:13:17can at least understand that the the
01:13:19kind of specter of of of concern, right?
01:13:23Texas, Dallas Dallas Children
01:13:26is the one of the premier.
01:13:30Gender clinics in the country.
01:13:32For for kids closed down even before a
01:13:35law was passed because they saw they saw
01:13:38the writing on the wall and and so right.
01:13:41I mean so this is a really difficult,
01:13:44important question about what should
01:13:46medical providers do in the face
01:13:49of this and you know, are there?
01:13:51Do we need a little civil disobedience
01:13:53or you know those kinds of things?
01:13:56Look, I I have to say that.
01:14:00I've struggled with this and
01:14:02I would say that I I would.
01:14:05I would be supportive of anybody who does,
01:14:07but I completely understand as a
01:14:10pragmatic fact why people don't the the
01:14:14law would take your licensure away.
01:14:17Period,
01:14:17it would just take it away and you
01:14:19wouldn't be a physician anymore.
01:14:21And uh and UAMS as as a state as the state.
01:14:25Only academic Medical Center and a
01:14:28state funded Medical Center would
01:14:30lose its funding and and and.
01:14:33Right and and and jeopardize its
01:14:36status as an academic Medical
01:14:39Center in in the state period.
01:14:42And it's again.
01:14:42It's the only one,
01:14:44so there are pragmatic reasons that
01:14:46unfortunately work against it and
01:14:47and the legislature knows that right?
01:14:49And so it takes advantage of that
01:14:51when you want to pass a law like this,
01:14:54and so I get it, I that is, I don't.
01:14:58I don't begrudge people for not
01:15:01having for not.
01:15:03Define the law should the law
01:15:06come into place.
01:15:07I do think we should push back on
01:15:10the wall absolutely and we have,
01:15:13you know the medical society and others
01:15:15have certainly done all the lobbying.
01:15:18You know that one can do,
01:15:19and and we've had rallies and
01:15:21and other things like that in
01:15:22this state about all of this.
01:15:24And we tried to convince the
01:15:25governor to veto.
01:15:26But in fact what happened was
01:15:28his veto was overridden.
01:15:29That's how strong the majority
01:15:31is in our state legislature.
01:15:32So you know, there's.
01:15:36So yes,
01:15:37I would be supportive of anybody who did.
01:15:39I don't know that I could argue that
01:15:41they have to write that that that they
01:15:44have some significant obligation to
01:15:46have to because of other obligations.
01:15:48Well,
01:15:48they might have an obligation to,
01:15:50but it don't know that it's the
01:15:52winning obligation 'cause they have
01:15:54other obligations to fulfill as well.
01:15:56And that's that's a.
01:15:57That's a tragic part of the moral life
01:15:59that we can't always have at all.
01:16:00In it. I trust me, I've gone to bed.
01:16:02Kind of sick about this after
01:16:04different meetings, but I don't.
01:16:06Yeah, I don't have a strong
01:16:08enough argument to say yes.
01:16:10We just defied a long ago. Thank you.
01:16:14I particularly like the
01:16:16analogy to cosmetic surgery.
01:16:17Has anyone ever tried to
01:16:19bend any of these procedures?
01:16:22Yeah, yeah. I mean,
01:16:24it's certainly physicians right?
01:16:25Different physicians in health care
01:16:27have talked about the idea that
01:16:30cosmetic surgery doesn't really fall
01:16:33under the umbrella of medicine,
01:16:36and so some people have tried
01:16:37to talk that way and that it's
01:16:39sure you get medical training,
01:16:41but that's that's a that's a.
01:16:43That's a weird fact of what you
01:16:44need to do to be able to do this,
01:16:46but it turns out that cosmetic
01:16:47surgery really isn't medicine,
01:16:49but that's actually a minority opinion,
01:16:50right? I mean, for the most part,
01:16:52people, people believe it is medicine.
01:16:55It's not central to medicine.
01:16:57It's not the illness and injury
01:16:59fixing or whatever.
01:17:00But it's still part of medicine
01:17:02because it because it falls under the
01:17:04skills and and expertise in medicine.
01:17:07And so right?
01:17:08I have people tried to ban the
01:17:10procedures of of cosmetic surgery.
01:17:12Some people certainly have argued
01:17:14ethically like things like when
01:17:16patient or person comes to you
01:17:18and wants their tongue split or
01:17:20something like that that some
01:17:22some practitioners will say no.
01:17:25I don't do that,
01:17:26but they don't necessarily then rolling
01:17:28insane all cosmetic surgeries off the table,
01:17:31right?
01:17:31They say,
01:17:32here's a procedure and for me I
01:17:34won't do it right and they don't even
01:17:37begrudge other people doing it necessarily.
01:17:40So it's interesting that we do regret
01:17:42other people giving transgender care.
01:17:44Sometimes right so I I doubt.
01:17:48I do think there's something to learn
01:17:50about how we look at other subspecialties.
01:17:53Specialties and subspecialties.
01:17:55Thank you next question.
01:17:57Some states allow abortion for
01:17:59teenagers without parental approval.
01:18:01In that same legal framework
01:18:03that created those laws be
01:18:05applied to trans affirming care.
01:18:07So this is. This is why I have that,
01:18:10you know. And in that bullet point
01:18:12on that next last slide I said I'm
01:18:15still rethinking all of this in terms
01:18:17of whether or not I think parents,
01:18:19whether or not parents say should go,
01:18:21or whether or not children can
01:18:23make the decision for themselves.
01:18:26I mean one, it's going to be a
01:18:27developmental thing. I don't.
01:18:28I don't think any 88 year old should
01:18:29make almost any decision for themselves,
01:18:31their deficits.
01:18:32And I love my three children.
01:18:34They were doofuses at 8 years old.
01:18:35Most medical decisions.
01:18:36I wouldn't let them make period,
01:18:38but right as they get older,
01:18:40you want you want to acknowledge and
01:18:43and even support their developing
01:18:45autonomy in those kinds of things.
01:18:47But the question is,
01:18:49is the analogy to things like reproductive
01:18:51health or abortion or something?
01:18:54Does that analogy hold?
01:18:56Do this and I think it might,
01:18:58but I haven't what I haven't been able
01:19:00to do is fully wrap my head around the
01:19:03kind of ethical normative principle
01:19:05that that that would make it acceptable for,
01:19:12say,
01:19:13the 14 year old to ask for gender
01:19:16affirming care him her themselves.
01:19:20In absence of their parents,
01:19:22I just haven't I.
01:19:23I tried to think about it for this
01:19:26talk and I just I couldn't come to
01:19:28that principle confidently yet.
01:19:31And that's why it's still open
01:19:32question for me.
01:19:33I might get there,
01:19:34but I haven't gotten there yet.
01:19:36But but yes,
01:19:37your question.
01:19:38Your questions in the right line,
01:19:40that is is there.
01:19:42Is there a set of conditions or
01:19:45kind of both practical and normative
01:19:49conceptual umbrella under which.
01:19:51We could say no.
01:19:52This is for teens to do, and it's not.
01:19:54It's not actually like
01:19:55the mature minor doctrine.
01:19:57That's not why,
01:19:57for example,
01:19:58we let reproductive health questions
01:20:00fall in the hands of teenagers.
01:20:02It's not because we think they're somehow
01:20:04mature about that and not these other things.
01:20:06It it's something else.
01:20:07It's the stigma, it's the.
01:20:09It's the protection of long term interests.
01:20:11It's those kinds of things and and I think
01:20:13there may be some similarities here.
01:20:15I just don't have it all worked out
01:20:16well. I think some of that just comes
01:20:18down to the the, the the sense that.
01:20:20For things and it gets to pregnancy.
01:20:23Sexually transmitted the disorders
01:20:25right or or even psychiatric issues.
01:20:27The sense that that children
01:20:29are best served by these laws,
01:20:31which is to say that kids
01:20:32might not seek out the help.
01:20:33They very much need if without this
01:20:36protection if they were required
01:20:37to get their parents permission.
01:20:39I'd rather not tell my parents
01:20:41that I have this disorder than
01:20:43or that I have this problem then
01:20:45seek treatment for it, you know.
01:20:48Right, and again,
01:20:49does that fully capture how trans
01:20:52transgender affirming care works?
01:20:55I I just don't know.
01:20:56I mean, like I said it,
01:20:58may I just don't want to go
01:20:59on record until I thought?
01:21:00Is that fair enough?
01:21:02So this is an interesting question.
01:21:03How does the safe law affect intersex kids?
01:21:09So it it has a it has a carve out for kids
01:21:14who are born with ambiguous genitalia.
01:21:18And those kinds of situations.
01:21:20Now you know what constitutes intersects.
01:21:22Of course, itself is still a not a perfectly
01:21:26defined concept but but there are some
01:21:30carve outs for situations like that, right?
01:21:32But of course, what does that mean?
01:21:34What's very interesting to what that
01:21:36means is it is possible in theory,
01:21:39then per the safe law that
01:21:43somebody born XY but with.
01:21:48Micro penis and the parents decide
01:21:52it's safer and better to surgeries
01:21:55them into it into a vagina and
01:22:00treat them as as as a female.
01:22:04It's not clear that the that the safe law
01:22:07would have a problem with that and yet.
01:22:10It's against the biological sex per
01:22:13their own definition of you know.
01:22:15And so yeah,
01:22:16there's also. There are also
01:22:18those who would who would ban the
01:22:20surgery for intersex conditions as
01:22:22well. Absolutely, absolutely.
01:22:23But that's a flaw.
01:22:25The safe law itself doesn't
01:22:28does not. It's really interesting,
01:22:31so here's something that, of course,
01:22:32is very front and center on this question,
01:22:35which is about the area of sports.
01:22:37Should the primary basis criteria
01:22:39for qualifying in competition?
01:22:41Should it be biological and
01:22:43not on the basis of gender?
01:22:45Can you give your thoughts about this?
01:22:48Had see I tried to avoid this in the time.
01:22:51He almost made it
01:22:53626. I know, I know.
01:22:54If I just if I just stole
01:22:56logging a fine, no look.
01:23:00This is a worldview issue and
01:23:02I can't say that I have all the
01:23:06parts worked out. To my mind.
01:23:11It is. To my mind,
01:23:15I am just fine with transgender women.
01:23:19Can't translated women competing as
01:23:21women in women's sports because again,
01:23:25we need to think about what the
01:23:28category and the categories were
01:23:30designed for in the 1st place.
01:23:32And it's not. I mean, heck,
01:23:34half the time I don't understand,
01:23:35for example, why, in curling, curling.
01:23:39Do we have a male and female?
01:23:44Curling and then when they get together,
01:23:47it's mixed, right?
01:23:48Is it is there somehow?
01:23:50If if you argue that somehow the
01:23:54difference biologically between
01:23:55men and women and curling.
01:23:58Makes a difference I I just
01:24:00called ******** on that.
01:24:01I mean, I just do it, just that.
01:24:04So so the problem is we create these
01:24:07divides for for long health social
01:24:11reasons about the division between
01:24:15men and women and and these kinds
01:24:18of these are cultural reasons.
01:24:19They're not.
01:24:21They're not tide,
01:24:23they're not necessarily
01:24:25tide to biology and stuff.
01:24:27Yes,
01:24:28biology and genetics have a say in many
01:24:31different kinds of athletic endeavors.
01:24:33No question about it.
01:24:35But in point of fact,
01:24:37Lea Thompson,
01:24:38who just won several but not all by the way,
01:24:42when several championship NCA
01:24:44Swimming Championships this past week.
01:24:49Actually her time was slower than Missy
01:24:54Franklin, time from several years back,
01:24:56or Kayla Dekese from several years
01:24:58back and no one questioned whether
01:25:01they were women, right? And so it is.
01:25:06It's simply not the case that
01:25:08simply because you were born with
01:25:12certain genetic characteristics,
01:25:13that you are necessarily going
01:25:15to be quote UN quote,
01:25:16better at sports than than.
01:25:21Other people in this category.
01:25:23If if other people in this category
01:25:26also had certain genetic conditions
01:25:28that may be different than yours,
01:25:30but there may be certain genetic
01:25:32conditions that make them stronger.
01:25:33Secretary this is, I mean no disrespect,
01:25:36but I just think this is
01:25:38an interesting thing.
01:25:38And again,
01:25:39nobody cared because it was horse racing.
01:25:41But Secretary had a had a heart
01:25:44twice as large as the standard
01:25:46normal heart for a horse.
01:25:49And it gave him, you know,
01:25:51the ability that the kind of
01:25:54cardiovascular ability to just pump
01:25:56oxygen and everything and run like bad.
01:25:59And everybody said, wow,
01:26:00that's great, that's right.
01:26:02So what is it?
01:26:04Which condition are you worried
01:26:06about so much that you're that
01:26:08you're worried about this?
01:26:10If we're going to divide the world
01:26:13of sports between men and women?
01:26:16Trans and sis just don't matter to me.
01:26:21That's but again, I I get why people
01:26:24are frustrated by it that we have to
01:26:27acknowledge that there's there are
01:26:29reasons people are frustrated by it.
01:26:31I just don't think they hold up.
01:26:35Hey Micah, we've come to the
01:26:36end of our time at 6:30.
01:26:38Any final thoughts you wanna share?
01:26:42Well, no, I mean, not, not necessarily.
01:26:44I think these were great questions and
01:26:46all that, so I I really appreciate it.
01:26:49But I I think I wanna just say in general,
01:26:51thank you for just allowing
01:26:52this conversation to happen.
01:26:54It is and it is an important conversation
01:26:56wherever you come down on it.
01:26:58Though if you're willing to
01:27:01listen and talk about it.
01:27:03So we've got. That's a good.
01:27:05That's a good space.
01:27:06Look, I I don't ever believe that everyone is
01:27:09going to agree with me or anything like that,
01:27:12but if people will engage me,
01:27:13I promise to engage you.
01:27:15And I think that makes for much
01:27:19better outcomes down the line.
01:27:21So thank you all for listening.
01:27:23Mark, thank you for inviting me.
01:27:25I'm honored to be a speaker for you all.
01:27:28Karen, you are great help Sam.
01:27:29What a great tech.
01:27:30Love it all.
01:27:31Thank you.
01:27:31Thank you so much Mike.
01:27:33And I would say there's a.
01:27:33There's a couple people had
01:27:35interesting questions and
01:27:36comments which we didn't get to.
01:27:37If you send them to us to Karen,
01:27:40Karen can forward them to Mike and he
01:27:41may be able to get back to you that way.
01:27:43I'd be happy to answer.
01:27:44Thank you so much Michael.
01:27:45For a terrific evening and we'll be in touch.
01:27:49And thank you folks very much.
01:27:50We'll see you again in a couple of weeks.
01:27:52Goodnight.
01:27:53Take care everybody. Bye from Arkansas.