Clinical Care for LGBTQ Youth: Ethical Case Studies

Transcript

• 00:00Hello everyone. Thank you so
• 00:03much for braving the weather and coming
• 00:04to join us here as well as on zoom.
• 00:08I have a couple of announcements.
• 00:10Just a reminder that next
• 00:12week for grand Rounds, Dr.
• 00:13Endres Martin will be our speaker and he'll
• 00:16be talking about his experiences and his
• 00:19journey in psychiatric medical education.
• 00:22So please come next week. Additionally,
• 00:25if you are hoping to get CEU for today,
• 00:28we have a new system,
• 00:30so in addition to using the text.
• 00:33Number to log on.
• 00:34Make sure at the end of today's
• 00:37presentation that you log off
• 00:40and that you also take the quiz,
• 00:43which is very easy.
• 00:46And everyone should take the
• 00:49quiz to test your knowledge.
• 00:52I am so delighted today to introduce
• 00:55to you our notable speaker,
• 00:57doctor Lisa Kampel and Goldstein.
• 01:01And she has come bravely all the way
• 01:04from Texas, originally from Albany,
• 01:06so she's not too unfamiliar with
• 01:09the inclement weather today,
• 01:11having received her BA in
• 01:13philosophy at Middlebury College,
• 01:15her PhD.
• 01:17In philosophy from Michigan State University,
• 01:20and most recently she has been appointed
• 01:23as the Harris L Kempner Chair in
• 01:27Humanities and Medicine Professor.
• 01:30She is also chair of the Department
• 01:32of Bioethics and Health Humanities
• 01:34at the University of Texas Medical
• 01:37Branch and the Institute for
• 01:39Bioethics and Health Humanities,
• 01:41where she is director of the
• 01:44Institute for Bioethics and Health
• 01:46Humanities and a professor.
• 01:47In the School of public
• 01:50and Population Health.
• 01:51And I heard Doctor Lisa speak
• 01:54to the broader pediatric Ethics
• 01:56Committee last spring,
• 01:57and I said we have got to have her here
• 02:00as well. And so here she is today.
• 02:03And so without further delay, welcome.
• 02:11Thank you so much, Lori,
• 02:12for the kind words and for having me here.
• 02:15I'm delighted to be here.
• 02:16I was supposed to come in the fall,
• 02:17but you know, I made it and that's OK.
• 02:19So, so glad to be here with all of you.
• 02:23So I will just jump right in.
• 02:24I'm supposed to stay
• 02:25within a little zone here,
• 02:26so I'm going to try.
• 02:27If I wander, Karen is going to let
• 02:30me know because I tend to get a
• 02:32little excited and moving around.
• 02:34But why don't I just start with and let's
• 02:37see if this is going to hopefully work.
• 02:40I want to start with some levity.
• 02:43Because we're going to be talking about
• 02:44some heavy issues here.
• 02:46So as this is my background,
• 02:48I'm not a clinician, OK?
• 02:50I'm a philosopher,
• 02:51but all the work I do,
• 02:54it comes from feminist and queer bioethics.
• 02:56This is me at a pride event last year.
• 02:59I don't know if you can read the shirt,
• 03:00it says can't think straight.
• 03:04And so this is me hitting the roller
• 03:06skating rink before all the students
• 03:07arrived because I didn't want to
• 03:09embarrass myself and fall down.
• 03:10So I did a couple loops and then I said,
• 03:13OK, I'm too old for this.
• 03:15But that just so you know that all my
• 03:18work stems from that sort of framing
• 03:20and that much of my work actually deals
• 03:23with reproductive ethics as well,
• 03:25some of these topics.
• 03:26So a lot of the very controversial topics.
• 03:30So that's why I wanted to
• 03:31have a little levity here.
• 03:32And you can see my ridiculous outfit.
• 03:35OK, so that's my quick background.
• 03:39The other thing I wanna say is,
• 03:41again, I'm not a clinician.
• 03:42I'm a philosopher,
• 03:43although I went into bioethics because
• 03:46I didn't want to just read dead white
• 03:48men and I wanted to collaborate.
• 03:50And I think there's so much
• 03:52value in getting people from
• 03:53different disciplines together.
• 03:55So I list up here some of the
• 03:57collaborations I've done with clinicians,
• 03:59with scientists, with social scientists,
• 04:01with all sorts of people.
• 04:03Because if you're ever interested
• 04:05in collaborating, please reach out.
• 04:06We have a great group.
• 04:08We love to collaborate.
• 04:09I've done a lot of collaborating with Laurie.
• 04:10Children's and Chicago since
• 04:12I did my postdoc there.
• 04:15But yeah,
• 04:15I think that's really important to know
• 04:17that I don't have all the answers.
• 04:18But I think when we get a handful of
• 04:20people together from different backgrounds,
• 04:22we can get closer at least.
• 04:24And that's the other thing I should
• 04:25say is I don't have all the answers.
• 04:27People are usually like,
• 04:28well, what should we do?
• 04:30And philosophers.
• 04:31If you walk away with more questions than
• 04:33answers, then we've done a good job.
• 04:35And I know that's infuriating,
• 04:37but we will try our best here.
• 04:40OK, So what are we actually doing today?
• 04:43We are going to identify some of the
• 04:46health disparities queer folks face.
• 04:48I'm going to say queer as an umbrella
• 04:50term so I don't get stumbled over LGBTQ.
• 04:53Plus I right,
• 04:54it's going to say queer.
• 04:56We're going to talk about some
• 04:58of the clinical,
• 04:59ethical considerations I
• 05:00played for queer youth,
• 05:02and then how can we provide high quality,
• 05:04inclusive care for all?
• 05:05So I know many of you are
• 05:07already experts in this,
• 05:08so I'll try to keep some of this short.
• 05:10And focus on the ethical issues.
• 05:12And I don't have any disclosures
• 05:13except for I'm happy to be here
• 05:15and it's nice to see Snow.
• 05:19So I believe you are all
• 05:21pretty familiar with this.
• 05:22I don't need to go into too much
• 05:24detail about gender identity,
• 05:26how it's different from gender expression,
• 05:28attraction and whatnot.
• 05:29OK, so I'm just going to cruise
• 05:31through that unless OK, good.
• 05:32And then of course we have all these
• 05:34different terms and they're constantly
• 05:36changing and evolving because language
• 05:38is changing and evolving, right?
• 05:40So I learned some new ones too
• 05:42when I was putting this together.
• 05:44But so for the most part,
• 05:46I'm just going to say queer.
• 05:49As you all know,
• 05:50the number of folks who identify as
• 05:52queer has been rising dramatically
• 05:53and some people are saying,
• 05:55oh, this is due to, you know,
• 05:57our society falling apart.
• 05:59I think this is just doing
• 06:01more social acceptance, right?
• 06:02My grandfather was left-handed
• 06:03and every time he tried to right
• 06:06with his left hand he got smacked.
• 06:08But when his kids when my father
• 06:10was growing up.
• 06:11Left hand, that was more accepted.
• 06:12There were more people in school
• 06:13who are left-handed.
• 06:14So when things become more socially
• 06:15acceptable and my father was
• 06:17disappointed that I'm not left-handed,
• 06:18he was hoping like to continue the
• 06:21trend and sorry, but as we become,
• 06:24you know,
• 06:24accustomed to different ways
• 06:26of being different people,
• 06:27people feel more comfortable being out,
• 06:29whether it's left-handed or queer right.
• 06:32And so, not surprisingly though,
• 06:33it's young folks who are most
• 06:35likely to be out.
• 06:36So you know, all of this,
• 06:37I don't need to go into too much detail,
• 06:39but just want to have that background.
• 06:42OK, So what are we going to do?
• 06:44We're going to do some cases.
• 06:45I think this will be more fun than,
• 06:47you know, again, dead Whiteman philosophers.
• 06:49I I worry some people think, oh, philosophy.
• 06:51She's just going to like,
• 06:52quote Socrates and it's going
• 06:54to be really boring.
• 06:55No,
• 06:55we're going to try to do
• 06:57this as applied as possible.
• 06:59So we have our first case and
• 07:00these are based on composite cases,
• 07:02real cases that I've worked
• 07:04on with clinicians.
• 07:05OK, so they are informed by the real world.
• 07:08We have Zach, he him.
• 07:10He's 16 and his parents are concerned he
• 07:13hasn't really been acting like himself.
• 07:16So.
• 07:18Again,
• 07:18I feel like I'm preaching to the choir here,
• 07:19so hopefully this is not too
• 07:21boring and redundant for you all.
• 07:23You all know that there is concern
• 07:26about coming out right at all ages,
• 07:29especially when you're young
• 07:30and you're dependent upon your
• 07:32parents or your guardians,
• 07:34and so there can be depression
• 07:36and anxiety around that.
• 07:38So Zach here is closed at home
• 07:41and he's bullied at school
• 07:43because people think he's queer,
• 07:44but he hasn't publicly come out.
• 07:47And so, you know,
• 07:49he's like this little picture here,
• 07:51like is it safe yet?
• 07:51When is it safe for me to come out?
• 07:53And This is why his parents
• 07:55are picking up upon is that
• 07:57he's been really withdrawn.
• 07:58What's going on here?
• 08:01So we know there's an increased
• 08:03stigma for being out,
• 08:04especially in certain places where
• 08:06it's less acceptable to be queer.
• 08:09I hung up a pride flag on my house
• 08:12and I was really worried about it,
• 08:15and thankfully it's been OK.
• 08:16But all the other houses next
• 08:17to me have Trump banners.
• 08:19So it's like Trump, Trump, Trump,
• 08:20a pride flag. Trump, Trump.
• 08:23You know, and, and I thought,
• 08:25well, we'll see what happens.
• 08:26And I'm a grown adult with lots of privilege,
• 08:29right? But there is this,
• 08:33this stigma associated with it.
• 08:34And this can lead to all sorts of health
• 08:37problems where you're less likely to get
• 08:38the care that you need because you're
• 08:40not going to see the health care provider.
• 08:42Or if you are,
• 08:43you're not telling them what's going
• 08:44on because you're scared, right?
• 08:46OK, so you know,
• 08:47one thing when I teach the medical students,
• 08:50I always tell them is to ask
• 08:53about sexual identity and gender,
• 08:54sexual orientation and gender identity,
• 08:57because so often they're not asked.
• 08:59And the reason most people don't
• 09:01disclose is because they're not.
• 09:02It's not that they're embarrassed,
• 09:04shamed, but what we see is in studies
• 09:06that people are willing to answer,
• 09:08including cysts,
• 09:09straight folks are willing to answer.
• 09:12There was a study done here.
• 09:15And I have something, oops,
• 09:16some of the citations.
• 09:17This is why I told you I need
• 09:18the non spill water bottles.
• 09:19I get too excited where they did a study
• 09:21in the ER of folks and ask them their
• 09:24sexual orientation and gender identity.
• 09:26And 90% of all people,
• 09:28this is again anyone that came into the
• 09:30ER was we're happy to say what they was,
• 09:32right.
• 09:32The clinicians didn't think
• 09:34anyone was going to disclose.
• 09:35So there's this discrepancy between
• 09:37what clinicians think because
• 09:38they're worried I'm going to
• 09:40upset people or infringe upon it.
• 09:41And the patients were like,
• 09:43Oh yeah, you know,
• 09:43all sorts of intimate things about me,
• 09:44why not this too? Right.
• 09:46So just ask and normalize it, right?
• 09:49You all know this already though?
• 09:52And.
• 09:54What we're going to be talking about
• 09:55in all this discussion here is just
• 09:58this SIS heteronormative framework
• 09:59that our society exists within, right?
• 10:02So we have these various forces,
• 10:05discrimination,
• 10:05stigma,
• 10:06denial of rights,
• 10:08and all these combined together
• 10:10in this funnel to lead to health
• 10:12disparities for queer folks.
• 10:14And that's what's happening for Zach
• 10:16here and and so many other folks,
• 10:18is that it's these forces at play.
• 10:20It's not necessarily, you know,
• 10:22bigoted providers.
• 10:23But all these other things that are
• 10:26leading on the structural level.
• 10:28So how does this play out then?
• 10:31Well,
• 10:31that we know that queer kids are more
• 10:35likely to have problems in school
• 10:38and not just the standard academic problems.
• 10:41Whereas most St.
• 10:42kids are saying,
• 10:44well,
• 10:44you know,
• 10:45I'm having trouble with class
• 10:46and my grades are not good,
• 10:48where kids are saying things
• 10:50like I don't feel accepted
• 10:53by my family, there's bullying,
• 10:55there's all these sorts of things.
• 10:56So the concerns they're
• 10:58bringing are really significant.
• 11:00And again, this is because of this.
• 11:01Structure of the CIS
• 11:03heteronormative world we live in.
• 11:06OK, mental health.
• 11:07Again, you all know this,
• 11:10so I'll go through it really quickly,
• 11:12but the rates of experiencing
• 11:14mental health conditions is so
• 11:16much higher among queer kids.
• 11:18And it's not that being queer
• 11:20is inherently linked to having
• 11:21mental health problems, right?
• 11:23If you are a marginalized member of
• 11:26any group, you're more likely to
• 11:28experience these problems because,
• 11:30again, of the structural aspects.
• 11:33OK.
• 11:36And I know you're familiar with these facts,
• 11:38but I want to kind of make sure we set
• 11:40the stage here and this would be some of
• 11:42the information we would be eventually
• 11:44sharing with Zack's parents so they
• 11:46understand the severity of the situation.
• 11:48But we'll get to that.
• 11:49So, umm, you know much queer kids are
• 11:52much more likely to face violence.
• 11:54Than straight kids.
• 11:56Pretty significant here.
• 11:57They're more vulnerable.
• 12:00These are probably really tiny,
• 12:02so you can't read all of these,
• 12:04but what we see here is just a
• 12:06lot of bullying for queer kids and
• 12:09this unfortunately continues into
• 12:11adulthood where adults who are career
• 12:15report bullying as well in their
• 12:17workplace where they feel like they
• 12:19can't talk about certain things.
• 12:20So again, not unique here.
• 12:25And the school is supposed to
• 12:26be a safe environment where
• 12:28they can learn and flourish.
• 12:29But many, some states,
• 12:31including Texas, where I live,
• 12:33have that don't say gay law,
• 12:34and this prohibits teachers and staff
• 12:38from talking about queer issues.
• 12:40And so imagine going to school and not
• 12:43being allowed to talk about yourself, right?
• 12:45Or this aspect of yourself.
• 12:47Or to talk about your parents who are queer.
• 12:49And I was talking to some other
• 12:51folks earlier and just saying.
• 12:53Some of these laws are written
• 12:55so poorly for so many reasons,
• 12:57but one of which is like,
• 12:58you can't talk about sexual
• 12:59orientation or gender identity at all.
• 13:01It's but they're talking about
• 13:02straight folks all the time.
• 13:03It's this folks all the time when you talk
• 13:05about Santa Claus like he has a gender,
• 13:07right? All the kids have a gender.
• 13:09So really what they're saying
• 13:10is don't talk about, like,
• 13:12the weird ones, right?
• 13:13You can talk about sexual
• 13:14orientation and gender,
• 13:15but not like, not queer ones.
• 13:17So this is a real problem for kids
• 13:19when they don't see themselves
• 13:21reflected in school curriculum.
• 13:23There's other states here that
• 13:26have laws that parents can opt out.
• 13:28That's the the lighter orange one of any
• 13:32curriculum that deals with LGBTQ stuff.
• 13:34And so the green states are the ones
• 13:37that allow explicitly require inclusion.
• 13:39And you can see those are only
• 13:40a handful of states, right?
• 13:42So queer kids are really not seeing
• 13:45themselves modeled in the curriculum.
• 13:47And we know queer folks have
• 13:49been around forever,
• 13:50so that can be really detrimental to them.
• 13:54Family support, we know,
• 13:56is hugely important to queer kids,
• 13:59and that queer kids who are
• 14:01supported by their family tend to
• 14:03do just as well as CIS het kids
• 14:05who are supported by their family.
• 14:08Look at some of these numbers
• 14:09when you look at this,
• 14:10where only 1/4 of queer kids feel
• 14:13like they can be themselves at home,
• 14:15that's really hard if they they're
• 14:17getting bullied at school for being
• 14:19themselves and now they come home and
• 14:20they feel like they can't be themselves.
• 14:22And this is, you know.
• 14:23As you all know,
• 14:24you're a psychologist, psychiatrist,
• 14:25crucial developmental time for them,
• 14:28and they're hearing negative things
• 14:30from their family members.
• 14:32Again, real.
• 14:32And no wonder then,
• 14:34we see so many who are unhoused, right?
• 14:37OK,
• 14:38so let's move to some of the ethical issues,
• 14:40because you all know the background.
• 14:43What do we do here when Zach
• 14:45comes to us and says, look,
• 14:48I'm gay and I don't want
• 14:50you to tell my parents?
• 14:53And again, I'm not a clinician,
• 14:54so in some ways I have it really easy.
• 14:56I can stand up here and say
• 14:57this is the ethical thing to do,
• 14:59and I don't have to live it in that way.
• 15:00So I, you know,
• 15:01I really,
• 15:02I recognize how challenging this is
• 15:03for you all on a daily basis and how
• 15:06privileged I am and how much more
• 15:08leeway I have in talking about these things,
• 15:10because I'm not practicing it.
• 15:13So what do we do here?
• 15:16Well, we have this ethical obligation
• 15:18to confidentiality, right?
• 15:20But when can confidentiality be broken?
• 15:23And usually we talk about imminent
• 15:26harm to oneself or to others.
• 15:28And this in this case,
• 15:29we don't see any imminent harm,
• 15:31right?
• 15:32I mean,
• 15:32hopefully not that from what we
• 15:34know so far about him.
• 15:35And we have to think about this fragile
• 15:38child who is disclosing something to
• 15:40you that he's really scared about
• 15:42talking about with anyone else.
• 15:44And how would that affect your
• 15:45relationship with him if you were
• 15:47then to tell his parents, right?
• 15:49So I think in this sort of situation,
• 15:52we really should uphold
• 15:54confidentiality to the best we can.
• 15:57However, it can get tricky.
• 15:59And this is what we were,
• 16:00Laurie and I were talking a lot about,
• 16:01is law and ethics don't always
• 16:03go hand in hand, right?
• 16:05Maybe they should, but they don't.
• 16:07And you need to work within
• 16:09your legal framework.
• 16:10I would never, as an ethicist say,
• 16:12do the illegal things.
• 16:13I don't want to get you in trouble.
• 16:15I can say to you the ethical thing
• 16:16is different from the legal thing,
• 16:18but it's important to keep in mind
• 16:20what privacy is in place for these
• 16:23kids and what legal protection they have.
• 16:26So in some states, parents.
• 16:27We no longer see their children's
• 16:29records when they reach a certain age,
• 16:31like in California.
• 16:32When they reach 12,
• 16:33their parents cannot see their
• 16:35records anymore.
• 16:36But in other states,
• 16:37that's not the same thing.
• 16:39So now you're dealing with this
• 16:41other ethical dilemma of, well,
• 16:42what do I put in the medical records, right?
• 16:44Do I want to acknowledge that this
• 16:46child is clear in the records?
• 16:48What if the parents see it?
• 16:49But if I don't acknowledge it,
• 16:50this child may not get the
• 16:52best care that he needs.
• 16:53And so it's really kind of tricky
• 16:55of how do you manage this,
• 16:58and I wish I had the easy answers,
• 17:00but I don't.
• 17:00But we can talk about this,
• 17:01and I would love to hear your
• 17:04thoughts and how you handle these situations.
• 17:07OK.
• 17:07The other thing I want to bring up that
• 17:10I think that supports confidentiality
• 17:13is that there are already examples
• 17:16of cases where minors can get
• 17:19healthcare without parental involvement.
• 17:21Some of these have been reduced
• 17:23recently through the jobs,
• 17:25but sexual reproductive healthcare,
• 17:27so, you know, STI treatment,
• 17:29birth control, these sorts of things,
• 17:31mental health, substance use.
• 17:33For many reasons,
• 17:34kids can get this treatment
• 17:36without parental notification.
• 17:38One is the stigma associated with all this,
• 17:40right?
• 17:40Kids are not going to feel
• 17:42very comfortable saying like,
• 17:43hey, parents, I have gonorrhea,
• 17:45can you take me to the doctor?
• 17:46Right.
• 17:47So they're not going to go and
• 17:48see the doctor unless they know
• 17:50it's going to be confidential.
• 17:52So if things are stigmatized or
• 17:54they don't want their parents
• 17:55to know they're having sex or
• 17:57some of these are public health
• 17:59matters where things are contagious
• 18:00and can spread to others.
• 18:01And so we as a society take this
• 18:04utilitarian approach where we
• 18:05want to maximize the greatest
• 18:06good for the greatest number.
• 18:08So we say,
• 18:09let's allow kids to get this treatment
• 18:11without their parents notification, right?
• 18:14Notable exception is abortion in many
• 18:16States and more and more so birth control.
• 18:19But for some of these others your kids are
• 18:22you don't ever have to disclose parents.
• 18:24Right.
• 18:25OK.
• 18:25So I think that is a nice precedent,
• 18:27nice model upon which we can base our claim
• 18:31that we should keep this confidential exact.
• 18:34So what do we do then? Do we?
• 18:36So now we know we're going to
• 18:38keep a confidential right?
• 18:39Do we encourage Zach to
• 18:42disclose to his family?
• 18:45And this is a tough one because we know
• 18:47a lot of families are not supportive.
• 18:50And so are we going to cause Zach more harm?
• 18:55Will this lead to him being kicked out?
• 18:57Will this lead to verbal abuse?
• 18:59Well, what? You know, what will happen.
• 19:01And if we don't know anything about
• 19:03his family that I don't think
• 19:04we should make a recommendation.
• 19:05I think we need to gain more
• 19:07information and learn more about his
• 19:09family and also strategize so he has a plan,
• 19:12right?
• 19:12So he doesn't just come home one day and say,
• 19:14like, oh, by the way,
• 19:15I'm gay, hurray, you know?
• 19:17So I think this needs to be done carefully.
• 19:21And be strategic about how
• 19:22to do this and see
• 19:24what Zach thinks.
• 19:25What does he feel comfortable doing?
• 19:27Are there ways he can kind of float the
• 19:30idea beforehand and talk about these
• 19:32issues and not talk about himself?
• 19:34Right. But I I I don't think that
• 19:36we should push him to disclose to
• 19:39his family because of the danger
• 19:41that is possibly present there. OK.
• 19:44But we do want to make sure that
• 19:47he's getting support and there are
• 19:49all sorts of support systems out
• 19:51there and with the virtual world,
• 19:54there's more and more access.
• 19:56And what we see is a lot of kids want
• 19:58to get support but they don't know
• 20:00how because they don't have money or
• 20:02they need their parents permission.
• 20:04But now with the social media world
• 20:06that I am too old to understand,
• 20:08I know there are lots of options
• 20:09out there and you probably all
• 20:10know them very well.
• 20:11You're all probably like
• 20:13tick Tock famous already.
• 20:14But there are these,
• 20:16these places here for them to
• 20:17go to where these are credible
• 20:19sources where they can get support.
• 20:22And I think that's really important.
• 20:24You know, they came out to you.
• 20:26They might already feel isolated
• 20:27and vulnerable to make sure they're
• 20:29talking to their peers who are
• 20:31in similar situations,
• 20:32so these local and online support
• 20:33groups I think are really great.
• 20:36So let's Fast forward six months.
• 20:41Zach has come out to his family and it
• 20:45went OK, maybe better than expected.
• 20:48They didn't kick him out.
• 20:49They but they want him to try conversion
• 20:52therapy because they think, you know,
• 20:54being gay is this real problem and it's
• 20:56going to make him not have as good of a
• 20:59life and blah blah blah and their mind.
• 21:01And so they want him to try this.
• 21:03They also associate being a gay man
• 21:06with having HIV. So they say we want
• 21:08you on Prep just to protect you.
• 21:11We're worried about it.
• 21:12There's that. You know, again,
• 21:13they're buying into this
• 21:14cultural narrative of, like,
• 21:15gay men being super promiscuous and
• 21:17having sex with anything that walks.
• 21:19So they say, let's put him on prep,
• 21:21even though we're trying
• 21:21to get rid of his gayness.
• 21:24Their words, not mine.
• 21:26So conversion therapy,
• 21:27I'm sure you're all familiar with
• 21:30this is the idea that you use.
• 21:32Pseudoscience or spiritual methods or
• 21:35psychological pseudo psychological
• 21:36methods to change someone's sexual
• 21:38orientation or gender identity,
• 21:40right?
• 21:42And. About 10% of adults have
• 21:45undergone this in the US and it
• 21:49is not banned in many states.
• 21:52It and the green states,
• 21:53those are the places where it is banned,
• 21:55where it is not allowed.
• 21:57But in other states there's either
• 21:59no comment about it or it's allowed.
• 22:02And you know, we,
• 22:03we talked a little bit earlier today too
• 22:05about like ethics and trying to be neutral.
• 22:06And I'm not very good at being neutral
• 22:08about these things I'm passionate about.
• 22:09So I will just be blunt.
• 22:11I think it's absurd that gender
• 22:13affirming care has been classified
• 22:15as child abuse when the state of
• 22:18Texas allows conversion therapy,
• 22:20which we know is so harmful.
• 22:22And so again,
• 22:22I'm in a place of privilege where I
• 22:25can say that as an ethicist and they
• 22:26can't come after my license because I
• 22:28don't have one or anything else like that.
• 22:31I don't have any patience.
• 22:32I just have you all here.
• 22:34But that that just is horrifying
• 22:36to me that when we look at the
• 22:39evidence for conversion therapy
• 22:41versus gender affirming care,
• 22:43if you were just to look at it scientifically
• 22:45and they allow conversion therapy.
• 22:47So unfortunately,
• 22:48this is the real thing that still happens
• 22:51and parents are still trying to get
• 22:53their kids to go to conversion therapy.
• 22:55So I think we have an ethical
• 22:57obligation to tell the parents that
• 23:00you should not send your kid there.
• 23:02And to try to have a conversation with them
• 23:05about all the harms associated with this.
• 23:08Because you know, it's not,
• 23:11it doesn't really work and it's harmful,
• 23:13right. And so I don't think you can be
• 23:16morally neutral about a type of treatment,
• 23:18right that is going to do harm.
• 23:20So I think you really do need
• 23:22to take a stand here as well.
• 23:23Umm. And then prep.
• 23:26So they're concerned about HIV AIDS.
• 23:29And I think it's important here
• 23:31to distinguish between negative
• 23:32rights and positive rights.
• 23:34So negative rights are the rights
• 23:35to be left alone. Autonomy rights.
• 23:37My rights to do my karate
• 23:39stops where your nose begins.
• 23:41I can't punch you in the face, right?
• 23:43And don't worry, I won't.
• 23:44I'm not violent.
• 23:45But this idea that we have the right
• 23:48to do what we want with our body,
• 23:50and that's why we can't do
• 23:52procedures against people, you know,
• 23:53if they're refusing, it's considered battery.
• 23:55Our assault so this is almost
• 23:59absolute in medicine.
• 24:00Almost.
• 24:01There are some cases if someone
• 24:02has very contagious Ebola,
• 24:04we might quarantine them.
• 24:05But for the you know, otherwise,
• 24:07we let people with COVID go out in public.
• 24:09We let people do all sorts of things.
• 24:11So I have real concerns though
• 24:13about forcing treatment on
• 24:15someone against his wishes,
• 24:16even if he's a minor.
• 24:21Oh, I'm sorry. Yes, thank you.
• 24:23Prep is a prophylactic to
• 24:26prevent HIV taking daily.
• 24:28It can prevent the likelihood
• 24:30of of acquiring HIV. Aids that.
• 24:32OK. Thank you. Yes, please.
• 24:33And feel free to chime in if there's
• 24:35things I'm missing or questions.
• 24:36Great. So, you know,
• 24:39I think even he's a child,
• 24:41he has negative rights and we
• 24:43should not force him to take a
• 24:46medication against his wishes,
• 24:47even if he is sexually active.
• 24:49And in this case, Zach was saying,
• 24:50no, I'm not sexually active at all.
• 24:52So it makes no sense because
• 24:53they're always going to be some
• 24:54side effects with medication.
• 24:55Why are you going to put this kid on the
• 24:57medication if he's not sexually active?
• 24:58If it's just because the parents are scared
• 25:01because they associate being gay with HIV,
• 25:03that's not a good enough reason.
• 25:05And again,
• 25:06I think we need to really support
• 25:08individuals bodily integrity and
• 25:09make sure that we are not doing
• 25:11things to them against their wishes,
• 25:13even if they are minors,
• 25:15even if they lack capacity,
• 25:17even all these situations,
• 25:18I think we have to think very carefully.
• 25:20About when we can infringe
• 25:22upon people's bodily autonomy.
• 25:24OK.
• 25:24Great.
• 25:25So some other reasons why
• 25:27I think we should not,
• 25:29we should say no to prep
• 25:30is it's not life saving.
• 25:32This would be a different situation
• 25:35if he were bleeding out and he was
• 25:36saying I don't want blood products,
• 25:38right?
• 25:38This is the classic bioethics case
• 25:40of the Jehovah's Witness family
• 25:41and the kid needs a transfusion.
• 25:43If that were the case,
• 25:44we would say this is all imminently
• 25:46life threatening situation.
• 25:47Give this kid blood.
• 25:49This is not the same case here, right?
• 25:51He's not sexually active and there are
• 25:53other ways to prevent HIV transmission,
• 25:55right?
• 25:55Condoms and spermicides and
• 25:57all these other things.
• 25:59So I think that's a bad idea.
• 26:01Also, just the logistics of forcing him.
• 26:03How are we going to do this every day?
• 26:04Are we going to tie him down and
• 26:07make sure he takes this pill?
• 26:08He's, you know, I.
• 26:11Big kid.
• 26:12This is going to be really challenging.
• 26:14How do we know he's not
• 26:15gonna throw it up later?
• 26:16And I think just the psychological harm
• 26:19of forcing people to take a medication
• 26:22against their wishes is significant,
• 26:24and we can't underestimate that.
• 26:26So I think this is just
• 26:27not going to be feasible,
• 26:28and I think it's also unethical to force him.
• 26:32OK.
• 26:34Hopefully you've all eaten,
• 26:36so the food is not too tempting.
• 26:38So some takeaways.
• 26:41Confidentiality is really, really important.
• 26:43You all know this.
• 26:45I'm preaching to the choir here.
• 26:47But when you, if you can uphold it,
• 26:49do so and think really carefully,
• 26:51carefully about cases where
• 26:53you would violate that.
• 26:54We need to support team decision making,
• 26:57especially when it comes to stigmatized care.
• 26:59They are coming to you as a safe place,
• 27:00as an ally.
• 27:01They are not going to other people.
• 27:03So we need to create that environment,
• 27:05which I know you're all doing the right to.
• 27:08Bodily integrity is hugely significant.
• 27:10There's lots of legal precedents
• 27:12and ethical precedent on this.
• 27:13So don't violate unless you have really,
• 27:16really, really good reasons to do so.
• 27:18And then encourage familial
• 27:20and social support.
• 27:22Should I take questions now?
• 27:23Just move to the second case,
• 27:25move to the second case.
• 27:25All right,
• 27:26we're going on.
• 27:30OK, we have Jackie here.
• 27:32She her 15 years old, assigned male
• 27:35at birth but identifies as female.
• 27:37Been on puberty blockers since 11 and
• 27:39she is super eager to start hormones.
• 27:41Can't wait and she wants
• 27:43to preserve her fertility,
• 27:44which we'll get to later on.
• 27:47OK, so what's going on here?
• 27:49Her parents are concerned.
• 27:52As we know, puberty blockers are reversible.
• 27:55It's kind of just putting a pause on things.
• 27:57But hormones are not.
• 27:59Hormones can lead to certain lifelong
• 28:01consequences and changes in one's body.
• 28:04So their parents are
• 28:05really worried about that.
• 28:06They strongly oppose bottom surgery.
• 28:08Well, good, because we're not doing
• 28:09bomb surgery on minors anyway.
• 28:11So all this stuff in the media,
• 28:12it's like genital surgery on 3 year olds.
• 28:14Not happening unless as I was talking with
• 28:16other folks about their intersex kids.
• 28:18And then we do that, which is also unethical.
• 28:21But I digress.
• 28:22So you know when we're really
• 28:24not doing bomb surgery on minors,
• 28:26so you can assuage their concerns about
• 28:28that and saying when they're eighteen,
• 28:29they can think about that.
• 28:32So and then fertility preservation,
• 28:34they say what a waste of money.
• 28:36Why do you need that?
• 28:38You know you should act according
• 28:40to your assigned gender,
• 28:41and if you're not going to do that,
• 28:42then you shouldn't have kids because
• 28:43it would be harmful to the children,
• 28:45blah blah blah.
• 28:46So they are, you know,
• 28:48they love their child,
• 28:49they're supportive of their
• 28:50child in many ways,
• 28:50but they're really concerned about
• 28:52this and not just psychologically,
• 28:54but also about the effect these
• 28:56hormones will have on their child.
• 28:59So who decides here in this type of case?
• 29:03So we have paternal beneficence, right?
• 29:06Parents who want to do well
• 29:07for their children.
• 29:08Again, it's not like parents are evil.
• 29:09Like, ha ha ha,
• 29:10let me make my child miserable, right?
• 29:12We know that's not what's happening here,
• 29:14but we also have jackies, autonomy.
• 29:16So how do we weigh these?
• 29:19And at what point do we listen
• 29:22to Jackie over her parents?
• 29:24And this gets tricky.
• 29:26But you know,
• 29:28the way I've tried to cash it out in my
• 29:29work and in conversations I have with others,
• 29:31is we need to look at the
• 29:33subjectivity of the treatment.
• 29:34If Jackie were to come in with strep throat,
• 29:38that's an objective test we can test
• 29:39for that we know how to treat that.
• 29:41We give them the drugs,
• 29:42we go on, blah, blah, blah.
• 29:44Same thing with a broken arm.
• 29:46It's clear we can test for
• 29:47that with an X-ray.
• 29:48OK, now we put the cast on.
• 29:50But for other things like gender identity,
• 29:53there's no test, right?
• 29:53We don't draw blood and say,
• 29:55Oh yes, congratulations,
• 29:56you really are a girl, right?
• 29:58So this is only something that Jackie
• 30:00can tell us that can come from her,
• 30:03can't come from anyone else.
• 30:05Same thing with things like reproduction,
• 30:07whether or not someone wants to
• 30:09have biological children that can't.
• 30:10Again, we can't do like an X-ray.
• 30:11And you're like, Oh yes,
• 30:12your eggs are ready and you
• 30:14want to have kids.
• 30:15So these are really deeply subjective.
• 30:18And so we need to listen to the children.
• 30:21Even more in these cases.
• 30:23And it needs to be coming from the kids.
• 30:26It can't be the parents and it can't.
• 30:29And this I think is really hard for a
• 30:30lot of parents because it does seem so
• 30:32subjective and everyone's like, well,
• 30:34subjective stuff is just squishy and but
• 30:35how do we know it's true and how do we know
• 30:37it's real and all these things and what,
• 30:39we'll talk about some of those things.
• 30:41But I have this chart here just to show that
• 30:44as things become increasingly subjective,
• 30:46we need to listen to kids more and more.
• 30:49So if that Blue Square is an app and,
• 30:50you know, appendicitis.
• 30:51We know what to do in appendicitis, right?
• 30:53We're not going to tell if the kids like,
• 30:55I don't want that because I
• 30:56want to wear a bikini. Too bad.
• 30:57We're getting your appendix out.
• 30:58OK. Sorry, kid, but if the kid,
• 31:01you know, the red lines here,
• 31:03says this is my gender identity,
• 31:05I think we need to listen there, OK?
• 31:08All right.
• 31:10And part of the way we support this and
• 31:13ethics is we talk about an open future.
• 31:16And this is the idea that we want to leave
• 31:19as many possibilities available for children.
• 31:22We don't want to limit what
• 31:25roads they may go down.
• 31:27So This is why, you know,
• 31:28we we don't do dramatic surgeries
• 31:30to children when they're young
• 31:32that might affect them lifelong,
• 31:34like some of the areas like surgeries because
• 31:35then it will close off certain paths,
• 31:37right.
• 31:37We want to keep.
• 31:38Things open so they can say yes,
• 31:40I choose this or no,
• 31:41I choose this and so that going
• 31:43back to the Jehovah's Witness case,
• 31:45that's part of the reason why
• 31:46we give blood products to minors
• 31:48who are Jehovah's Witnesses,
• 31:49because we want them to have an open future.
• 31:52So when they reach 18,
• 31:53they can say this religion is not
• 31:55for me and I'm glad I'm alive.
• 31:56Or they can say this religion is for me
• 31:58and I wish then give me blood products.
• 32:00But I guess I'm alive and I can
• 32:02decide on my own next time.
• 32:03OK,
• 32:03so this idea of an open future
• 32:06is really important.
• 32:08But sometimes when we're thinking
• 32:09about hormones we're doing,
• 32:11we're looking at omission versus
• 32:12Commission and people are saying,
• 32:14oh, but like, you know,
• 32:15if I give them hormones or puberty blockers,
• 32:17I'm the one interfering and
• 32:19I'm doing something to them.
• 32:21So I'm causing them harm.
• 32:23I think that's sort of that line of
• 32:26reasoning neglects that Natal puberty
• 32:27is harmful for some kids, right?
• 32:29If you assume Natal puberty was neutral,
• 32:32then yes,
• 32:32doing something that could change
• 32:34that could be harmful.
• 32:35But for many of these kids,
• 32:37Natal puberty is going to be really
• 32:39damaging and it doesn't have
• 32:41to be inevitable.
• 32:42We have the tools to change that,
• 32:44just like we have for other
• 32:46sorts of healthcare issues.
• 32:47We can change something that might be
• 32:49inevitable by treating it in advance,
• 32:51right?
• 32:51So Commission versus omission,
• 32:53I don't think that's an important
• 32:55distinction here,
• 32:55but sometimes people bring that up.
• 32:58The other thing to bring up is that
• 33:00puberty blockers are not permanent,
• 33:01so we can allow Jackie to go on them
• 33:03for a few years so she can grow and
• 33:05develop and see what she thinks.
• 33:07There is, of course a psychological
• 33:09delay to puberty.
• 33:10I mean, 9th grade is hard enough.
• 33:12Now imagine you're only one hasn't puberty.
• 33:15But again, when we're weighing harms,
• 33:17that might be the lesser.
• 33:22There are physical harms
• 33:24associated for Jackie here.
• 33:26If she's getting hormones on her own
• 33:28and dosing that, if she's talking,
• 33:30all these sorts of things that she's
• 33:32doing without intervention, without help
• 33:34from a care and healthcare provider,
• 33:36can be causing herself more physical harm.
• 33:39There are so many psychological harms we
• 33:41could spend forever talking about all these.
• 33:43Unfortunately again, bullying at school.
• 33:49More likely to use substances I had.
• 33:51I had to cut down some of these slides.
• 33:52Like way too many 1/4 attempts suicide.
• 33:55There's even numbers that are
• 33:57higher than that, even more here.
• 33:59All sorts of things.
• 34:01More likely to drink,
• 34:04more likely use marijuana, blah blah blah.
• 34:06I know these responders.
• 34:07Really tiny, huh?
• 34:08But I guess the point is.
• 34:11They are more at risk for
• 34:13all these sorts of things,
• 34:14for sexual violence, for substance,
• 34:16all this for bullying because of
• 34:19being transgender, if not, again,
• 34:20being trans that causes this.
• 34:22It's this structural,
• 34:23this heteronormative SIS,
• 34:24normative structure in which they live.
• 34:27So these psychological harms are enormous.
• 34:29I don't think we can underestimate
• 34:31how significant these are,
• 34:32and I know again,
• 34:33appreciation for the chair.
• 34:34There's also lifetime harms that we need
• 34:36to think about is that people who are
• 34:38trans are more likely to experience violence,
• 34:41more likely to be unhoused.
• 34:42And this disproportionately effects
• 34:44people of color who are trans.
• 34:46More likely to be incarcerated.
• 34:48All these sorts of things.
• 34:49So it's not just, oh, now I'm 18,
• 34:51I can make my own decisions.
• 34:53Hooray,
• 34:53this continues over a lifetime.
• 34:59Texas is Texas and there's all sorts
• 35:02of laws being introduced, as you know.
• 35:05What you can see from the chart on the
• 35:08right is the number of bills that have
• 35:10been introduced, anti trans bills.
• 35:12And look at how much it's increased
• 35:15over the last six years dramatically.
• 35:17The ones in pink are bathroom
• 35:19and locker room bills,
• 35:20the ones in blue are restrictions on care,
• 35:23and the Gray ones are just other ones.
• 35:25But. You know,
• 35:27I think as the conservative movement has.
• 35:30Had success with anti abortion
• 35:33rights legislation.
• 35:35They now need a new wedge issue and
• 35:37they are using anti trans legislation
• 35:39to fill that gap because these are
• 35:41very similar in a lot of ways.
• 35:43They are both pushing for this white
• 35:46supremacy gender binary understanding
• 35:48of the world where everyone has
• 35:50their clear roles and so they can
• 35:53get their base mobilized by talking
• 35:55about these sorts of things.
• 35:56And so it's not surprising that we
• 35:58see all these laws coming through
• 36:00we've already this was.
• 36:02This article was in February.
• 36:04350 anti trans laws in 36 states.
• 36:07I mean Can you imagine if those
• 36:09laws were for things like making
• 36:11sure kids get like food, you know,
• 36:14support and love,
• 36:15like think of all the good we could do.
• 36:17So, you know, again,
• 36:19I think this is really just a
• 36:21wedge issue to push this forward.
• 36:23So what are some of the objections
• 36:25to her gender affirming care?
• 36:26I'm sure you've seen this Texas
• 36:28classified as child abuse.
• 36:30Again, you know my feelings on that.
• 36:33You know,
• 36:33and sometimes this is hard to argue against,
• 36:36that people think they're there
• 36:37is this gender binary and God
• 36:39created woman and God created man,
• 36:41and this is they have different roles,
• 36:42I suppose, to do different things.
• 36:43And it is very hard to argue
• 36:45against people's religions, right?
• 36:46Doesn't matter if you give them the
• 36:48whole history and all the other things.
• 36:50But that is sort of the argument
• 36:53that's at play there.
• 36:54Another argument is that kids are
• 36:56not able to meaningfully decide.
• 36:59We let kids make all sorts of
• 37:01decisions that affect their lives.
• 37:02We let 13 year olds decide to
• 37:05stay pregnant or get, you know,
• 37:07because that's we think that's OK.
• 37:09Somehow, even if the child wants an abortion,
• 37:11we say, no, we're going to let you do this.
• 37:13Kids can make decisions for themselves,
• 37:16especially when they're about
• 37:18these subjective things,
• 37:19because only they know their values.
• 37:20And, yes, are their values perfect? No.
• 37:22Will their values change over time?
• 37:24Probably. Guess what? They're human.
• 37:26They're like all of us.
• 37:27These things change and develop.
• 37:29But you know,
• 37:29no one is better positioned to
• 37:31make these decisions than they
• 37:33are because it's about themselves.
• 37:34My potential for regret?
• 37:36We will get into that in just a second
• 37:39because this always comes up so.
• 37:42There's this idea of Desistance
• 37:44where children are we're starting
• 37:47on a a gender journey and then
• 37:50went backwards, OK?
• 37:51And so some people are saying, no,
• 37:53it really what's happening here is
• 37:55that these kids are regretting it.
• 37:57They're not mature enough
• 37:57to make these decisions.
• 37:58But that's not what we see in the literature.
• 38:01And the more recent literature shows
• 38:02that less than 4% of kids desist.
• 38:04There is some older literature
• 38:06out there that has some really
• 38:09problematic methodological features.
• 38:10I'm not going to go into all of that.
• 38:11But like, you know,
• 38:12if the kid never comes back to your
• 38:13clinic and you count them as a.
• 38:14Sister, maybe they just moved
• 38:16to another state, right?
• 38:17You can't just count them as that.
• 38:19But no, this is like interesting language.
• 38:21We have like a whole term for people who
• 38:24we see as changing their gender back again.
• 38:27I just,
• 38:28I find it really interesting that
• 38:30we did this all this like catchy
• 38:32language that can be used in the media
• 38:34to kind of push this debate forward
• 38:36and that these terms are culturally loaded,
• 38:38right?
• 38:39And they're morally loaded as well.
• 38:41So,
• 38:42but what we see again is that really most.
• 38:44Kids are persistent, not distant.
• 38:47And this has a lot of text, so I apologize.
• 38:51But even if people desist,
• 38:53it doesn't mean they regret it.
• 38:54And some but.
• 38:55So we need to separate
• 38:56regret from desistance.
• 38:58But I do want to take a second to talk
• 39:00about regret because there are lots of
• 39:02places where people regret their surgeries.
• 39:04I had knee surgery,
• 39:05I regret that surgery, and no one ever
• 39:07asked me whether I regret or not.
• 39:08No one seemed to care.
• 39:09But I regret it and I will go tell them,
• 39:11maybe one day.
• 39:14But look at all these other
• 39:16things these adult patient regret,
• 39:1827% who had moderate to severe
• 39:21regret after major head neck surgery,
• 39:2430% regret robotic assisted,
• 39:25you know prostate removal,
• 39:27all these people are having regrets.
• 39:31Nope.
• 39:32What's normally regulated though
• 39:34is elective hysterectomy.
• 39:35But they'll regret rate is so low for that.
• 39:38But all these,
• 39:39you know,
• 39:40ACOG had the American Congress of
• 39:42College of Obstetrics and Gynecology
• 39:44had to come out and say look,
• 39:46if if you have assist woman who wants
• 39:48instructed me and she doesn't have kids,
• 39:50you have to do it for her.
• 39:50You can't just be like sorry honey,
• 39:52you're going to want kids down the line.
• 39:53You're going to regret this
• 39:54because that's what was happening.
• 39:57And they don't regret it.
• 39:59Again, this is a very subjective thing.
• 40:01Only that person knows what they want.
• 40:04And yes, some of them may come to regret it,
• 40:06but that number is really small.
• 40:08But I don't hear any
• 40:09politicians or anyone saying,
• 40:11Oh my gosh, neck surgery.
• 40:12We got stopped that next surgery,
• 40:13everyone's regretting it. Never.
• 40:15But I do hear about hysterectomy, right?
• 40:18And so they're looking at
• 40:20pediatric and parental regret.
• 40:22What we see is that some kids do regret
• 40:25not being included in decision making.
• 40:27So the first step here is about quarter
• 40:29of a Y cancer patients regret that they
• 40:31were not included in decision making,
• 40:33that the parents and the clinicians
• 40:35made those decisions without them.
• 40:37About third regret, DSD surgery,
• 40:40differences of sex disorder and then again
• 40:42looking at another type of DSD hypospadias.
• 40:45A lot of parents regret doing that
• 40:47surgery and yet intersex surgery for
• 40:49babies is legal and accepted in the
• 40:52medical community despite the fact
• 40:54that his parents regret it and no one
• 40:56is thrown around that information.
• 40:58So I feel like we use this
• 41:00information to push forward sort of
• 41:02our political beliefs and agendas.
• 41:04OK, so there's lower regret.
• 41:07The numbers I'm seeing are under
• 41:101% for gender affirming surgery.
• 41:12And it's also important distinguishing
• 41:14why people might have regrets.
• 41:16Like, is it just medical?
• 41:18Like you don't like the way your new genitals
• 41:21look or you're not able to orgasm as easily?
• 41:23Is it social?
• 41:24Now you're having trouble getting along,
• 41:26you know, at work because you don't.
• 41:27People don't have to handle you.
• 41:29What's going on?
• 41:29Or is it really true?
• 41:31Oh my goodness,
• 41:31this is the wrong gender.
• 41:33And what we see is a lot of the reasons
• 41:35people determination is external pressures,
• 41:37social stigma, family pressure,
• 41:38these sorts of things.
• 41:39It's not that they change their mind.
• 41:43OK,
• 41:43so getting back to Jackie's supportive
• 41:47parents similarly are super important
• 41:50and this can make all the difference
• 41:53for trans and non binary kids.
• 41:56And So what we see here is that
• 41:58kids who are get to use the
• 42:00names they want do much better,
• 42:02and especially in all different arenas,
• 42:04home, school, whatnot.
• 42:06And that trans kids who are supported by
• 42:09their parents to just as well assist kids.
• 42:11Really what happens is if
• 42:13trans kids are not supported,
• 42:14then they do poorly psychologically.
• 42:17So it's all about providing them support.
• 42:21But there are these barriers
• 42:22to care for Jackie and others,
• 42:24things like parental consent.
• 42:28And This is why I think it's
• 42:29interesting as well is that,
• 42:31you know,
• 42:31we talked about some of these
• 42:33areas of medicine where kids
• 42:34can get treatment without their
• 42:36parents knowledge or or approval,
• 42:38but we don't allow that for gender
• 42:41affirming care and I don't see
• 42:43why not because I think there's
• 42:44a lot of similarities.
• 42:45This is stigmatized.
• 42:46This has to do with sexual
• 42:48sexuality and gender,
• 42:50which are very subjective and
• 42:51there have been some ethicists
• 42:53out there making the case that we
• 42:55should allow kids to get access to this.
• 42:58As well, like we do for STI treatment or
• 43:01contraception or all these other things.
• 43:03So I would welcome your thoughts
• 43:04on that too. When we talk.
• 43:05Some of the barriers to care too are
• 43:07just like the visibility of it, right?
• 43:08If you're taking birth control,
• 43:10no one may know, but if your body
• 43:12starts changing in certain ways,
• 43:14it's going to be obvious.
• 43:16Another huge barrier is just expense.
• 43:19These procedures are hugely expensive,
• 43:22and the states in orange are the ones
• 43:24where Medicaid explicitly says they will
• 43:27not cover any gender affirming care.
• 43:29So if your insurance doesn't cover
• 43:31it and you're on Medicaid, too bad.
• 43:34Texas, all right,
• 43:36I want to quickly come to fertility
• 43:40preservation because it's something else.
• 43:42Jackie was interested in gender affirming
• 43:44care because can cause infertility,
• 43:46infertility, and sterility.
• 43:47And there's an interesting New York
• 43:49Times article about this woman on
• 43:52the right hand side here who is
• 43:54trans and underwent gender affirming
• 43:57care and then detransition.
• 44:00So according to some of those stats,
• 44:01you would be AD transitioner so
• 44:03that she could produce viable.
• 44:04Firm so she and her partner could
• 44:06have a genetic related child and
• 44:07then she went back on hormones.
• 44:09So she talks about going through
• 44:10puberty multiple times.
• 44:11I think once was more than enough,
• 44:14so good for her.
• 44:17And this is where I think we can
• 44:18distinguish we talk about negative rights,
• 44:20autonomy rights, rights to be left alone.
• 44:22Positive rights are the right to something.
• 44:24So in this country there really
• 44:26isn't a positive right to healthcare
• 44:27except for an emergency situation.
• 44:29There is a positive right to
• 44:31K through 12 education some,
• 44:32and that means someone has to provide it.
• 44:34So the government provides it.
• 44:35We don't say anything about
• 44:36quality or whatnot,
• 44:37but someone provides it.
• 44:38So positive rights and medicine
• 44:40are pretty limited and there isn't
• 44:43a positive right to reproduction.
• 44:45There are in other countries and Israel,
• 44:48it's very pronatalist.
• 44:48And they will pay for you to have
• 44:50two live birth babies because they
• 44:52really want people having babies or
• 44:53certain types of people having babies,
• 44:55and many other European countries as well.
• 44:58They will even give you money to have kids.
• 45:00So they're trying to encourage that.
• 45:03And cost here is going to be a barrier.
• 45:06It's super expensive to just get the
• 45:09games retrieved and then to store them.
• 45:12It's hundreds of dollars each year.
• 45:14And this is not covered by insurance.
• 45:16And as far as I'm aware,
• 45:17there are no charity programs
• 45:18for trans folks.
• 45:19There are for folks with
• 45:21infertility and folks with cancer.
• 45:23So this is going to be really expensive.
• 45:24And what,
• 45:2515 year old has this kind of
• 45:27money to shell out, right?
• 45:29There are alternative
• 45:30family building structures.
• 45:32Again, these can be expensive.
• 45:33Adoption can cost easily 20 to 50 grand,
• 45:37and there are all sorts
• 45:38of discriminatory laws.
• 45:39So these, the yellow triangles,
• 45:41are states that refuse,
• 45:43that can where it's legal to
• 45:46refuse adoption to queer families.
• 45:49So, you know,
• 45:49if you're living in Texas and
• 45:51you're a queer family,
• 45:52state agencies can say,
• 45:53sorry,
• 45:54I'm not going to adopt you because you're
• 45:55not a suitable home for this child.
• 45:57So it, you know,
• 45:59there's extra barriers there for folks.
• 46:01So the case takeaways here are the
• 46:04subjectivity of gender affirming
• 46:05care and how this means I think we
• 46:08need to pay even more attention
• 46:10to the child's preferences.
• 46:12Again, supportive environment,
• 46:14I know you knew that.
• 46:15And then having those conversations
• 46:17early about reproductive autonomy,
• 46:19because what we see is that
• 46:21that's really important to a lot
• 46:22of young people and they never
• 46:23have those conversations.
• 46:24And often they're so eager to go on
• 46:27hormones and then they regret that later.
• 46:29So just having those
• 46:31conversations as soon as you can.
• 46:32So talk takeaways.
• 46:33These things are deeply personal.
• 46:35We need to listen to youth, and we need
• 46:38to be supportive and be advocates.
• 46:40All right.
• 46:41I will be happy to take any
• 46:42questions or comments.
• 46:49You so much. Thank you
• 46:51for leaving. Plenty of time
• 46:52for us to talk.
• 46:55Yes. Clarification, yes.
• 47:00And Amy ask, can you clarify
• 47:02in the states where conversion
• 47:03therapy is banned and is it banned
• 47:05for everyone or only for minors?
• 47:07Minors. Yeah, good question.
• 47:09Adults can do what they want,
• 47:11but minors is banned for.
• 47:19Could you just clarify what you said really
• 47:21fast at the end of the year?
• 47:23You said something like
• 47:24they regret that later.
• 47:26Was that about hormones, hormone
• 47:28therapy affecting fertility?
• 47:30So they sometimes regret not preserving
• 47:33their fertility, especially as they
• 47:35get older and learn that these.
• 47:37So a lot of them are interested in
• 47:39alternative family building options,
• 47:40which is great.
• 47:41But I don't think they realize when
• 47:43they're 15 that there's all these
• 47:45discriminatory practices that will
• 47:47prevent them from having kids.
• 47:49That way. And so. But you know,
• 47:51given all the conversations you have,
• 47:53that regret.
• 47:53I'm not saying that we should, you know.
• 47:55Push them to have fertility preservation.
• 47:57That's actually some of the other work I've
• 47:59done is what do we do in situations where.
• 48:02Teenagers don't want to have
• 48:03fertility preservation,
• 48:04but their parents do want them to have it.
• 48:06And how do we balance autonomy there?
• 48:09Because yeah, I mean,
• 48:10like most 16 year olds are worried
• 48:12about not getting pregnant right
• 48:14now about getting pregnant.
• 48:15And so I think there just needs to
• 48:17have a lot of conversations and just
• 48:19let kids know that alternative methods
• 48:21may not be a viable option for them,
• 48:23unfortunately.
• 48:26Thank you so much. We have a
• 48:27couple of questions from zoom.
• 48:29I see that Doctor Sheldon and please
• 48:31go ahead and ask your question.
• 48:38Hello. I'm actually Doctor Calhoun,
• 48:40but I'm here with Doctor Sheldon.
• 48:41We're in the same room.
• 48:42Uh my name is Amanda.
• 48:43I am a fourth year adult child
• 48:46psychiatry resident wanted to say I
• 48:48have a question actually and a comment.
• 48:49So first, you know,
• 48:51I appreciate your presentation.
• 48:52I would say, you know,
• 48:54I did find it a bit problematic that
• 48:56the family you chose to portray that was
• 49:00uneducated thought queer people spread
• 49:02HIV was a black or brown appearing family.
• 49:05I think it's very important to be mindful.
• 49:08That often black and
• 49:09brown parents are racist.
• 49:11They portrayed as less educated,
• 49:14less in the know.
• 49:15And personally I've had many white
• 49:17families that also think that.
• 49:18And actually that concept
• 49:19was started by white people.
• 49:21So I just wanted to add that.
• 49:23And my question for you is,
• 49:24you know, you mentioned I loved,
• 49:26you know,
• 49:27all the aspects of your talk.
• 49:29But I did find what was missing was
• 49:32an acknowledgment of white supremacy
• 49:34and the fact that oftentimes the
• 49:36queer folks who are elevated.
• 49:38Are white appearing?
• 49:39And my question for you is how are
• 49:41you collaborating with folks to
• 49:42take an anti racist lens to this?
• 49:44Because you know, you know you well,
• 49:47I appreciate you showing people
• 49:49of different racial backgrounds.
• 49:51There was really no mention of the
• 49:52fact that like black transgender
• 49:54people are the ones who are getting
• 49:56murdered at really high rates.
• 49:57The impact of racism and how
• 49:59that is also playing roles.
• 50:01I guess my question is how are you
• 50:03adding not just the CIS heteronormative
• 50:06agenda and pushing against that?
• 50:08But also the white supremacist agenda.
• 50:11Yeah. Thank you so much for that.
• 50:12And then just look at that camera, I think.
• 50:15Thank you so much for that question.
• 50:16I'm pointing that out,
• 50:17and I think you're absolutely right
• 50:18that we need to be mindful about that.
• 50:19So I appreciate that, that comment.
• 50:22So some of the things that I'm doing is
• 50:25working with some community groups where
• 50:28there are a lot of people of color in
• 50:31queer groups to advocate in that way.
• 50:34Because I think you are so right that,
• 50:36and I think I have that one tiny little
• 50:39diagram that showed you that like people
• 50:41of color who are queer are more likely
• 50:43to get this exacerbated in every way.
• 50:46Because of white supremacy.
• 50:47And it is white supremacy that you know
• 50:49has led to these gender binary the way
• 50:51we understand it in our culture now,
• 50:53so completely and there are many
• 50:55other communities where there
• 50:57are third genders and you know,
• 51:00communities of color are from
• 51:02around the world that where it's
• 51:04just totally acceptable.
• 51:05So I think that's a really important point.
• 51:07I try to work with, like I said,
• 51:10communities in my area who are of
• 51:13color and other underrepresented
• 51:14groups who try to work with really.
• 51:16A lot of rural folks who are queer because
• 51:18they're often really disadvantaged as well,
• 51:21and folks with disabilities.
• 51:22So trying to get other
• 51:24voices heard besides mine,
• 51:26because I recognize that, you know,
• 51:27as a white affluent woman,
• 51:29my views are often limited.
• 51:30So I need to hear other people's voices.
• 51:32Thanks.
• 51:39Thank you. I'm Lilia Benoit,
• 51:41Challand Allison psychiatrist.
• 51:44And I would like to ask you if if
• 51:48there was a component maybe on,
• 51:50on the first case for the parents
• 51:54willing to to implement the prep therapy
• 51:57like as a preventive therapy really
• 52:00do you think there might be
• 52:02something around making that
• 52:05their child experience?
• 52:07The difficulties and the challenges of having
• 52:11sexual and dating life as a queer person,
• 52:16I wonder about that because the
• 52:19the reason they explicitly said
• 52:21was they are worried about HIV.
• 52:24But from families I've been seeing,
• 52:28there was also sometimes
• 52:29this component of saying,
• 52:30like, oh, you know,
• 52:31life is more challenging when you're
• 52:33a career and you have to get used to it.
• 52:35And so maybe kind of.
• 52:37Along the line of conversion therapy,
• 52:39kind of showing the kid how difficult
• 52:41it is and all the side effects
• 52:44of having to take medication.
• 52:47So I just wonder if it's something you
• 52:49that was part of this case or it's
• 52:52something that that you also saw.
• 52:54Yeah.
• 52:55Yeah. No, thank you.
• 52:56And I think it was something we saw
• 52:58because the parents did love their
• 53:00child very much and they didn't want
• 53:02their child to live a life where they
• 53:04would be disadvantaged or hurt or
• 53:06anything like that or at greater risk.
• 53:07For certain things.
• 53:08And so I don't think it was just
• 53:10homophobia that led to this.
• 53:11I think it was your life is going to
• 53:14be a lot harder because you're going
• 53:16to face this type of discrimination.
• 53:18But I think the way Zach internalized that
• 53:22was you don't approve of me and who I am.
• 53:28So I think just having. Yeah, go ahead.
• 53:32Yeah, I think there's a
• 53:35question from Victoria stop.
• 53:38Oh, yes. Thank you.
• 53:40I just wanted to say thank you
• 53:42so much for this presentation.
• 53:44I found it really refreshing and
• 53:47I was curious your thoughts on so
• 53:50you talked a lot about teenagers,
• 53:53but you know gender development
• 53:55starts and happens much earlier.
• 53:57And I'm just curious about maybe
• 54:00some tips or strategies you might
• 54:02have for folks that are are working
• 54:05with kind of variance much earlier
• 54:07or family systems that are stifling?
• 54:10That variance,
• 54:12yeah, no, it's a great question.
• 54:16And there are a ton of books out there,
• 54:18so I'm not going to list them all.
• 54:19But for the can't remember when this book
• 54:22came out, but it's and tango makes 3.
• 54:24Maybe some of you are familiar with it, yeah.
• 54:27I've been giving that to
• 54:28everyone I know who has kids.
• 54:30They know they're going to get
• 54:31that book for me. And I have.
• 54:33It's a story of two Penguins.
• 54:34It's based on the real story
• 54:35at the Central Park Zoo.
• 54:372 male Penguins who mate and they keep
• 54:39sitting on rocks and none of their rocks,
• 54:41you know,
• 54:41crack and become a little baby Penguins.
• 54:43So they finally give them an egg and
• 54:45then they raise this baby and tango makes 3.
• 54:48It was my, like, subtle move.
• 54:50It's some of my more conservative family.
• 54:53And they're like, oh, Penguins, how cute.
• 54:55We were expecting something more
• 54:56controversial from you, Lisa.
• 54:57I'm like, oh,
• 54:58wait till you read this book.
• 55:00So I think there's a ton
• 55:03of resources out there.
• 55:06I think sometimes having it be somewhat
• 55:09innocuous and more palatable framing
• 55:11will help people listen to it a
• 55:14little more than they might otherwise.
• 55:16But I mean,
• 55:16I can always send you a list of stuff,
• 55:18but I would just look.
• 55:19There's just so much stuff to
• 55:20that answer that question.
• 55:23OK. Thank you.
• 55:27OK, I'll be.
• 55:31Go ahead. So I just,
• 55:33I wanted to just make sure I kind of got
• 55:35the right information.
• 55:37So in the state of Connecticut.
• 55:39The parent makes all the decision
• 55:41until the individual becomes 18.
• 55:44Unless it's birth control or so
• 55:47I'm kind of trying to figure out.
• 55:50Where does a kid get to decide
• 55:51in the state of Connecticut?
• 55:53Question is in the state of Connecticut,
• 55:55what medical decision making rights
• 55:57does do a child have and when?
• 55:59And in Connecticut as far as you can tell,
• 56:02I so I'm not a lawyer.
• 56:04Yeah, so sorry I can't answer that.
• 56:07What I can say is in most States and
• 56:09I would talk to your legal team here,
• 56:12in most states minors are allowed to
• 56:14make decisions independent from their
• 56:16parents regarding birth control,
• 56:18like regarding reproduction.
• 56:19Exception of abortion in a
• 56:21lot of places such sexuality,
• 56:23conception of gender affirming
• 56:25care but things like STI's,
• 56:28mental health and substance use.
• 56:30They are allowed to seek that
• 56:31type of care without their parent
• 56:33knowing or being notified.
• 56:34Does that align with what the
• 56:36clinicians in the room experience here?
• 56:38We have the director of our outpatient
• 56:40clinic here who can tell us at what
• 56:42age in our clinic can kids come for
• 56:44therapy and not tell their parents?
• 56:46Doctor Michelle Goyette Ewing.
• 56:49It's at 16 and
• 56:50you can only come for six sessions
• 56:52unless it can be documented that the
• 56:55child or youth would be at risk for
• 56:58disclosing that they were in treatment.
• 56:59And this is specifically for gender
• 57:01dysphoria. Or is this for all kids?
• 57:03OK, yeah. So the laws vary.
• 57:05So sorry, I you know.
• 57:08And I don't know them
• 57:09all in different places,
• 57:10but often those are the reasons why.
• 57:12Oops. This is why I need spill
• 57:15proof for any reason they can
• 57:16come in for up to six visits.
• 57:18OK, so that's broader than
• 57:19some other places, actually.
• 57:22I know when I was in New York,
• 57:23like the clinicians were allowed
• 57:25to give birth control to 12 year
• 57:27olds without their knowledge,
• 57:28without parental knowledge,
• 57:29because they treated them as
• 57:31independent or emancipated in some
• 57:32ways when it came to those decisions.
• 57:34So I would check your state
• 57:36laws and talk to a real lawyer.
• 57:41Well, we really appreciate all of the ways
• 57:44that you have empowered us today to be
• 57:47passionate advocates. Don't be neutral.
• 57:50Thank you. Thank you all.