Child Study Center Grand Rounds 11.17.2020

March 24, 2021

Controversies in Treating Transgender Children and Adolescents

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00:00To treating trans children
00:02and we really learn a lot.
00:06A lot of content, a lot of knowledge,
00:09but also we love Jack and Jack had
00:12a wonderful presence and a wonderful
00:14way of conveying information.
00:16And so we became Jack fans.
00:19And as I think of things,
00:21to introduce you to Jack for those
00:24of you who don't know him because.
00:28I'll share a secret.
00:29He's not perfect.
00:30He's not a child psychiatrist.
00:32But other than that,
00:33he comes pretty darn close.
00:35He is a clinical professor
00:37of psychiatry at Columbia,
00:38and although he's not a card
00:40carrying child psychiatrist,
00:41he very much is a developmental thinker.
00:44And everything that I've heard him speak
00:46and he has for many years been one
00:49of the leading experts in the therapy.
00:52An understanding of gay and lesbian youth.
00:56We are fellow editors and
00:58I just learned that Jack.
01:00I knew he had been an editor and
01:03we both get us into the decade.
01:06Each Jack was the editor in Chief
01:09of the Journal of Gay and Lesbian
01:11Mental Health Training in 1997,
01:14and he took that Journal from an
01:16occasional publication every.
01:18However now,
01:18the leading Journal with the monthly
01:21issues and a very robust scholarship there.
01:24And Speaking of that,
01:25is the.
01:26The official outlet publication outlet of
01:29the Association of Game was in Psychiatry,
01:32which track is a member?
01:35Jack also is a card carrying
01:37psychoanal training list I think,
01:40and he has written a book really.
01:43One one of the fundamental books in the area,
01:47the psychoanalytic treatment
01:48psychoanalytic therapy of the game,
01:50ma'am,
01:51which was really a groundbreaking work,
01:53and more recently, Jack,
01:55more recently over the past decade,
01:58Jack has been making major contributions
02:00to the field of gender dysphoria,
02:03gender diversity, trans health.
02:05Transmute and really helping
02:07us with these issues.
02:09Jack is now the section editor
02:11for the upcoming revision of
02:13the DSM 5 Gender Dysphoria,
02:15so he really is an authority in the
02:18area and what I love about Jack's
02:20work is that his authority comes
02:23from clinical direct care from
02:25Real Immersion in clinical work,
02:28and for that I get off my head.
02:31Do you Jack?
02:32I also tip my hat as I learned
02:34you went to medical school in
02:35Italy and partly Italiano and he
02:37could like train Italian,
02:38but for today he's gonna look training.
02:40So Jack. Welcome to the Child study center.
02:42Thank you for joining us take their way.
02:48OK well. No, you guys will let me
02:52know if you can hear me if we have
02:55any sound problems, OK, perfect,
02:57you're perfect right? Alright so.
03:01Trying to do this.
03:07OK, so. My I'm not a child psychiatrist
03:12and actually don't treat children
03:14like maybe older adolescents,
03:17but came interested based on these
03:19work that I started doing back in
03:232008 with the DSM five work group on
03:26****** and gender identity disorders
03:28or and then and then later here.
03:33And then later with the Icy River
03:36Working group on ****** disorders
03:38impression talk a little bit about that.
03:41And apparently I'm in section
03:43editor of the DSM 5 text revision
03:46chapter on gender dysphoria.
03:49So one of the things that happened
03:51when when I when I started working in
03:53this area prior to this I had seen some
03:56patients with transgender but mostly was
03:58working with gay and lesbian patients was I.
04:01I became struck by like the the idea that
04:04there's a big picture that I can't see.
04:06You know that and I could.
04:08I didn't need anybody who
04:10did see a big picture.
04:11And the closest I could come to
04:13the big picture was six blindfolded
04:15scientists trying to describe
04:17an elephant that you know,
04:18as you'll see.
04:19They promote will talk about there's
04:21so many moving parts in this subject,
04:24it's really hard to reduce
04:25the conversation to oh,
04:27it's just one thing because it's not just
04:30one thing when we're talking about the
04:32way we understand and perform our genders.
04:35So I'll start right with the headline.
04:39This was last year,
04:40year ago, October.
04:41There was the headline in Texas
04:43was up to parents who had seven,
04:46were divorced,
04:47had seven year old Twins that
04:49were assigned male at birth,
04:50and one of the Twins experience gender
04:53dysphoria and the mom wanted to have the
04:55child socially transitioned to female.
04:57The dad was supposed in this went to
05:00court and I'll come back to this.
05:02But this is something that's in the
05:05news now and I will have some more
05:08headlines at the end of the talk.
05:11So this is the table of contents
05:13I'm going to define some terms
05:15for you in the audience.
05:17I'm going to give you a little bit of
05:19history about how these diagnosis evolved,
05:22and we thought about some of the
05:24controversies around these diagnosis.
05:25Something about the treatment
05:27approaches of the children,
05:28and some brief mention of where
05:30the DSM five in the DSM will.
05:32This involved in the ICD 11 now stand?
05:35So *** refers to biological
05:37attributes of being male or female,
05:39usually understood in terms of reproductive.
05:41Passing loving *** chromosomes
05:43gonads Celeste.
05:44Turn off your sound *** hormones and non
05:47ambiguous internal and external genitalia.
05:49Gender is the public and usually
05:53legally recognized lived role
05:55is boy or girl man or woman.
05:57Biological factors seen as contributing
06:00and interaction with social and
06:02psychological factors to gender development.
06:05****** orientation refers to
06:07a person's ****** response,
06:08tendency, or ****** attractions.
06:10You they directed some of the
06:12same *** which we call homosexual,
06:14the other sexes, heterosexual or both sexes,
06:17bisexual.
06:17These terms are not great when
06:19we're talking about transgender
06:21individuals, because when are
06:22we talking about a person ******
06:25orientation before or after transition?
06:27So the import. So so better words
06:29which are in the literature.
06:31Androphilic means the person is
06:33attracted to men and gynephilic.
06:35Means oppression is attracted to
06:36women and this is an important
06:38distinction because historically,
06:39until the middle of the 20th century,
06:41for the most part,
06:42that gender identity and ******
06:44orientation were conflated with each other.
06:46They're not,
06:46and we'll talk a little bit
06:48about some of the differences.
06:50Now ****** identities or ******
06:53orientation identity is refers
06:55to the subjective experience of
06:571 ****** desires or attractions,
06:59and so callings when somebody, themselves,
07:02someone who calls themselves homosexual,
07:05lesbian, gay, bisexual.
07:06These identities involve some measure of
07:09self acceptance of their homosexual desires,
07:12and perhaps identification within a community
07:15of others having same *** attractions.
07:18OK, ****** identities required overtime.
07:20It's a developmental process.
07:22Not everybody who experiences a
07:25********** desire or participates in
07:27homosexual behavior develops a gay,
07:29lesbian bisexual identity.
07:30The Centers for Disease Control,
07:33the CDC, for example, and follow.
07:37Could people mute themselves please?
07:41So back Jack, do me.
07:43I'm gonna mute everyone.
07:44And then
07:44you're the only one who needs to
07:47unmute himself. OK, give me just
07:48one second. OK, thank you.
07:55OK, you can hear me now.
07:58Yep, perfect, thank you.
08:00So the CDC for example in tracking HIV
08:02infections doesn't keep track of gay men.
08:05They keep track of men who have ***
08:07with men because not all men who
08:09have *** with men identify as gay.
08:12So ****** identity how I think and
08:14feel about my ****** attractions is not
08:16synonymous with the ****** orientation
08:18to whom I'm attracted to. Hold on.
08:25OK, a gender identity, on the other hand,
08:28is an identity that refers to an
08:30individual's identification as either male,
08:32female, or occasionally some
08:33category other than male or female,
08:35and to repeat a gender identity.
08:37Whether I think of myself as male or female,
08:40tells you nothing about
08:42my ****** orientation,
08:43whether I'm attracted to men or women.
08:45Historically, this did seem to matter.
08:47If you were assigned birth as
08:49male and were attracted to women
08:51and you went to see the doctor
08:53about having a gender transition.
08:55You couldn't tell them that you were
08:57attracted to women because they
08:59weren't going to produce a lesbian.
09:01These are not the standards
09:03of care in the 21st century,
09:05but in the beginning of of
09:06the of this kind of treatment.
09:08It was a standard of care.
09:10Gender atypical refers to somatic features
09:12or behaviors that are not typical in
09:15a statistical sense of individuals
09:16with the same assigned gender in a
09:18given society and historical error.
09:20Another way of talking about
09:22his gender nonconforming.
09:24No,
09:24a birth sign boy who likes to play
09:26with Barbies doesn't necessarily
09:28have gender dysphoria,
09:29but they have what might be called
09:32an atypical gender interest.
09:34Transgender is a popular,
09:35not a scientific term for people whose
09:37gender identity or gender expression
09:39or behavior does not conform to that
09:42typically associated with the *** to
09:44which they were assigned at birth.
09:47Other terms that people are using
09:49an known I Presley cannot keep
09:52track of all the terms,
09:54but they include things like gender,
09:56fluid, gender nonconforming,
09:58nonbinary, genderqueer,
09:58bigender, to search these.
10:00Alternatives to calling oneself
10:02male or female?
10:06A gender expression is how an individual
10:08demonstrates their agenda to others.
10:10Myra manner of dress behaviors and
10:12appearance and the term is increasingly
10:13being used in non discrimination documents.
10:16That is, you don't necessarily have to
10:18be a transgender person to have a gender
10:20expression that's not typical of your gender,
10:23but so the laws that are being written
10:25saying you refer to your gender expression.
10:28You shouldn't be discriminated
10:29against yourself because of how
10:31you publicly express your gender.
10:33Gender variant is a non pathologizing
10:35term used to describe individuals
10:37at any age who might be otherwise
10:39referred to by the medical terms,
10:41such as gender dysphoric, which we
10:43use in the DSM and gender incongruent,
10:45which is we're using in the ICD.
10:49Gender Simon.
10:50Historically,
10:50people used to talk about people's
10:52biological females or biological males,
10:54except we don't know where the biology of
10:57transgender or cisgender presentations lies.
10:59So the more descriptive terms being
11:01used are birth assigned male or female,
11:04or individual sign male or female at birth.
11:07I would point out there is another term
11:09Natal male or female which we were using
11:12in DSM 5 and was considered acceptable.
11:15But as the language changes now it is
11:18not considered an acceptable term.
11:20A disorder of *** development.
11:22Historically,
11:23what we refer to as from Africa is
11:26Mafra Dites or an intersex condition.
11:28Conditions of inborn somatic deviations
11:30of the reproductive tract from the norm
11:33or discrepancies among the conventional
11:35biological indicators of male and female.
11:38As there is also an intersex
11:40movement that doesn't,
11:41members of whom not all but some
11:43members don't like the medicalization
11:45of their of their bodies they liked,
11:47they prefer to call it differences
11:49and *** development and there is a
11:52debate about what we will use in DSM.
11:545 TR.
11:56Gender dysphoria is a longstanding
11:57term that refers to the distress
11:59that can accompany the incongruence
12:01between ones experienced or expressed
12:03gender and ones assigned gender,
12:05and it's the term we came up with
12:07to replace the diagnosis of gender
12:09identity disorder or GID.
12:11In DSM 4 this is now the name of
12:14the diagnosis in DSM 5.
12:16In the in the ICD 11,
12:19this is a marked and persistent
12:21in congruence between individuals
12:22experience gender and assign gender.
12:24This replaced the diagnosis of
12:26transsexualism and gender identity
12:28disorder of childhood in ICD 10,
12:30and most importantly in the ICD 11,
12:33this diagnosis was moved out of the
12:35mental disorder section of the ICD and
12:38in the International Classification
12:40is part of part of a chapter called
12:43conditions related to ****** health
12:45and we may talk about that.
12:47Further,
12:47gender reassignment or gender
12:49confirmation is an official and
12:52sometimes legal change of gender.
12:54People used to call these things *** change.
12:59Gender can be with children,
13:01prepubescent children's particular.
13:02This transition is a social transition.
13:04No medical treatment or surgeries
13:07are done in prepubescent children.
13:09Some adults also only transition socially.
13:11They do not take hormones or
13:13use surgery with hormone
13:15treatment. Feminizing hormones
13:17are used to create female effect,
13:19and someone assigned male at
13:21birth or masculinizing hormones,
13:23and someone assigned female at birth.
13:26Gender confirmation surgery,
13:27which used to be called *** reassignment
13:30surgery or procedures by which a person's
13:32physical appearance and function of
13:34their existing ****** characteristics are
13:36altered to resemble that of the other ***.
13:39It has other names like gender
13:41reassignment surgery, gender realignment,
13:42surgery and I'll repeat,
13:44surgery is rarely performed in minors who
13:46do not have a disorder of ****** development.
13:49Transsexual is a historic term in medical
13:52term for individuals who receive hormonal
13:54or surgical treatment to modify their bodies.
13:57So it conforms to the gender identity that
13:59the treatment can be partial versus complete,
14:02and that can vary for any number of reasons.
14:05Some people don't want every don't
14:07want everything that can be done.
14:09Some people can't afford
14:10everything they want.
14:11They want to be done if its transition
14:14from assigned male to female.
14:16The literature refers to these people as MTF.
14:19The community refers to such
14:20a person as a trans woman.
14:22If the if it moves in the opposite
14:25direction from female to male,
14:27the literature talks about female to male,
14:29FTM,
14:30and the community refers to such person
14:32as a trans men and again keeping in
14:35mind that gender identity and ******
14:37orientation may be independent variables.
14:39So Caitlyn Jenner is,
14:40as we as probably everybody knows,
14:42is a very famous trans woman
14:44who publicly transitioned,
14:45is publicly known to be going to fill it.
14:48That is,
14:49she was attracted to women before transition
14:52and it's still attracted to women.
14:54Chaz Bono, the child of Sonny and Cher,
14:58is again probably known to be
15:00going in the filak,
15:02attracted to women,
15:03identified as a lesbian before
15:06transition and so.
15:07Cisgender now this is a term used
15:09in the transgender community to
15:11describe an individual whose gender
15:14identities aligned with their sign,
15:16*** at birth and its parallels.
15:18The historical current coinage of the
15:21terms homosexuality and her *********.
15:23For example,
15:23the word homosexuality actually was was
15:26in use way before the term heterosexuality.
15:29There was normal people
15:30and they were homosexuals.
15:32But eventually scientists and
15:34researchers started calling people
15:35who weren't homosexual heterosexual's
15:37an this term is the same.
15:39So transgender people.
15:41Coined the term cisgender,
15:43which is derived from the Latin meaning
15:45on the same size as in the sense SIS,
15:48trans.
15:48Isomer distinction in organic chemistry,
15:50and if you remember your organic chemistry,
15:52if you draw an invisible a
15:54plane through the through,
15:56the two molecules here they both
15:57have the same number of atoms,
15:59but there one is assists isomer
16:02because the two molecules in green
16:04on the same side of the invisible
16:06plane and the trans out isomers
16:08because the two molecules are in
16:10opposite signs of the invisible plane.
16:13Transphobia is derived from
16:14the term homophobia,
16:15which meant an irrational
16:17fear or hatred of gay people,
16:19both internal or external.
16:20Transphobia includes a wide range of
16:23negative attitudes or feelings or
16:25actions towards transgender people.
16:26It's seen as underlying much of the
16:29social stigma confronted by transgender
16:31individuals such as bathroom bills,
16:33which are mentioned a little bit later,
16:36and it's also presumed to be the
16:38cause of the fatal violence,
16:40which is disproportionately
16:41affecting transgender women.
16:43Color so some other terms.
16:45Misgender misgendering refers to naming
16:48somebody by the incorrect gender.
16:50So if you meet a trans person
16:54who's presenting female and you
16:56use male pronouns or male name,
16:59that would be referred to as misgendering.
17:02Deadnaming refers to using the name of
17:05a person after they've transitioned
17:08their that is their pre transition name,
17:12which many.
17:13Trans people find offensive.
17:15An important distinction is that.
17:18Sometimes this can be accidental,
17:20which happens to everybody
17:22or can happen deliberately,
17:23which is often meant to be hurtful.
17:27Pronouns are another issue.
17:29Many probably no.
17:30Facebook offers more than 50
17:32gender options for pronouns.
17:33I have not remembered the list.
17:37Best way to deal with the issue of
17:40pronouns is to ask what are your pronouns,
17:42not what are your preferred pronouns.
17:44Just. What are your pronouns?
17:46Gender policing refers to the
17:49imposition or enforcement of normative
17:52gender expressions on others.
17:54Mundane example of gender policing.
17:56Whichever he might he might do is if
17:58you're walking out of the Mens room.
18:00If you're a man walking out of Mens room,
18:03you sold in the accident,
18:04you know inadvertently walking in.
18:06You might tell her she's walking
18:07into the wrong restroom,
18:09because that's the way we police
18:11gender in public.
18:12Gatekeeping refers to the role this commit.
18:15The trend that comes from the community.
18:17This was the term they gave to the
18:20role of mental health professionals
18:22who were given the assignment
18:24of determining who was a real
18:27transsexual and who was not,
18:28and so there was a time
18:30when transition involved.
18:32There is still some gatekeeping
18:33that's going on.
18:35Particularly surgeons would likes
18:36mental health professionals to agree
18:38that the surgery is necessary,
18:40but not so much the case for
18:43hormones anymore.
18:44And of course,
18:45Countertransference is a common thing
18:47that occurs if you're treating a
18:49transgender patients where a lot of
18:51people think that they're supposed
18:52to talk the patient out of their
18:54gender dysphoria and not make any
18:57decisions that would lead to a gender change.
18:59Gender beliefs are implicit cultural
19:01ideas about the essential qualities
19:03of men and women that usually only
19:05allow the existence of two sexes.
19:07An gender beliefs are expressed
19:09in everyday language.
19:10Data science of binary,
19:11gendered meanings to what individuals do,
19:13think, and. Dylan just mundane examples.
19:17The need to qualify the fact that
19:19your doctor is a woman or the
19:21qualified affect the nurse treating
19:22in the hospital as a male because
19:25we usually think of the of these
19:27professions as being gendered.
19:28Maybe not so much in medicine.
19:30You know, for positions as much,
19:32but certainly for the nursing profession,
19:34it's still seen as a female profession,
19:36but most. Gender binaries are
19:38maintained by insisting that every
19:39individual be assigned to the category
19:42assigned to the category of man and
19:44woman at birth and that individuals
19:46conform to the categories to which
19:48they've been assigned thereafter,
19:49and the categories of man and woman or boy
19:52and Girl are considered mutually exclusive.
19:55So now I'm just going to talk a little
19:57bit about the history of the diagnosis.
20:06So Richard von Krafft Ebbing and
20:09German Austrian psychiatrists in the
20:1019th century wrote a very famous book
20:12called the Psychopathia Sexualis,
20:14mostly written in Latin,
20:16so that only priests and
20:18doctors could understand it,
20:19and in it he documented cases of
20:22gender dysphoria and gender variant
20:23individuals born to one *** but
20:26living as members of the other ***.
20:28But he referred to this as homosexuality.
20:31That is, it's not until the middle of
20:34the 20th century that that there's more
20:37common discernment between the notions
20:40of ****** orientation and gender identity.
20:43So transgender people described in
20:45this book are seen as happiness,
20:47psychiatric illness,
20:48and are also seen as coma sexuals.
20:52It's actually Magnus Hirschfeld,
20:54another German psychiatrist who
20:55was openly homosexual himself,
20:57who did the guy who first wrote
20:59about distinguishing the desires
21:01of homosexuality to partners of
21:03the same *** from the desires of
21:05transsexualism to live as the other ***.
21:08And in fact,
21:09by the 1920s,
21:10positions in Europe,
21:11or performing gender confirmation surgeries,
21:13so that when Christine Jorgensen
21:15had her surgery in 1952,
21:17this has been going on for decades,
21:19not in the United States,
21:21but certainly in Europe.
21:23This was a story that made international
21:25headlines that the New York Daily
21:28News ex GI becomes blonde beauty but
21:31but the the the the account that
21:33the medical account of the surgery
21:36action was published in the Journal
21:39of the American Medical Association.
21:42So these so these diagnosis of
21:44which we now call gender dysphoria,
21:47gender and gender incongruent,
21:48don't actually appear in the
21:51DSM one or DSM two,
21:52or in the Icd's seven or 867 or eight and
21:56many in the middle of the 20th century.
22:00Many physicians and psychiatrists,
22:01and particularly psychoanalytic
22:03practitioners, would criticize the use
22:05of surgery and hormones, irreversibly,
22:07treat people suffering from what
22:09they thought was either severe,
22:11neurotic or psychotic.
22:12Delusional condition.
22:13In need of psychotherapy and reality testing,
22:16there's actually a very
22:17prominent psychiatrist.
22:17Paul McHugh,
22:18who was the former chair
22:19of Psychiatry at Hopkins,
22:21who shut down their gender
22:22clinic in the 1980s,
22:24who actually still believes this,
22:25although he hasn't actually come up
22:27with the protocol of how one talks a
22:30person out of their gender dysphoria.
22:32But he does have a lot
22:33of opinions about it now.
22:35There were several several people who
22:37I won't go into detail today about.
22:39These are names that you might
22:41want to look up even on even
22:44on Wikipedia if you want.
22:45People who who did early research
22:48on gender identities and who whose
22:51work led to the inclusion of the DSM.
22:53Three of these diagnosis and later in
22:56the ICD as well having to do with gender.
23:02So this is just look historically
23:04of where the diagnosis existed in
23:06the various iterations of his DSM.
23:09It's important to keep in mind some people
23:11called the DSM the Bible of psychiatry.
23:14It's not a Bible, it's a user's manual,
23:17and it's important to keep in mind that that
23:19are thinking about some of the things that
23:23psychiatrists approach changes overtime.
23:25This new knowledge is approaches, so these
23:27diagnosis did not exist in the first DSM.
23:30There's something called transvestitism
23:31in the DSM 2, but the DSM.
23:34Before DSM three, there were not these
23:37lengthy descriptions of the diagnosis,
23:38so we don't know if that's
23:41referring to transsexualism.
23:42Sometimes the two terms were used
23:44as synonyms, but it does appear
23:46as transsexualism in the DSM 3,
23:48where it's considered a
23:50psychosexual disorder in the.
23:51DSM 3 gets moved in the DSM 3R to disorders,
23:55usually first evident in infancy,
23:57childhood, or adolescence,
23:58then gets moved in DSM 4 to
24:00****** and gender identities.
24:03Disorders and then the DSM 5.
24:06The diagnosis of gender dysphoria
24:08was separated from the other ******
24:11and disorders, ****** dysfunctions,
24:13and paraphilias and given a chapter
24:17all its own.
24:18A similar kind of migration you see
24:21take place in the ICD ICD before ICD.
24:24Six was a mortality document,
24:27only didn't include diagnosis.
24:28Only in the 1948 did the World
24:31Health Organization take over
24:33its publication in 1965,
24:35and that again Transvestitism appears.
24:37The meaning not entirely clear.
24:39Today referred to as a ****** deviation.
24:45In 1970
24:51let me let me do this again.
24:52I'm gonna mute everyone and
24:54then you will unmute yourself.
24:55Apologies for that check.
25:00OK. You're good. OK? So then in 1975,
25:04in the ICD 9 diagnosis called
25:07transsexualism with the hyphen
25:09does appear as a ****** deviation.
25:16And then in ICD 10.
25:19Transexualism appears in in the
25:21chapter called Gender Identity
25:23Disorders with a number of other
25:25related diagnosis and then in ICD 11,
25:27this new chapter which came out last year,
25:30you have a new chapter called conditions
25:32Related ****** Health which is no longer
25:34a mental disorder and the diagnosis
25:36are referred to as gender incongruence
25:38and we didn't use the diagnosis of
25:41gender dysphoria be cause dysphoria
25:43implies some emotional discomfort
25:45and since it's not a mental disorder
25:48anymore we just used in congruence.
25:50So what are some of the controversies?
25:53Well, I'm going to talk
25:55about a few controversies.
25:57One is the weather that there
25:59should be a diagnosis at all,
26:02and others public accommodation of
26:04transgender people and the other
26:06is rapid onset gender dysphoria in
26:08adolescence and then lot lot more
26:10on treating prepubescent children,
26:12which is controversial.
26:14So when I was appointed to the DSM
26:185 workgroup in 2008. The AP a.
26:20This was the first DSM to be done in
26:23the Internet age and and it generated
26:26a lot of publicity in the newspapers.
26:29Front page.
26:29Stories in the times about the DSM process,
26:32including this diagnosis and the API,
26:34was accused of stigmatising expressions
26:36of gender variants that symptoms
26:38of a mental disorder and just as
26:41homosexuality was removed in 1973,
26:42people wanted the diagnosis removed
26:44from the DSM.
26:46Not everybody agreed or while there
26:48are many public outcries against it.
26:50There's lots of private calls in
26:52the background saying none, none,
26:54none, none, none,
26:55no,
26:55please don't take this diagnosis
26:57out because if you take out the
27:00diagnosis people will not have
27:02a medical diagnosis code.
27:03In order to access the care.
27:05And this is a patient population that
27:08doesn't have a lot of access to care.
27:11Usually until 9 actually wasn't until 2014.
27:13That Health and Human services
27:15finally overturned in 1981.
27:16Decision that.
27:17Called gender transition services.
27:19Experimental and allowed Medicare and
27:21Medicaid to pay for these procedures.
27:24Another group that didn't want
27:26the diagnosis out where trans
27:28advocacy organizations that
27:30protect incarcerated individuals,
27:32or transgender who are not being
27:34allowed access to care to hormones.
27:37For example,
27:38and since denying a transgender
27:40inmate hormone treatment,
27:42is considered denying them medical treatment
27:44in the United States Constitution,
27:47that's considered.
27:48Cool and usual punishment and we're
27:50advocacy organizations have won
27:52lawsuits to get these incarcerated
27:54prisoners of their hormones have been
27:56by arguing that this is a medical
27:58diagnosis and they shouldn't be denied it.
28:02So the challenge to our work group
28:04was really how to reduce the
28:06stigma of having a diagnosis
28:08while maintaining access to care.
28:10It's the sound bite after a couple of
28:12years of listening to all the arguments.
28:15So we did a few things.
28:17We just we voted to recommend
28:18a PA that the keeper diagnosis
28:20to allowed to access to care,
28:23but to change the name to gender dysphoria,
28:25which was less stigmatising to
28:27the Community then having the
28:29word disorder in it.
28:30And this was received well,
28:31it was suggested that the diagnosis.
28:33Be separated from ****** dysfunctions
28:35and paraphilias since they have
28:37no relationship to them prior.
28:39Prior iterations of DSM,
28:40it was thought that if a child had
28:43an intersex condition that that was
28:45an exclusionary factor for making a
28:48diagnosis of gender identity disorder.
28:50It turns out that some of the
28:52kids who have TSTS and who made
28:55it were given gender assignments.
28:57They're given incorrect gender assignments.
28:59That is, they get.
29:00They do develop gender dysphoria,
29:02so it was decided to add a specifier.
29:05Whether it was with or without a DSD?
29:08But in terms of the access to care issue,
29:11the concern was, well, what happens?
29:13A person had gender dysphoria.
29:15They had hormones, they had surgery.
29:17There are no longer dysphoric.
29:19Do they still have a diagnosis?
29:21Well, you need a diagnosis to continue
29:23access medical care, you know.
29:25Follow up. They have to transition.
29:27So we added a post transition specifier so
29:29they could always have a diagnosis code.
29:32We suggested removing the ******
29:34orientation specifier since it
29:35had no clinical usage whatsoever.
29:37There was one objection.
29:38Well, it has research, Houston said well,
29:41yes, but you know,
29:42we do research on depression and
29:44differences between men and women,
29:46and we don't do specifiers you
29:48know about whether the depression
29:49is in the manner in a woman.
29:52So it wasn't really relevant.
29:54We try to narrow criteria to
29:56reduce false positives so that
29:57nobody should have a diagnosis.
29:59Who doesn't want one?
30:00And we the only recommendation we made
30:03that wasn't character was the removal
30:06of what used to be called the Nos,
30:08or not otherwise specified category in DSM 4,
30:11because that allows people to get diagnosis
30:14who don't have enough symptoms to qualify,
30:17but the DSM file Mac,
30:19what I call bureaucratic conversation.
30:20Every diagnosis hasn't NEC or not
30:24elsewhere classified category.
30:25So,
30:26so these are the diagnosis in DSM,
30:29one for children,
30:30one for adolescents and adults
30:33another and an unspecified.
30:35An ICD 11 similar process,
30:37a little bit different.
30:40CD is put together by the
30:42World Health Organization.
30:43The ICD codes are used by almost
30:45every country in the world.
30:47Although each country modifies
30:48the codes to their own uses
30:50as we do in the United States.
30:52Again,
30:52the issue was stigma versus access to
30:54care and the decision was to remove the
30:57gender diagnosis from the mental disorder.
30:59Section 22 new chapter conditions.
31:00Related ****** health.
31:01We could do that in ICD.
31:03We can do the **.
31:04We had a rather binary
31:06choice was either in and out.
31:08The only other possibility
31:09was to make it a V code.
31:12Which we didn't do because nobody
31:14reimburses for the code so it
31:16wouldn't accomplish the task
31:18of maintaining access to care.
31:20So the so however,
31:22although there was no controversy
31:23in the community of both clinicians
31:26and patients about the ICD 11
31:28decision for adults and adolescents,
31:30there were people who were very
31:32upset about the retention
31:34of a child diagnosis, and they would
31:36say they used to say we were cycle
31:39pathologizing the children and then they
31:41said we were pathologizing children.
31:44But it's really important to know that
31:47normal spontaneous delivery and menopause
31:49also have ICD codes, and they're not.
31:51Illnesses so that you don't have to
31:54be an illness to have an ICD code.
31:56And these are the diagnosis,
31:59childhood, adulthood and adolescence,
32:01and unspecified in the ICD.
32:05Another culture, another issues,
32:06public accommodation.
32:07You know what role should transgender
32:09people have in our in our culture
32:12under the Obama administration,
32:14there they were made to feel welcome
32:16under the Trump administration.
32:18There's been a lot of rules to try and
32:21prevent them from entering the service.
32:24School locker rooms are
32:25big controversial issue.
32:27Again,
32:27different attitudes during the Obama
32:29versus the Trump administration
32:31of whether an adolescent should.
32:32Transgender adolescents should
32:34be allowed to use the lock room
32:37of their experience gender.
32:38Same thing with Trip Sports team.
32:40Should people who have transitioned.
32:42Usually the complaint is is
32:43people of transition to female?
32:45Should they be allowed to perform
32:47on female sports temp teams?
32:48And then there are bathroom bills?
32:50Bathroom bills started with North
32:52Carolina although other states have
32:54introduced them and the idea was that
32:55you should only be allowed to use
32:57the bathroom of your assigned birth,
32:59which would mean that Caitlyn Jenner
33:01would have to use the men's room and Chaz
33:04Bono would have to use the latest truth.
33:06Now the people who talk about
33:08these bills we talked about.
33:10We're trying to prevent,
33:11you know,
33:11men in dresses from assaulting
33:13our daughters in the ladies room.
33:14But the real reason purpose of
33:16these laws is to to make the lives
33:18of people like this miserable,
33:20because if they followed the
33:21law they would have,
33:22they would have to publicly expose
33:25themselves as transgender in places that
33:27maybe would not be the best thing to do.
33:30Another controversy has to do
33:31with something called rapid
33:33onset gender dysphoria paper,
33:34written by Lisa Libmanan at Brown University,
33:37which she surveyed parents who reported
33:39that their adolescent and young adult
33:42children showed signs of what she
33:44called a rapid onset of gender dysphoria.
33:47There were 256 parental reports
33:49of children of their children
33:51identifying itself identifying
33:52as transgender at the same time
33:54as others in their peer groups,
33:56and the parents said these children
33:58were involved in the process of
34:01immersion and social media preceding
34:03their child becoming gender dysphoric.
34:06And so there's a question raised
34:08by parents about social contagion
34:09similar to eating disorders.
34:11Let them define RGD as a development of
34:13GT observed beginning an adolescent or
34:15young adult who did not meet criteria
34:18for gender dysphoria in childhood,
34:20but this is an important point.
34:22A lot of people who don't have a
34:24rapid onset gender dysphoria also did
34:26not meet the criteria in childhood.
34:28We we think today that this is not
34:31a homogeneous group of patients but
34:33that the childhood diagnosis does not
34:35have evolved naturally into the
34:37Dell diagnosis. And people have
34:39been dealt are Allison diagnosis to
34:41necessarily have a child diagnosis,
34:43so there was immediate criticism of the
34:45study two weeks after publication journals
34:48announced the Post Publication Review,
34:50Brown University retracted its press
34:52release promoting the study and removed it
34:55noticeably from its webpage criticisms.
34:57Was that the study was
34:59seen as a political attack.
35:01As one activist said,
35:02a poisonous lie used to discredit
35:04trans people and methodological
35:06criticism with that was actually a
35:09survey of parents rather than the.
35:11Young people themselves or
35:12their health care providers,
35:14so the article went underwent a revision.
35:17There was a correction.
35:18It was republished by the
35:20same Journal Year later,
35:22and their visor versions that basically
35:24the author updated the title.
35:26Abstract introduction and address
35:28the concerns raised in the
35:29editorial reassessment.
35:31The materials and methods were
35:33updated to include new information
35:35and more detailed descriptions
35:36about recruitment sites and to
35:38and to remove two figures.