Ethical Considerations in Caring for LGBTQ Youth

May 02, 2022

April 27, 2022

Lisa Campo-Engelstein, PhD

Director, Institute for Bioethics & Health Humanities
Harris L. Kempner Chair in the Humanities in Medicine
Associate Professor, Preventive Medicine and Population Health
University of Texas Medical Branch

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ID: 7784
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00:00Good evening friends and welcome to
00:03the Yale Pediatric Ethics program.
00:05Our evening ethics seminar series.
00:09This evening we have a special
00:10guest and I and I will get to
00:12introducing her in just a moment.
00:14In the meantime, I just kind of let you
00:17know how the evening is going to go.
00:19I'm going to introduce Doctor Campo
00:22Engelstein who will speak tonight on
00:24caring for LGBTQ youth and and she'll
00:27speak for about 45 minutes, give or take,
00:30and then we'll open it up for conversation.
00:33The conversation will go until 6:30 Eastern
00:36Time and we'll have a hard stop at 6:30.
00:38So, as always, I apologize to whoever
00:40has the best question at 6:28
00:42because we're not going to get to it.
00:44If you would, please put your
00:46questions in through the Q&amp;A portion.
00:48The Q&amp;A function of the zoom.
00:51I'll then be reading your questions
00:53to Lisa and we will go from there.
00:57My name is Mark Mercurio,
00:59I'm the director of the program and Karen
01:01Colby is our program manager and we are
01:04very happy that you folks are here tonight.
01:06We alternate these with the
01:08program for biomedical ethics,
01:09which is also we have our associate
01:11director as Jack Hughes and Sarah
01:13Hall as well for that program.
01:15But tonight is the focused on Pediatrics
01:17and our guest tonight is Doctor Lisa
01:19Campo Engelstein who is the director of
01:22the Institute for Bioethics and Health,
01:24Humanities and the Harris L
01:26Kepner Chair in Humanities.
01:28In medicine at the University
01:30of Texas Medical Branch,
01:31she specializes in reproductive
01:34medicine and in her words from a
01:37feminist and queer perspective,
01:40she is her words are her work,
01:42rather is widely acknowledged.
01:45She's been interviewed in The New
01:47Yorker and the Canadian Broadcasting
01:48Company and the BBC, NPR.
01:50The BBC names are one of 100 inspiring
01:54and influential women of 2019.
01:57Her educational background is
01:59certainly most impressive.
02:01She has a BA in philosophy
02:03from Middlebury College,
02:04a Masters and PhD in philosophy
02:06from Michigan State.
02:07She did a postdoctoral fellowship
02:09at Northwestern and also received a
02:11graduate certificate in Clinical Ethics
02:13Council station at Albany Medical College.
02:16So she is widely respected and has
02:19spoken far and wide on this subject
02:21and on other issues related to
02:23the medical ethics and and now,
02:25of course at the very pinnacle.
02:26She speaks at the Yale Pediatric ethics.
02:28Program and this is it's it is so
02:31bittersweet because you get a chance
02:32to meet such nice and interesting
02:34people when we do these and yet we
02:36don't have Lisa here in New Haven,
02:38so our hope is that we get here in
02:39New Haven sometime in the future.
02:41But for now, in zoom world,
02:43at least,
02:43we're very grateful that you made the time.
02:45So without further ado,
02:46I will now introduce Doctor Lisa
02:48Campo Engelstein take it away.
02:51Thank you so much for that kind
02:53introduction and for inviting me
02:54here and to Doctor Mercurio for
02:56all the help you've done, and.
02:58All the good work you're doing
02:59and and to Karen for all the
03:01logistical help and Sam as well.
03:03So let me go ahead and share my screen and
03:06hopefully everything will run smoothly.
03:09I also before I start want to give a
03:11shout out to a special person on the line
03:14who has been really influential in my life.
03:18Doctor Maria Trumpler was one of
03:20my professors in undergrad and my
03:23undergraduate thesis advisor and,
03:25you know, without her,
03:26I don't think I would have gone
03:28down this path.
03:28He really was so encouraging
03:30and inspiring and helpful,
03:32so just wanted to say thank you there
03:34and just how important and wonderful
03:37these mentorship relationships are.
03:39OK, so let's move along so I
03:43don't have any disclosures.
03:44The learning objectives for today is
03:46we're going to identify some health
03:49disparities that LGBTQ youth face.
03:50We're going to talk about some of
03:52the ethical considerations that are
03:54involved in caring for this group and
03:55then describe ways to provide inclusive,
03:57high quality care.
03:59For all and just didn't know that actually
04:01we were talking about before we got started,
04:03I'm going to use the language of queer
04:06when referring to the LGBTQ community.
04:08Part of this is just it's a
04:10lot easier and faster to say,
04:12but often the word queer is used as
04:14an umbrella term to include to be
04:17inclusive of everyone underneath that.
04:19I know that term has been used
04:21in a negatory negative way,
04:23especially for people of certain
04:25generations or cultural backgrounds,
04:27but there has been a reclaiming of that term.
04:29Especially in academic scholarship where
04:31people talk about doing queer studies,
04:34so that's what the word I'm going
04:35to be using today,
04:36I wanted to give you that heads up.
04:38I'm sure you're probably all
04:40familiar with many of these terms,
04:42but just in case you're not, I want
04:43to quickly talk about some of the terms.
04:46So let's look at this
04:47adorable gender Unicorn.
04:48So the category of sex refers
04:50to biology such as genitals,
04:52chromosomes, and hormones.
04:53At birth,
04:54children are assigned female,
04:56male or intersex,
04:57and intersex refers to someone who
05:00sex does not align with standard
05:02definitions of female or male.
05:04For example,
05:05they may have ambiguous genitalia,
05:07or different chromosomal patterns.
05:08Which is XY gender identity refers
05:11to your psychological sense of self,
05:15how we identify and only we can
05:17determine what our gender identity is.
05:19No one else can tell us what it is.
05:22Gender is.
05:22Expression is the way that we
05:23actually express it. What do we wear?
05:25How do we talk these sorts of things?
05:28So for people whose gender identity
05:30aligns with their sex assigned at birth,
05:33those people are considered
05:35cisgender for people whose gender
05:37identity is not align.
05:38With the sex they were assigned at birth,
05:41those people are considered transgender.
05:43We also have under the category
05:45of sexual orientation who you're
05:47physically and emotionally attracted to,
05:49and some people may not
05:51experience physical attraction.
05:52Often we talk about those
05:54people as being asexual.
05:55They use those sorts of labels.
05:57So emotionally attracted to us who you like?
05:59Like if you want to take it
06:01back to to middle school.
06:02OK, so there's a lot of terms out there.
06:07I don't expect you to know them
06:10all or to remember them all and
06:12they're constantly changing
06:13and like any part of language,
06:15language is constantly evolving
06:16to be more inclusive and so we see
06:19more and more terms getting added to
06:21the acronym which is in part why.
06:23I'm just going to use the word queer
06:25so I don't stumble over a long acronym.
06:28All right,
06:28a little bit more factual information
06:30before we jump in is just to give
06:33a sense of how many people identify
06:35as queer in the US and the total
06:38population is about 5 1/2%.
06:39But as you notice from this chart
06:41on the right hand side,
06:43the number of people in each
06:45generation has increased dramatically,
06:47and the reason for this is that
06:49it's more socially acceptable if
06:50it wasn't socially acceptable,
06:51people would not feel as comfortable
06:54identifying this way.
06:55We don't have good numbers on the
06:57number of folks who identify as intersex.
06:59The range is tremendous there for
07:02folks who identify as transgender,
07:04usually in the whole US population,
07:06including adults, about .6%,
07:09but about 2% of high school
07:12kids identify as trans,
07:13and again a more welcoming
07:15environment allows this to happen.
07:17Just like people didn't used to be
07:18left handed because it was seen as bad,
07:20right?
07:20Even if someone was left handed,
07:22they would hide it.
07:23Same thing today and more
07:24socially welcoming environment.
07:25Allows people to express who they really are.
07:29OK,
07:29so I know this is mostly a clinical audience,
07:31so rather than bore you with
07:35philosophical jargon,
07:36what I want to do is look at some actual
07:38cases and these are based on composite cases.
07:41Real cases that I've been involved in,
07:43or that my colleagues have
07:45been involved with,
07:45so these are real situations
07:47that you may face,
07:48so we have three cases we're
07:50going to cover here today.
07:53The first is Zach.
07:54He hand pronouns, he's 16.
07:56And if this is the case of
07:58a closeted gay teen,
08:00so his parents are concerned that
08:02he hasn't been acting like himself,
08:04he's a little down.
08:05He seems upset.
08:06They're not quite sure what's going on.
08:08It seems more than just the typical
08:11Moody teenager.
08:12And so is that comes to see you and you say,
08:16yeah, you do seem depressed and anxious.
08:18What's going on here?
08:20And Zach does disclose to you
08:22that he identifies as gay,
08:24but he doesn't feel comfortable
08:25telling his parents he's worried
08:27about their reaction.
08:29He's not out at school either,
08:31and but he is being bullied
08:33because people assume he's
08:34gay and they treat him differently.
08:37And so you know, although I said it's
08:39becoming more welcoming of environment,
08:42we're not all the way there yet.
08:43And unfortunately,
08:44I'm going to share some pretty
08:47devastating stats and laws with you
08:49that are quite detrimental to queer.
08:51Folks, but this has a huge
08:54impact in healthcare,
08:56so the rates of patients being
08:58after their doctors really depends
09:00dramatically on a number of factors.
09:02Things like whether you're rural or urban,
09:04other social factors.
09:05But the biggest thing here is that
09:08increased stigma is more likely
09:10to keep people closeted with
09:12their family with their doctors.
09:14With everyone,
09:14and this can have serious health
09:17consequences such as miscarry
09:19opportunities and even incorrect
09:20diagnosis if someone isn't telling you.
09:23Everything's gonna be hard for
09:24you to diagnose them correctly.
09:26And increased the ground also
09:27makes it so that people are less
09:30likely to utilize healthcare,
09:31which reinforces some of these
09:34already existing health disparities.
09:37So what's 1 practical tip
09:38that you can do as clinicians?
09:41You can ask patients about their sexual
09:44orientation and gender identity.
09:46Don't put the the burden on your patients
09:48to be the ones that need to disclose it.
09:50Most people are willing to disclose,
09:52but they don't necessarily want
09:53to be the ones to bring it up.
09:55So the study.
09:56Listed here found that 80% of health
09:59care providers thought patients would
10:01refuse to disclose sexual identity.
10:03Patients of all sexual orientations.
10:05But what they found was only 10%
10:08of patients actually refused,
10:10so huge disconnect between what
10:12providers thought and providers
10:13that they were infringing on.
10:15But patients were saying, hey,
10:16you're a trusted clinician.
10:17I'm willing to tell you this.
10:19You need to ask me.
10:20So just ask and normalize it.
10:23Make it something you ask everyone.
10:24Hey, you know what's your sexual identity?
10:26What is or segmentation?
10:27What's your gender identity?
10:29What pronouns do you use if
10:31it becomes normalized,
10:32it's not as scary then for
10:34people to bring it up.
10:36So I mentioned some of
10:38these health disparities.
10:40Our society is structured in a way
10:44that benefits and privileges folks who
10:46identify as straight and cisgender.
10:48So there's this framing in our society
10:50that the normal family is right.
10:52Mom and Dad and 2.5 kids in the picket fence,
10:55and that you know, mom and dad.
10:57They're both cisgender and so often
10:59the way this works in our society is
11:02this trickles to medicine as well.
11:04And this means that queer individuals
11:06are likely to face stigma,
11:08discrimination and denial of rights.
11:10So if you mix all of this together,
11:13what we see is that there are a lot
11:15of health disparities for queer folks,
11:17and I want to be really clear
11:19that it's not that being queer
11:21is inherently a risk factor for
11:23all sorts of health conditions.
11:25It's similar to racism.
11:26It's not that being of a certain
11:28race increases your risk.
11:30It's that racism.
11:32It's the structure that leads
11:34to these types of problems.
11:35If we lived in a kumbayah, equal,
11:37perfect, beautiful society,
11:38there wouldn't be the same health.
11:41Areas that we see now.
11:44So let's talk about some of these.
11:47And I start with this one because
11:50it's powerful because this shows
11:52that for non queer youth their
11:55biggest problems tend to be academic,
11:57which we consider normal for teenagers right?
12:01Whereas the biggest problems for queer
12:03youth are things like discrimination,
12:05mistreatment by family,
12:07classmates and others,
12:09and so they're dealing with very
12:11different issues in their lives and this
12:13results in these health disparities
12:15that have been talking about.
12:16So we see that.
12:17Queer kids are six times more
12:19likely to experience depression.
12:21About 2/3 of had symptoms of
12:24anxiety in the past two weeks,
12:2640% have seriously considered suicide,
12:28and actually that number is
12:30a lot higher in some.
12:31According to some literature.
12:32It really varies,
12:33but it's usually at least
12:35somewhere between 20 something,
12:36and I've seen as high as even 60 something,
12:38so quite high and almost half have
12:42engaged in self harm in the past year.
12:48Queer kids are especially vulnerable
12:50because of this discrimination they face.
12:52Because of this, denial of rights.
12:54And So what we see is that queer kids are
12:57much more likely to experience dating
12:59violence and sexual assault and rape.
13:06And then if we look at school
13:07they experienced in addition
13:09to sexual dating violence,
13:10they also experience bullying at school.
13:12I know the frontier is probably pretty small,
13:15but 82% were bullied due
13:18to sexual orientation.
13:192/3 felt unsafe due to sexual
13:22orientation and most of these
13:25kids about 61% don't report it.
13:27And the reason they don't report it is they
13:29don't think they're going to be believed.
13:32And what we see is that about
13:33third of kids who did report said
13:35the school did absolutely nothing.
13:37Afterwards,
13:37and so this discourages kids from
13:39bringing this up if they don't
13:41feel like the adults in their
13:42life are supposed to help keep
13:44them safe are keeping them safe.
13:45And this is not just on an
13:48individual school level.
13:49If we look more broadly,
13:51this is a systems level.
13:53So where is the majority of states do not
13:56have anti queer school laws and legislations.
13:599 states do.
14:00Those are the states there and this is I'm
14:03sorry seven states do the ones in green.
14:05But we have states like Missouri
14:07and South Dakota who have laws
14:09preventing schools from adding
14:10queer protections to anti bullying
14:13and nondiscrimination policies.
14:14So you're allowed to.
14:16Fully queer folks,
14:17but not other groups of individuals.
14:20Arkansas,
14:21Tennessee and Montana have state
14:23laws requiring parental notification
14:25of queer inclusive curricula and
14:26allowing parents to opt out of this.
14:28Go Texas right where I live now and
14:31more recently Florida have what are called.
14:34Don't say gay policies which restrict
14:36teachers and staff from even talking
14:39about queer issues and people.
14:41How are career youth supposed to succeed
14:44in school when their identity is
14:46erased and the identity of their families,
14:49who may also be queer and their
14:51loved ones and their friends?
14:55So even at home only about 1/4 of
14:57queer youth feel that they can be
15:00themselves and that their families are
15:02supportive of the queer community.
15:03close to half of families make queer
15:06youth feel bad about being queer,
15:08and 2/3 make negative comments
15:10about queer people.
15:12This lack of familiar support explains
15:14the exceedingly high number of queer
15:17youth who are homeless, extremely high.
15:18As you see here,
15:20and especially among trans kids.
15:22As we'll talk about in the next case.
15:25So what are your ethical obligations then,
15:28here as Zack's healthcare provider?
15:31Well, we all know the importance
15:34of confidentiality.
15:35And of course there are some
15:37exceptions to confidentiality,
15:38such as tarasoff laws.
15:40If someone is is going to harm
15:42themselves or others,
15:43that's not the situation here.
15:45Also,
15:45sometimes we talk about minors and it
15:47gets a little trickier of what you need
15:50to disclose to parents or not parents.
15:52But I would say you have an ethical
15:54obligation to a potentiality,
15:55unless there is good reason to break
15:58that and what we see is that legally
16:01this varies depending on your state.
16:03So it would be helpful to know
16:04what your state laws are.
16:05California, for example,
16:06has a law that when minors reach age 12,
16:10they have the legal right to
16:12health information privacy.
16:13So that means that their parents
16:15can't view certain information
16:17in their medical records.
16:18So again, it depends state by state.
16:21They also.
16:22Have the right to discuss healthcare
16:25without their parents being present.
16:27And I think this is really important
16:30when we're talking about stigmatized
16:31conditions that it's building this
16:33trusting relationship with your patients.
16:36If you disclose this information,
16:37you could really upset that,
16:39especially since you know Zach
16:41is over already worried that
16:43his parents are not supportive.
16:46And this is not that radical, as it may seem.
16:49We already have areas of healthcare
16:51where miners can get health care
16:54without parental involvement.
16:56Things like sexual reproductive,
16:58mental health and substance use
17:00care are all things that in most
17:03states for the most part,
17:05with some notable exceptions like abortion.
17:08They can't get access to the treatment
17:11without getting their parents involved,
17:12and there are good public health reasons,
17:14right?
17:15We don't want people spreading gonorrhea,
17:17but part of the reason here is that
17:19these are highly stigmatized conditions
17:22and our concern is that these kids
17:25will not seek treatment without,
17:27you know if they were required
17:29to get parental support,
17:30and these are deeply personal
17:32issues and that only the child
17:35can provide that perspective.
17:37So we'll talk about that more
17:38in the next case.
17:39As well, but some have argued that.
17:44Trans care should also be included here,
17:46even though it's not as we'll
17:47talk about soon because if we're
17:49considering gender dysphoria,
17:50a medical condition,
17:50which again,
17:51there's some disagreement about whether
17:52that should go in that category,
17:54then this should fall within the
17:56mental health bucket and kids
17:57should be allowed to seek mental
17:59health care without
18:00parental notification.
18:01So just to point out that there
18:03already is this established framework
18:04of types of care that minors can
18:07receive without parental notification,
18:09and it seems like healthcare regarding
18:11sexual orientation and gender identity
18:13does fit nicely. In there as well.
18:16So what do you tell, Zach?
18:18Do you encourage him to disclose to
18:20his family? This is a tough question.
18:22I think you know.
18:24Ideally you would want him to have an open
18:27and honest relationship with his family,
18:29but given some of the numbers here you I
18:31think you need to talk to him more carefully.
18:34Half of teens get a negative reaction
18:36from their parents when they come out a
18:38quarter are forced to leave their homes.
18:40That's a huge number and 2/3 experience.
18:44Some sort of rejection from their families.
18:47Zach has already told you that he's
18:49worried his family will reject him and.
18:51So we're talking about not only his
18:53mental safety here, but his social safety.
18:56If they reject him, where will he go?
18:58What are the next steps in place?
18:59So I think this is like this
19:01has to be a conversation.
19:03Excuse me, or multiple conversations.
19:05I wouldn't just willingly encourage
19:07him to go disclose to his family
19:09without laying out a plan of well.
19:11If they respond this way,
19:12what do you do if they respond this way?
19:14How do you respond?
19:16Because there can be really severe
19:19negative consequences of this.
19:21But this doesn't mean that
19:23Zach doesn't have any support,
19:25and so some researchers showing about half
19:28of queer kids want to get counseling,
19:31but they've been unable to get it.
19:33Part of the reason is they
19:34often need parental permission,
19:35and another reason is cost.
19:37So this is where you can help
19:39them and say hey,
19:41there are some local groups here.
19:42There's a capital pride center that
19:44you can go to and get support for.
19:46Free or online groups that are free.
19:49Or maybe there are other services out there.
19:51I have a sliding scale and they can
19:53get those services because it's really
19:55important and this is going to be one
19:58of the take home take home messages
20:00here to make sure that our queer
20:02youth are supported and this I mean
20:04obviously holds true for all youth,
20:06but queer youth are especially vulnerable,
20:08so it's really important that make sure
20:10that they're getting support and then
20:11they feel like they're getting that from you.
20:13And that's why I hesitate to,
20:16you know, break confidentiality unless
20:18you have good reasons and to two
20:20strongly encourage that to disclose.
20:21His family,
20:22unless you have it all planned out.
20:25All right,
20:25so you see Zach six months later,
20:27you would planned it all out about
20:29how you'd come out to his family.
20:30He's been seeking support from other
20:32corners of the world, and now he's out.
20:35And his parents are not thrilled,
20:38but they're taking them more
20:39of a approach of let's,
20:41you know,
20:41fix this problem.
20:42Let's minimize the harms here,
20:44so they want him to be involved
20:46in conversion therapy,
20:47and they also wanted to take prep and
20:49let me talk about each of these in turn.
20:51So conversion therapy therapy is the
20:54pseudoscientific practice of attempting
20:56to change someone's sexual orientation
20:58or gender identity using psychological,
21:00physical, or spiritual interventions.
21:02There's no evidence that this works,
21:05and in fact there's copious evidence
21:08that it's extremely harmful,
21:10especially to minors.
21:11Yet there are 22 states,
21:13including where I live in Texas
21:15that do not prohibit this,
21:17and from what we can tell,
21:18about 10% of queer folks have
21:22undergone conversion therapy.
21:23So here I think you have an ethical
21:26obligation to step up and prevent
21:28this sort of harm from happening
21:30to Zach and to be his advocate,
21:32and to lay out.
21:33The facts here and say this
21:35is not shown A to work,
21:36and in fact it's really harmful to kids.
21:40So let's find other ways to you know,
21:42talk about this and move
21:44the conversation forward.
21:44But this is not something that
21:47clinicians should be advocating for,
21:48or even tacitly condoning.
21:52Prep medication to prevent
21:55transmission of HIV AIDS.
21:58Zach's parents are concerned about HIV AIDS.
22:00Unfortunately,
22:00there continues to be this cultural
22:03narrative that if you're gay then you're
22:05automatically have HIV AIDS or you're
22:07going to get it at some point in your life.
22:09However,
22:10the number of new infections among young,
22:12gay and bisexual men has been decreasing by
22:15about a third in the last handful of years.
22:18With declines and men of all races,
22:20but African American men and Latino
22:22men continue to be severely and
22:25disproportionately affected here,
22:27so zacht parents are saying,
22:29OK if he's gay,
22:30then we need to put him on this to
22:33prevent further harm from happening.
22:35So should you do this?
22:38I think we need to talk about
22:39different types of rights that we
22:41have and negative rights are the
22:42rights to be free from something.
22:44So my right to punch stops
22:47where your nose begins.
22:48You have a negative right to be free
22:51from my karate chops here and this
22:54rate is almost absolute and massive.
22:56There are very few circumstances where we
22:59infringe upon someone's negative rights.
23:02It's considered assault or battery and
23:03this is true not just for adults but
23:06also for children and for people who lack.
23:08Capacity we need to have good reason
23:11to infringe upon their negative
23:12rights and so here I don't think
23:15this is something we should support.
23:18We need to support Zach's bodily
23:21integrity and sexual autonomy.
23:23Prep is not life saving,
23:25at least not imminently.
23:26So and so they and there are less
23:28invasive options available to him,
23:30like condom use.
23:31We also haven't clarified whether
23:32Zach is sexually active or not.
23:34He's not sexually active.
23:35This may not be an issue,
23:37but to force someone to take a pill.
23:39Every day when there are
23:40alternatives out there,
23:41I think that would be
23:43really harmful to his sexual
23:45orientation. That would associate his sexual
23:47orientation with AIDS and taking a pill
23:50and doing something against his wishes.
23:52And we want to encourage his
23:55sexual autonomy and identity. Also,
23:57there's just the logistics of forcing him.
23:59Are we going to keep track of this every day?
24:00Make sure he's taking out.
24:01We're going to, you know, test him to
24:03ensure that he's actually doing this.
24:04How are we going to do this?
24:06He's 16 years old.
24:07I think there's going to be
24:09some logistical difficulties.
24:10So what are the key takeaways and
24:12in hindsight maybe I shouldn't put
24:14food here because I know you're
24:15all have dinner after this.
24:17Hopefully you're not too hungry.
24:19This case takeaways confidentiality,
24:20is key for the patient
24:22coalition relationship.
24:24I know that something you all know so much,
24:26but especially,
24:27we're talking about vulnerable
24:28and marginalized groups and we're
24:30talking about types of care that
24:32can be really stigmatized.
24:33Hugely important.
24:34All for the right to uphold bodily integrity.
24:38Right now, Zach is depressed and anxious.
24:40He's getting bully, doesn't feel supported.
24:42We want to give him control.
24:44We want to empower him,
24:46and one way we can do that is to
24:48give him control over his own body.
24:50And again, as I said before,
24:51familial and social support
24:54is unbelievably important.
24:55This is so huge for this community.
24:59OK, let's move on to the next case.
25:03We have Jackie Jackie a trans team
25:06seeking hormone, so I'm sorry Jackie
25:08was the name I had before for her.
25:10Sorry I changed it to Alex last minute.
25:12Alex OK you name here.
25:15She her pronouns is 15.
25:19Alex was assigned male at birth,
25:20but identifies as female.
25:22Alex been a few blockers since about
25:2411 and this is pretty standard.
25:26The standard of care guidelines for
25:29trans kids experiencing gender dysphoria.
25:32They usually go on puberty
25:34blockers around Tanner Stage 2.
25:36Around around 16 ish,
25:38often they'll start hormones,
25:40so that's the normal standard
25:41of care here and Alex.
25:43Like many trans kids are very
25:45eager to start hormones.
25:47She also wants to consider
25:50preserving her fertility.
25:52However, her parents have some concerns.
25:55Bring them for going on puberty blockers
25:57because the effects of those are reversible.
26:00She goes off the puberty blockers.
26:02She will continue with her Natal puberty.
26:04But hormones can have irreversible effects
26:06and her parents are worried about that.
26:09Her parents are also strongly opposed
26:11to bottom surgery and usually bottom
26:14surgery doesn't happen until a kid is 18,
26:16so this is not really something
26:18we need to factor in right now,
26:20but I just want to throw that in
26:21there to contextualize the case a
26:22little bit more and they don't think
26:24fertility preservation is necessary.
26:26They think,
26:26why doesn't she just have kids the
26:28old fashioned way like everyone else?
26:29Why are we going to spend all this
26:31time and money to preserve your
26:33fertility when you can just do it the
26:35way everyone else has been doing?
26:37So who decides here?
26:41Well, we have the parents.
26:42On the one hand who are acting, you know,
26:45according to paternal beneficence,
26:47their parents.
26:48They're not, you know,
26:49and most of the parents were
26:50talking about these,
26:51and in general they want what's
26:52best for their kid, right?
26:54Going back to the previous piece of Zach
26:56Zach's parents were promoting conversion,
26:59therapy and product because they
27:00were looking out for their kids.
27:01Not like they were, you know,
27:02evil and malicious.
27:03You know, Doctor Evil sort of thing here.
27:05They want what's best.
27:07They're worried about their kids,
27:08and Alex's parents are worried about her and.
27:11But she might not be able to
27:13make these types of decisions,
27:15and that there might be consequences
27:17that she's not yet able to anticipate.
27:19On the other hand, we have Alex's autonomy.
27:22And Alex at 15,
27:23you know is able to make some
27:25of these decisions on her own.
27:27The American Academy of Pediatrics
27:29recommends that children participate
27:31in medical decision making and
27:34that the child's wishes should
27:35and value should inform this.
27:37And this is especially so for cases
27:40that are considered subjective or
27:42personal ones that are connected
27:43to your identity and values.
27:45So imagine that blue bar there on
27:48the chart on the bottom left hand
27:50is is pneumonia conditions like.
27:52Ammonia are diagnosed objectively, right?
27:54We use labs. We use imaging.
27:56We can confirm that there's a
27:58an infection and we
27:59can say all right.
27:59Here are the pharmaceutical
28:01treatments that we use.
28:02Tada, right. Pretty clear cut.
28:05Now look at the Red Barn.
28:06That's something like gender dysphoria.
28:09It is a much more subjective diagnosis.
28:12You can't just do a test to figure
28:15out how much someone's gender
28:16dysphoria is affecting them,
28:18and it's something that no
28:19one else can really determine,
28:20except for that individual, and we can.
28:22Have an outsider perspective,
28:24but we really need to hear from the
28:27child about what their personal
28:29experience is and what their values are.
28:32That's what should be driving
28:34these types of decisions,
28:35and so as healthcare becomes more
28:38subjective and more you know.
28:40Considering the subjective values
28:42and personal beliefs we need
28:43to listen to the kids voices,
28:45whereas for pneumonia we might say
28:47there's not really that many personal
28:49vowels or values or identities that
28:52are associated or tied into that.
28:54So you've probably heard this
28:55idea of open future for kids,
28:57and this is the idea that we want
28:59to keep as many opportunities
29:00available for them as possible.
29:02We don't want to close off any
29:04doors so that you know if they
29:05want to become a famous violinist.
29:07They could still do so, right?
29:08We don't want to prevent them from
29:10their career as a world you know,
29:11soccer champion or whatever they want to do.
29:13We want to keep opportunities
29:15available for them.
29:17And so when we're talking about,
29:19then what should we do for Alex?
29:21Some people become worried that
29:23if we put Alex on gender affirming
29:25hormones that were closing off an
29:28opportunity that we are making changes
29:31that are irreversible and inevitable,
29:33and that we should,
29:34it's better just to defer to nature
29:36and just let nature take its course
29:38and that Natal puberty is the
29:40inevitable consequence or the default.
29:42And why don't we just err on that rather
29:45than being the ones to initiate a treatment?
29:48That can close off future doors.
29:51I think this is somewhat misguided
29:52in the case of trans care,
29:54because there is this idea that
29:55there will be all these kids who
29:57are going to detransition.
29:58We're going to change,
29:59change their mind about their gender
30:01identity later on and really regret it.
30:02And the literature just doesn't show that.
30:04And as soon as gets misconstrued when it
30:06when people talk about in the public.
30:08So I, you know,
30:09based on the empirical evidence out there,
30:11I don't think that's much of a concern.
30:13And also,
30:14you know,
30:15we need to think about what's in
30:17the best interest for Alex here,
30:19and that in some ways.
30:21Their Natal puberty is natural,
30:23it's the one that she would undergo,
30:25but it's extremely harmful for her
30:27and we need to waive that.
30:30So we'll talk about some of those
30:32harms in a moment.
30:33We have our own puberty blockers right now.
30:35We can continue those to keep our
30:38future open until she turns 18,
30:40but keeping her on puberty blockers
30:42is not morally neutral.
30:43It's harmful to her. It's tough
30:45enough being 15 or 16 in high school.
30:48Now imagine that you're the only
30:49one who hasn't gone through puberty.
30:51There's a real psychosocial cost to
30:53delaying puberty for her, and there
30:55can be some health related stuff too.
30:57If you're on, you know indefinitely,
30:59which no one is suggesting we do.
31:02OK, So what are some other harms here?
31:04Well there if we if she doesn't go
31:07on hormones, there's a concern that
31:09she might do it yourself hormones.
31:10And there is a whole market out there
31:13for folks to get hormones on their own
31:15and we don't know how safe those are.
31:18If they're actually what they say they are.
31:19People are taking them in the
31:21right dose or not.
31:22So there's those types of concerns.
31:24Also, there's concerns about, you know,
31:27chafing if she's talking her penis in,
31:30and all you know all these other sorts
31:31of things that trans kids sometimes do.
31:33They combine their chest.
31:34And all these other physical things
31:37that have consequences for their
31:38body and can cause harm.
31:40There are serious psychosocial
31:42harms involved as well,
31:44so I have a whole bunch of stats
31:46here with some of these quickly,
31:47but trans kids are much more likely to use.
31:52Was it substances again,
31:53in part as a coping strategy because
31:55of the discrimination that they face?
31:57Many of them feel unsafe at school.
31:59They're bullied,
32:00they attempt suicide.
32:01I have even more information on
32:03this because it's just it's so
32:06overwhelming and I wanted you to see.
32:08You know how significant this is?
32:13And the chart here on the left.
32:14Some of it compares trans youth to cissus.
32:18And what we see is that trans youth are
32:21much more likely to say smoke cigarettes
32:24or to drink alcohol binge drink.
32:28And again this has to do with the
32:31environment that they're living in.
32:33They are much more likely to have
32:37suicide ideation and attempt suicide,
32:39so self harm as we said before,
32:41here is a stat of 2/3.
32:44Have recently tried to self
32:45harm so these numbers we don't
32:47have perfect statistics on this,
32:48but they are exceedingly high.
32:51And over a lifetime there are numerous
32:54harms that the trans population
32:57faces more than half experienced,
32:59intimate partner violence.
33:00A fifth have experienced
33:02homelessness at some point,
33:03and they're more likely to be incarcerated,
33:06especially black and indigenous trans folks.
33:09And so that's another important
33:10thing to to look at here is to
33:12take an intersectional approach,
33:13and how this affects individuals with
33:16multiple marginalized identities.
33:18Individuals who are trans and also people
33:20of color or also have a disability.
33:22We're also are poor.
33:23These sorts of things.
33:25These multiple marginalization can
33:27lead to devastating health outcomes.
33:31So again, lots of concerns here.
33:34Health disparities for this population,
33:37and it's not helped at all by what's
33:39going on in our public sphere.
33:41And I, you know,
33:43I can't be neutral about this.
33:45Texas has labeled gender affirming surgery
33:47and gender affirming care more broadly.
33:49It's child abuse.
33:50Remember, I said earlier Texas
33:52is OK with conversion therapy,
33:55which we know is harmful.
33:57They are not OK with gender affirming care,
34:00which we know is helpful and is
34:02approved by the medical profession.
34:04The medical profession does
34:05not support conversion therapy,
34:07so Texas is not really looking at
34:10medical professionals and what
34:11their standard of care is.
34:13They're basing this on political
34:15beliefs and using it.
34:16It's a wedge issue and this is harming kids.
34:20It's harming people in general,
34:22and if anything this is just
34:24radically increasing.
34:25You see the numbers here in
34:28this year already.
34:29240 anti queer bills with most
34:31of them targeting trans folks.
34:33That's as of March 20th.
34:35I mean, that's astounding.
34:37The amount of time and effort
34:39that is getting put into these
34:41types of bills when we have,
34:44you know,
34:44kids who are suffering and trying
34:45to harm themselves.
34:46And So what sort of message does this send
34:49to our trans kids out there when they
34:51see this and we know that it's harming them?
34:54Psychosocially, we know this.
34:56So what can we do and what can you
35:00as a clinician do to support Alex here?
35:03Well,
35:03encourage her parents to be supportive.
35:06Again,
35:06this is so important and it can
35:08be a life saving life saving.
35:10If we look at the numbers here,
35:13those with supportive parents
35:14which are in the blue dots,
35:16only 4% attempted suicide.
35:18Those without supportive parents
35:20and the purple .57% huge numbers.
35:22Look at the number of those who
35:24have faced housing problems.
35:26None who have supportive
35:28parents over half who don't.
35:30So this can be again.
35:33Lifesaving, I don't know how
35:34you say it more strongly there,
35:36but it's really important to get Alex's
35:39parents to be supportive and also for
35:42social and medical support as well.
35:45The chart here on the left.
35:47Is looking at trans kids who could
35:49use their chosen name at home,
35:51school and work and what we
35:53find is the orange bar where
35:55they're able to in all contexts.
35:57They have the lowest levels of depression,
35:59suicide, ideations, suicidal behavior,
36:01not surprising, right?
36:03If someone's calling you by
36:04something you don't identify with,
36:06that can be harmful to your
36:08to your mental health.
36:09Also look here at the chart on the right.
36:11What we see here is in pink trans
36:14adolescents who knocked out in treatment.
36:16The blue those who had started
36:18puberty blockers and then we compare
36:20it to cisgender analysen what we see
36:22is that trans kids who are getting
36:25medical support are doing just as well
36:27if not better than cisgender kids.
36:30So again it's not that being trans
36:32inherently comes with some medical
36:34conditions or health conditions.
36:36It's that the environment we live in
36:38right and I'm feeling the dysphoria
36:41that we have options to treat with.
36:43OK, So what what do we do?
36:46Well,
36:47there are some barriers to
36:48care unfortunately,
36:49and in most states miners need parental
36:51consent for gender affirming hormones.
36:54They also need consent for
36:57fertility preservation,
36:58so Alex could seek emancipated status,
37:02but there's still some problems with that,
37:04one of which is visibility of
37:05treatment and so transforming care is
37:07different than other types of treatment.
37:09If someone goes on birth control,
37:11we may not know that they're not.
37:13There may not be any visible.
37:15Manifestations of it.
37:15But as you can see from the chart here,
37:18when folks go on hormone therapy,
37:20that is the point they want to
37:22see that physical transformation,
37:24and if they're seeing it,
37:25other people might be seeing it too,
37:27and that can lead to problems if
37:29they're on these gender forming
37:31hormones and their parents don't
37:33agree with their starting to see
37:35some differences in them,
37:36so that's one concern.
37:38Also, there's just cost.
37:41These treatments are expensive,
37:43even just going on hormones can
37:45be quite expensive.
37:46Surgeries are extremely expensive,
37:47and I know that the chart on
37:50the map on the right is small,
37:52but what it's showing is that the
37:54States and orange, including Texas,
37:56USA,
37:57is one of 10 states that explicitly
38:00excludes transgender health
38:01for individuals with Medicaid.
38:04So even if Alex were to come of
38:06age and want to get some of these.
38:08Trees and doesn't have the
38:10resources available,
38:10but qualifies for Medicaid.
38:11If she was living in Texas,
38:13she wouldn't be able to get this covered.
38:15The States and green are ones
38:17that explicitly say we are
38:19going to include trans care.
38:24So Alex had also mentioned that she's
38:26interested in fertility, preservation.
38:27Gender affirming care can
38:30cause infertility hormones.
38:31We don't exactly know how what
38:33the effects of hormones will be.
38:35We know that some trans people can go
38:37off hormones and have kids genetic
38:39related kids and some may struggle more.
38:41They can also cause sterility if you have
38:44gender affirming surgery and you remove
38:45your gonads that will run to you sterile.
38:47So this is something that
38:49should be talked about.
38:50All trans folks should receive.
38:52Toby preservation counseling.
38:53But this doesn't happen.
38:55A lot of the time.
38:57And so the story on the right is
39:00of a New York Times reporter who
39:03started taking gender affirming care,
39:06and then she and her sister,
39:07gender partner wanted to have
39:09a genetic child.
39:10So she ended up going off her hormones
39:12and this tells the story of these 4
39:15puberty and and just all the chaos
39:17that ensued from her hormones bouncing
39:19all over the place and the gender
39:22dysphoria she felt going off of it
39:24and that could have been avoided if
39:25she had been able to preserve her fertility.
39:27Beforehand.
39:30But you know,
39:31that's not always possible,
39:33as we're going to talk about,
39:34and it can be expensive as well.
39:36So let's let's touch base
39:37about this a little bit.
39:38So we talked about negative rights.
39:40Let's turn to positive rights,
39:41so positive rights are
39:43the right to something,
39:44and this means someone has
39:46an obligation to provide it.
39:47So an example in the US,
39:49everyone has a right to K
39:51through 12 education,
39:53and this means the government
39:53needs to provide it.
39:54Doesn't say anything about the
39:56quality of the education right now
39:58that but every child is entitled to.
39:59Through 12 education.
40:01Positive rights and medicine
40:03are quite limited,
40:05so I can't just walk into
40:06my Commission and say, OK,
40:07I want these medications.
40:08I want these surgeries and the physician,
40:11or the clinician has to say,
40:11oh sure, let me do that right.
40:13Clinicians are not vending machines.
40:15They don't have to provide
40:17whatever patients want.
40:18And so this is going to be
40:20harder for Alex to get this.
40:22And there isn't a positive right
40:23to reproduction in this country.
40:25This is unlike countries like Israel,
40:26which is quite pronatalist and various
40:29European countries which do cover fertility.
40:32Reservation infertility treatment
40:33for all sorts of folks.
40:35But we don't hear in this country and
40:38cost is a huge barrier for Tilly.
40:41Preservation is expensive.
40:41It can cost thousands if not
40:4310s of thousands of dollars,
40:45typically not covered by insurance.
40:48There is a movement though to
40:49have this covered by insurance
40:51more and more for folks with
40:53medically induced infertility.
40:54So individuals who say have cancer and
40:56are undergoing potentially sterilizing
40:58treatment as part of their cancer,
41:00they some places now will cover fertility.
41:03Reservation for those folks and there
41:05are charity programs like Livestrong
41:07for individuals who have cancer.
41:08They're also charity programs for
41:10individuals with physiological and fertility.
41:12As far as I'm aware, there's no charity
41:15program for our transgender folks,
41:18and some might say, well, OK.
41:19Just like that,
41:20there's other ways to build families,
41:21and they're just wonderful and beautiful.
41:23However, they're expensive.
41:24Adoption is usually about 20 to 50 grand,
41:28so quite expensive,
41:29and there are all these discriminatory laws.
41:32The states with the little yellow triangle.
41:34Are ones that allow adoption agencies
41:37and foster care agencies to refuse
41:39to help folks who identify as queer.
41:42So in these states they
41:44may not be able to adopt.
41:47OK, So what are the case takeaways here?
41:51Treatment regarding gender
41:53regarding reproduction.
41:55Sexual orientation are all deeply
41:57subjective and we have to then listen to
42:01the child's voice, the minor's voice.
42:03We can't impose that on.
42:04There's no test for this.
42:06These are deeply personal matters.
42:08Supportive environment can't
42:10stress enough is essential,
42:11and we should look for ways to preserve
42:16fertility for these kids so that they
42:17don't have to go off hormones in the future.
42:19Or if they try to go off
42:20hormones in the future. And I.
42:22Realize, oh I'm infertile now,
42:23so let's be preventative and
42:26adjust this beforehand if possible.
42:29Alright,
42:29last case.
42:31We have an intersex baby baby X
42:33was born with ambiguous genitalia.
42:35One of the clinicians that go to
42:37says we should do a gonadectomy
42:39and genital surgery.
42:40The parents don't know what to do.
42:42So historically.
42:43When the baby was born with
42:46ambiguous genitalia,
42:47it was seen as a medical emergency and
42:49treatment and had to start immediately.
42:51We need to fix the body and this was
42:53done through surgery and through hormones,
42:55and then we need to train the
42:57kids to socialize the kid to have
42:59the correct gender identity.
43:01The one that we assigned for them and
43:03the correct so sexual orientation,
43:06which of course was heterosexual and
43:09intersex, was often kept a secret.
43:11Many people didn't know they were
43:13intersex until they found this out as adults.
43:15So that is historically how it
43:17has been handled in the US.
43:19Going back half a century or so,
43:21and there has been some changes
43:23we'll talk about.
43:24What do I mean by these
43:26normalizing surgeries?
43:26Well,
43:27normalizing surgeries are different than,
43:29say,
43:29medically indicated surgeries
43:30and medically indicated surgery
43:32would be something like a child
43:34does not able to avoid,
43:35so we need to do a surgery so we can
43:37expose their arethra so the child can pee,
43:40right?
43:40We everyone needs to pee.
43:41We want to do the surgery to do that,
43:43whereas a normalizing surgery,
43:44what we're doing here is we're trying to
43:47alter the body to fit into the gender binary,
43:50and this is not to scale,
43:53although it says it is but.
43:55Not on your screen to scale,
43:56but the idea here is that,
43:58well,
43:59you know normal girls have
44:00a ******** of this size,
44:01so if you have clitoral meglia
44:03your ******** is too big.
44:04We're going to reduce the size of
44:06your ******** if you have a micropenis well,
44:09you can't be a real man with a small
44:11penis and the saying was it's easier
44:12to dig a hole and build a pole.
44:14This idea that, well,
44:15you know penises have to do all these
44:17things like become erect and all,
44:19and this but vaginas just need to be
44:21a whole that accommodates a penis.
44:23And so why don't we just?
44:24This kid with a micropenis into a girl.
44:27Obviously we all know that vaginas
44:29do all sorts of cool things,
44:30so these are the types of
44:31surgeries I'm talking about that
44:33are not medically necessary.
44:34Other things like gonad economies,
44:36sometimes like vaginoplasty.
44:37Again, we're taking the body and
44:40trying to fit it into this binary,
44:42and the reason again was not malicious
44:44that people were doing this.
44:46They really thought it would improve
44:48psychosocial health and there
44:49was always this question of like,
44:51well, what about the locker room?
44:52Why? If someone sees you in
44:53the locker room and you're?
44:54Genitals are abnormal.
44:55I mean I think kids are
44:58always self just like adults,
44:59self conscious about their bodies
45:01and there's lots of things going on.
45:02I don't think we're going to,
45:03you know,
45:03do surgery on all sorts of kids
45:05bodies so they feel comfortable
45:06when the locker room that doesn't.
45:07It doesn't seem like that's the best
45:09way to handle this is to do individual
45:10surgery on our bodies rather than
45:12focusing on the systemic issues.
45:13Here,
45:13I want to give you some
45:15examples of this from interact,
45:17which is an advocate organization
45:19for intersex Youth.
45:21Just so you kind of know
45:22what I'm talking about here.
45:24So this individual.
45:24Says that you know she had surgery
45:26starting at about four months
45:28and multiple ones that followed,
45:29and this is often the case.
45:30There's often a cascade of surgeries.
45:32Once you have the first one
45:33because his parents were told that
45:35he needed to pee standing up.
45:36But if you want to be a real boy,
45:38you need to pee standing up.
45:40And again is that medically,
45:42necessarily necessary?
45:43I mean,
45:43there's plenty of people out there who
45:46don't pee standing up and identify as men,
45:48and they do just fine again.
45:49How many people are coming
45:51into the toilet stall with you?
45:52Especially if you go into A1
45:54stall and maybe not?
45:56Again,
45:56this is the kind of thing
45:57we're talking about.
45:58These are the types of non medically
46:00indicating that normalizing surgeries
46:02this individual is X chromosomes,
46:05ovaries and then naturally larger ********
46:07and they wanted to make her clearer.
46:10Smaller because I thought it was
46:11too big for a girl to have OK,
46:13so those are some examples.
46:14Does this happen today?
46:16It's hard to say.
46:18Some studies say yes,
46:19this is happening at a pretty high rate.
46:22Others are saying not as much as it used to.
46:24Hard to find information on this.
46:27So ethically,
46:28what are some of the issues here?
46:29Well,
46:30one issue is that infants cannot consent,
46:33and this is irreversible surgery.
46:36As we talked about before, the greater
46:38the subjectivity of the treatment,
46:40the child's voice should be increased.
46:42And the reason we're OK with doing certain
46:45types of treatment for the two previous
46:47cases is that they were both teenagers.
46:50There were 15 and 16.
46:51They are able, you know,
46:53to have a voice and to reason they
46:55would meet many of the standards.
46:57Of decision making capacity
46:59and invent clearly does not,
47:02so we don't want to do something
47:04on a child that they can't consent
47:06you that they can't ever change and
47:09these are deeply subjective conditions here,
47:12as we're talking about.
47:13So what are some other ethical issues here?
47:15Well, this reinforces the gender binary
47:18and says there's only two types of bodies,
47:21so it pathologizes atypical bodies
47:23and says your body's bad or wrong.
47:25There's something wrong with you,
47:27and so it's not.
47:28Surprising then that folks with
47:29intersex we've had a lot of surgeries,
47:31have negative body image that they,
47:34you know,
47:34feel badly about their body.
47:35And why am I going getting all
47:37these surgeries on my genitals?
47:38None of my friends do that.
47:39What's wrong with me?
47:41And I'm intentionally using
47:42the language of intersex.
47:44In this talk,
47:45you may be more familiar with the
47:47medical term of differences or
47:50disorders of sex difference DSD.
47:52I don't like using that term as much though,
47:54because a lot of intersex
47:56adults reject that terminology.
47:57They don't like this idea that they're
48:00considered disordered or diseased.
48:01They see themselves as just
48:03a normal variation.
48:04People have different sized noses and ears,
48:06people different size clitorises right?
48:08There's normal variation.
48:09There's something pathological about it.
48:14And there are physical harms
48:16associated with surgery.
48:17As we said, sometimes additional
48:18surgeries and treatment are
48:19common and not just surgeries,
48:21but things like vaginal dilators,
48:23which can be really uncomfortable,
48:24especially if you're a young child.
48:25They're complications from this things
48:28like impaired clitoral sensitivity
48:30difficulties with vaginal penetration.
48:32Like I said,
48:33you might need a vaginal dilator,
48:35and these concerns are
48:37more prevalent in kids.
48:39There's more likely to be
48:40damaged and side effects,
48:41negative side effects and kids than adults.
48:44And surgery can often be
48:45delayed with similar outcomes,
48:47so if we can talk to a 6 year old
48:49about this and they have some
48:51input that's very different than
48:52doing this on a 6 month old right,
48:54versus doing that a 16 year old
48:57who probably has capacity and can
48:59make these decisions themselves.
49:01Another factor consider here is
49:03just the harm to gender identity.
49:05We talked about preserving an open future.
49:08We don't know how this intersex
49:10baby is going to identify.
49:11Only you can determine your
49:13own gender identity.
49:14Only baby X can tell us what
49:16their gender identity is,
49:18and so the best way to preserve an
49:20open future is to let that baby decide
49:22when they get older and what we see
49:24is about half of people who I do.
49:26I intersects you use pronouns
49:28outside the binary.
49:30They don't see themselves
49:31as squarely female or male,
49:33and so it might be.
49:35Psychologically devastating for them,
49:36then to know that their
49:38genitals were altered in a way
49:40that goes against them right?
49:41That maybe they identify as male
49:44and we made their clear as smaller,
49:46and that's really detrimental
49:47to them because they don't see
49:49those ******** they see it as
49:50a penis and we just took away
49:52somewhere their masculine identity.
49:53These sorts of things I think
49:55are important to recognize,
49:56and if we can't predict it and we
49:57need input from that individual,
49:59let's wait till we can get that information.
50:04Goodnight, Anthony was historically done
50:06for intersex kids and part of the reason
50:08was there was concern about cancer risk.
50:10And that especially if someone has internal
50:12gonads, they're difficult to monitor,
50:14and in certain intersex conditions they might
50:17be more likely to become cancerous. However,
50:19there's a range of intersex conditions,
50:21and so we need to look case specifics.
50:23I don't think we have a blanket statement
50:25that we remove gonads for everyone,
50:27but part of the reason they were removed
50:29is this idea that they also lacked purpose.
50:31They didn't produce traditional
50:33hormones and there was no fertility.
50:36So First off, we know now that there can
50:38be fertility for folks with intersex.
50:40We know there are people who have
50:41said Turner syndrome who have been
50:43able to have genetic children,
50:44so they're not totally lacking purpose.
50:46And even if they don't produce
50:48hormones in the same way.
50:50Are gonads affect our
50:52gendered identity right?
50:54I put up here what that takes over is to do,
50:56but often the more colloquial is that takes
50:58balls to do right and there's a lot of
51:02association with genitals and our identity.
51:04There's been interesting studies done
51:06looking at women who've had overreacted,
51:08lies,
51:08and the woman who had both her ovaries
51:11out feels like less of a woman.
51:12The woman who had one of her ovaries
51:14out the woman who has one of her
51:16ovaries and it goes on and on.
51:18So like even though no one
51:20sees their ovaries.
51:21Knowing that they're there
51:22impacts their gendered identity,
51:24makes them feel more of a woman.
51:27Some people may also have a
51:29preference for endogenous hormones,
51:30and going that ectomy is
51:32effectively sterilizing these,
51:33so trying and giving them the opportunity
51:37to potentially have genetic children.
51:40Another concern here with doing
51:42these types of surgeries is that
51:44it can foster distrust that kids
51:46can feel betrayed by their parents,
51:49especially if their parents hide this
51:50from them or feel like why are you
51:52making these decisions about me that
51:54are so deeply personal they can feel
51:56betrayed by medicine and distrustful
51:57and not want to go and see healthcare
52:00providers for other things because
52:01of this lack of trust which we see
52:04in the queer community broadly,
52:06lack of trust has often means
52:07they use health care less.
52:09And then difficulty in relationships,
52:11especially intimate relationships.
52:12People can feel very self conscious.
52:14They're told their bodies are bad.
52:16All these sorts of things also play a
52:18role to just a culture of this trust,
52:20which can make it difficult to
52:23have the relationships.
52:24If we look at the ethical
52:26principle of justice.
52:27We see that we're allowing some
52:29of these intersex surgeries,
52:30but yet as a culture we oppose other
52:32types of genital surgeries on infants,
52:34such as female genital cutting,
52:37and then also there's a growing
52:40movement against male circumcision.
52:41Intactivists they're called and
52:43this idea is foreskin.
52:45Is not.
52:46You know this person has outside
52:47is not a birth defect.
52:49It's not a medical abnormality.
52:51Why are we removing a child's foreskin
52:52if there are no real medical benefits
52:55or contested medical benefits?
52:56Why not let the child?
52:58Decide when they get older.
52:59If this is important to them or not.
53:02So it's been a growing consensus over
53:04the last decade that doing these types
53:07of normalizing surgeries is unnecessary
53:09and it should not be done without
53:11informed consent of the individual.
53:13But obviously the surgery is still
53:16do continue, and that even here,
53:18the same without informed consent of the
53:20person or their parents or guardians.
53:22Most people they are pushing
53:23and saying really should be the
53:24individual should be the child.
53:25They need to be the one
53:27consented For these reasons.
53:28On the national level,
53:30we have folks also saying
53:31that we need to be able to.
53:33Make our own decisions regarding this.
53:36And that you know, all these reasons
53:38we gave before that you know,
53:39well, psychosocial problems.
53:40Well at the locker room they're
53:42not really relevant.
53:43They're not really.
53:44They haven't played out, and so why
53:47don't we preserve their decision making?
53:49Because we know these surgeries can
53:51lead to decreased sexual function,
53:53increased substance use, disorder, suicide.
53:55All these sorts of things that we talked
53:57about with the previous two cases.
53:59Just in the last couple of years,
54:01a couple of U.S.
54:02hospitals.
54:02I said there are no longer going to do
54:04certain types of intersex surgeries,
54:05so there is this growing movement.
54:08So what do we do now with the BX's parents?
54:11Well, we need to educate them.
54:13We need to tell them about what we just said.
54:16We have to offer them resources interactive,
54:18a great one for intersex youth.
54:21Have them go see a specialist.
54:22Someone who cares specifically
54:24for intersex kid who's familiar
54:25with this and then connect them
54:27to parents of intersex kids.
54:29That's really important.
54:30Normalize it so you can.
54:32I think sometimes you know
54:33when parents hear Oh my gosh,
54:34something wrong with my baby,
54:35they're like just do whatever
54:36you need to do like fix it.
54:37I don't want my baby to suffer,
54:39but if you haven't talked to
54:40other folks they might then.
54:42So, uh, this is not that big of a deal.
54:43This is not that bad.
54:46And the message is we should give
54:47them is intersex is not a variation.
54:48Again people have all different
54:50shapes and sizes of all different
54:51body parts and that's OK.
54:53That loving and supporting a child
54:55is what's most important and
54:56that children can decide about
54:58surgery when they're older.
54:59So the case takeaways here don't
55:02pathologize different bodies.
55:04We need to uphold future gender
55:06and sexual autonomy and the way
55:08to do that is to not do early
55:10surgery for normalizing reasons.
55:12And you know, if they want to do these.
55:15To surgeries is irreversible surgeries.
55:17They can decide on that when they're older,
55:19but we shouldn't do non medically
55:21indicated irreversible surgeries.
55:23OK,
55:23so the dessert the talk takeaways
55:26so covered a lot.
55:30The two take home points here is that
55:32when we're talking about sexuality,
55:34gender, and reproduction,
55:35these are deeply, deeply personal.
55:37These are not things you can do a lab on,
55:39or you know, do a questionnaire
55:41on in the same way you need to
55:42listen to that person's voice.
55:44You can't treat this in the
55:45same way as other things,
55:47like strep throat,
55:48so we need to incorporate that child's
55:51voice to essential and a supportive
55:54environment is necessary as well,
55:56and that especially if the child doesn't
55:58feel like they have support in their family.
56:00Not your right school or elsewhere.
56:02You can be that advocate for them.
56:03You can be their confident you
56:05can be the person helping them
56:06and giving them resources.
56:08So I'm going to end there.
56:09I would be happy to take any
56:11questions or comments and you can
56:12always reach out to me afterwards.
56:16Thank you so much,
56:17that's example engleton.
56:18This is really, really interesting,
56:20really good. I learned a lot.
56:23I'm sure the folks in the
56:24in the group did as well.
56:26Let me, I'll take the Farragut
56:28to ask the first question.
56:29As others, I'll invite everybody to
56:31please enter your questions through
56:32the Q&amp;A I see we've got a few already,
56:34and then I'll ask Lisa one or a
56:37time as we do this.
56:38So I have.
56:42I think first of all,
56:44let me let me absolutely validate
56:45something you said about the being
56:46a one of the more Gray haired
56:48individuals in the crowd here.
56:49That this was indeed seen.
56:51These kids with intersex these babies
56:53intersects was seen as a surgical emergency.
56:55This had to be fixed very quickly.
56:56This child had to be assigned
56:58to a 2A gender to a sex right
57:01away that that was the reality.
57:03And of course that's been
57:05reconsidered in recent years.
57:06For all the reasons that you pointed out.
57:09But I'm interested in the
57:11idea about preserving an open
57:13future in babies and I sense.
57:16And then consistency a little bit
57:18or or some tension with open future
57:21because I see when we talk about
57:23treating kids during or, say,
57:25early adolescence for example.
57:28Of with various treatments, some of
57:30which are more reversible than others.
57:32Is there the same sense that we have
57:34to absolutely preserve an open future
57:36for adolescents as there is for babies
57:38and and I guess tied into that we had
57:40a speaker not long ago in this program
57:41and she referred to some European studies.
57:43And maybe you can help with this.
57:44I'm not really familiar with the data about.
57:49People who changed their minds and
57:52that that perhaps is one of the
57:53big concerns about doing surgery
57:55on a 12 year old or a 15 year old
57:57or a 16 year old because he or she,
57:59you know, in 10 years,
58:00may wish they hadn't had the surgery
58:02and and I wonder if you could speak to
58:05how often that happens and how you think.
58:07See the concept of preservation
58:09of an open open future,
58:12which in in the newborn period is
58:14something you've advocated for.
58:15Strongly. Do you feel that is?
58:17Do you feel that is strongly
58:18for the adolescence?
58:19And is that related to the?
58:21Is that related to the likelihood
58:23that a young adult is going to say?
58:25I wish I hadn't had that
58:26surgery or that treatment?
58:28Yeah, I know. It's a great question
58:29and I feel much more comfortable
58:31allowing teenagers to make decisions
58:33that are irreversible because I think
58:35they can actually have some meaningful
58:37impact and input into that decision.
58:40Whereas a 2 year old really
58:42can't share their values, right?
58:44But a 12 year old probably can.
58:46And if we look at some of the
58:48empirical literature we see.
58:49A lot of 14 year olds are just as good
58:51as predicting their future and making
58:53decision making as 24 year olds and and so,
58:55and especially for these kids who have been,
58:58you know, marginalized and vulnerable.
58:59With they have grown up fast like we see with
59:02kids with like chronic health conditions.
59:04And so I think they're really thoughtful.
59:05This is not something they're rushing into.
59:07This is something they've been
59:08dealing with for a long time.
59:09So yes, I I want to be careful.
59:11I don't want to do irreversible
59:13treatments at age 8,
59:15but I also want to point out that
59:16the standard of care guidelines
59:17really doesn't do that the earliest.
59:19Most people would be having surgery is 16,
59:21with some exceptions.
59:23Occasionally they will allow masculines and
59:25top surgery at a little younger than that,
59:28but for the most part these are,
59:30you know we're just doing that.
59:32Puberty blockers and gender affirming
59:34hormones that don't start till 16.
59:36So up until 16.
59:38It's still open future and that kid at 16.
59:41I think it's pretty well equipped
59:43to make these types of decisions.
59:44There is some literature about kids.
59:46Detransitioning I you know,
59:47I don't go into all the
59:49details of the studies.
59:50There are a lot of flaws
59:51with some of those studies,
59:52and some of them got taken out
59:54of context and and now I think
59:56there's this whole concern about.
59:58Well,
59:58what if they regret it and
59:59what they change it later?
01:00:00It's interesting to me that I only
01:00:02see this type of concern come up
01:00:04when we're talking about things
01:00:05like gender and reproduction,
01:00:06so we see a lot of OBGYN's who
01:00:08won't do a tubal ligation on a
01:00:10woman who's 25 because I'm like,
01:00:11well, you might want to have kids.
01:00:12You don't think kids?
01:00:13How do you know you're going
01:00:14to regret it later?
01:00:15But when I had knee surgery,
01:00:16no one was like you might regret this later.
01:00:18You know? What should we do?
01:00:19This knee surgery? Should we not?
01:00:21And I do regret it.
01:00:22Actually I regret having any surgery,
01:00:24I'll just say.
01:00:26It is very specific about
01:00:28gender and sexuality,
01:00:29and I think that's because we have such
01:00:31firm norms about what it means to be like.
01:00:34You know,
01:00:35a real woman or what it means
01:00:36to be a normal mother,
01:00:37or these sorts of things,
01:00:39and so that's what we're trying to
01:00:40get those people into those boxes.
01:00:42We don't have those same norms
01:00:44about knee surgeries.
01:00:45Did that answer all the pieces?
01:00:46And that
01:00:47was very interesting. No, no, it did I.
01:00:49I'm curious to know what the data are,
01:00:51because I'm always worried. I mean,
01:00:52I have taught you know that in general,
01:00:55when one comes to a fork in the road.
01:00:57And one is unsure which way to go if
01:01:00one is truly unsure which way to go.
01:01:02The wisest course is to take the
01:01:03course that's most easily reversed
01:01:04if it's not at all, which way to go.
01:01:06But I also recognize and you've touched
01:01:08on this, that two delay, for example,
01:01:11puberty blockers or so delay affirming
01:01:14medical treatment even through adolescence.
01:01:16Comes at a cost so that
01:01:19child's mental health,
01:01:20and so it's if if it were absolutely free
01:01:24to stall then I would say let's just stall.
01:01:27And then one could say well,
01:01:28how long should you stall because one thing
01:01:30that we also recognize that 18 year olds,
01:01:32though they are legal adults,
01:01:34you know their abilities to really think
01:01:36long term assets are not as good as they're
01:01:38going to be in many cases in 10 years.
01:01:40But we don't say to 22 year olds
01:01:42when you're not really smart enough.
01:01:43You have to make decisions.
01:01:44We draw a line at 18 for
01:01:46historical reasons and otherwise.
01:01:47But I also recognize,
01:01:48and you pointed this out that
01:01:50that to tell a 16 year old, no,
01:01:52we can't do this yet could come
01:01:54at a cost to that kid.
01:01:55So that's I mean,
01:01:56as we balance these out,
01:01:57the risk that the kid may wish I hadn't
01:01:59had it to the risk of the kids saying,
01:02:01I wish I had it sooner.
01:02:03Especially when when the numbers are
01:02:06so tiny of folks who detransition
01:02:09and the risk of suicide is so high.
01:02:12I mean, this is a life saving
01:02:14treatment for these kids,
01:02:16so that means, so that's actually valuable
01:02:18information for people who are looking
01:02:19to figure out what to say to these kids
01:02:21or what to say to the parents even more.
01:02:23As importantly is that you feel the
01:02:25risk of suicide is actually higher
01:02:27than the risk of detransition?
01:02:29Yeah, that's that's.
01:02:30I think a really important
01:02:32piece of information, right?
01:02:33Let me let some other folks.
01:02:34Of the conversation here.
01:02:36So on, one person asked if you
01:02:38could comment on general surgery for
01:02:40general surgery for intersex babies.
01:02:41I think you've commented on that fairly well,
01:02:43and I think that this was early this talk.
01:02:46Someone said, go Connecticut,
01:02:48I think when you're showing
01:02:49one of those maps,
01:02:50or maybe just because they're talking
01:02:51about our basketball team, I don't know.
01:02:55So I'm going to ask for a copy
01:02:56of the periodic table of terms.
01:02:57Is that available to be shared
01:02:59through email me?
01:03:00Or you can find it online?
01:03:02You can find it online, there you go.
01:03:03Just take a look online and if you can't
01:03:06reach out to me and I'll reach out to Lisa.
01:03:08So let me see.
01:03:09Here's a question or a comment.
01:03:11I completely agree about the importance
01:03:13of granting our teen patients some degree
01:03:16of autonomy in healthcare decisions.
01:03:18However, I'm having some trouble reconciling,
01:03:20denying or not encouraging potentially
01:03:23life saving medication like Prep.
01:03:25With our encouragement of other
01:03:28medications like HPV vaccine, I would.
01:03:31I would greatly appreciate
01:03:32your thoughts on this.
01:03:33Thank you.
01:03:34A very important and timely conversation.
01:03:37No good point and I.
01:03:38That should be clear.
01:03:39Maybe I wasn't as clear in the talk.
01:03:41I'm not discouraging it,
01:03:42but if if if Zach after education and
01:03:46numerous conversations is still saying no,
01:03:49I don't want prep.
01:03:50I don't think we should force it.
01:03:51I have real concerns about forcing treatment
01:03:54on teenagers against their wishes.
01:03:55I think we need to have that honest
01:03:57conversation with him and say,
01:03:58just like HPV vaccine.
01:03:59Just like you know,
01:04:00your flu shot all these things.
01:04:02You really should get them.
01:04:04Am I going to hold Zach down and
01:04:06make sure he takes a pill every day?
01:04:08I don't think so.
01:04:08I don't feel comfortable doing that.
01:04:10Because it's not something like
01:04:11the classic case bioethics case
01:04:13about Jehovah's Witness Child,
01:04:14who needs a blood transfusion
01:04:16to live in that moment.
01:04:17That's not what we're talking about here.
01:04:18HIV AIDS is a chronic condition now.
01:04:20He could leave, you know,
01:04:22a long and healthy life with it.
01:04:24So that's where I'm drawing the line.
01:04:26That's a good point.
01:04:27Thank you. What are the implications
01:04:30for society and families to promote
01:04:32the promote the in quotes right to
01:04:35distress your parents as young as age 12,
01:04:37especially in an era when social
01:04:39media and destructive influences on
01:04:41the Internet are so available to
01:04:43take over the value for kids between
01:04:4511 and 14 when developmentally kids
01:04:47need to move incrementally into
01:04:49the world of autonomous function.
01:04:53Right, another good point here.
01:04:54And I I agree. I mean,
01:04:55I think kids need to gain autonomy over time.
01:04:59It's not like a switch those off,
01:05:00although that kind of happens at 18 right
01:05:02all of a sudden you're free to make your
01:05:04own decisions and the stuff on the web.
01:05:08Good goodness.
01:05:09Hopefully they're you know they,
01:05:11but they are accessing that,
01:05:12so I don't think it's I wouldn't call,
01:05:15though I wouldn't frame it as a
01:05:17right to distrust your parents.
01:05:18I think it is this idea of giving
01:05:21them some autonomy and and it can be.
01:05:23He can, incrementally.
01:05:24I mean, I remember as a child the first time,
01:05:27I can't believe I remember this.
01:05:28I think I was like 8 when the clinician
01:05:30met with me without my mom in the room
01:05:33and it was like wow this is the big time.
01:05:35Now you're like anything you
01:05:36want to talk about, no?
01:05:37And OK. Here's your lollipop,
01:05:40but you know,
01:05:41just starting to have those
01:05:42conversations so the child can build
01:05:44a relationship with the provider.
01:05:46And at that point I'm sure the collision
01:05:47went and told my mom was in the hallway.
01:05:49Exactly what happened and it was fine.
01:05:51But as the kids get older,
01:05:52I think we need to give them a lot of time.
01:05:53Especially about these sorts
01:05:55of things where they,
01:05:57depending on their home environment,
01:05:59they may not be getting support about.
01:06:01This can be really harmful as well,
01:06:03and this is also where you can use the
01:06:05opportunity to educate because and to
01:06:07counter all the stuff and getting on
01:06:08the web have that information available,
01:06:10talk to them about it.
01:06:11You know you're an authority figure,
01:06:12you're a trusted figure.
01:06:14Depending on their relationship with
01:06:15their parents, they may not have that,
01:06:17so I don't.
01:06:18I would never say distrust your parents,
01:06:20but I also think we need to be careful.
01:06:21Like in the case we talked about.
01:06:23You know Zach coming out to his
01:06:25parents could mean that he's getting
01:06:27kicked out of the house like there
01:06:29are serious consequences here that
01:06:30you know need to be discussed and be
01:06:32thought through carefully before certain
01:06:34things may be revealed to parents.
01:06:36That might be a controversial say,
01:06:38but I think that that you know this is
01:06:41largely an audience of of a pediatric
01:06:43clinicians who I think was strongly
01:06:44agree with that I I live in a strange
01:06:47pediatric world of newborn intensive care,
01:06:49so I don't directly care
01:06:50for these kids at this age,
01:06:52except when they become parents.
01:06:55But I mean, I think much of your advice
01:06:57is very well will take and will received.
01:07:00I particularly like your point,
01:07:02and I bet the the pediatricians,
01:07:03the general pediatricians are the call.
01:07:05Already knew.
01:07:06They just the idea of
01:07:08asking about orientation,
01:07:09asking about identity in such
01:07:10a way that just like asking,
01:07:12are you right handed or left handed
01:07:14with the implication and the way
01:07:15one asks that you know it's OK.
01:07:17Either way, it's fine either way.
01:07:18Just let me know which one you are
01:07:20and then we can talk some more.
01:07:21If you want the idea that that
01:07:23by asking the question.
01:07:25And and in some ways it it can
01:07:28normalize the situation and make
01:07:30kids feel much more comfortable.
01:07:32All right,
01:07:32let's get down to some some heavy stuff here.
01:07:34Even heavier stuff.
01:07:35Now get ready,
01:07:36in which circumstances would you
01:07:39consider evolving Child Protective
01:07:40Services and possibly separating
01:07:42queer youth from their parents?
01:07:44Are there any Special Situations
01:07:46besides the traditional indications
01:07:48like family abusing the kid?
01:07:50And in your experience,
01:07:51how often does something like this happen?
01:07:53And by the way,
01:07:54thank you so much for this
01:07:56wonderful presentation.
01:07:58Oh, that is a tough question and
01:08:00this is part of the reason I like
01:08:03bioethics is that it's a team
01:08:05sport and so is clinical medicine,
01:08:07and so that is when I would defer to my
01:08:10social work and other colleagues to talk
01:08:13about some of this as a philosopher.
01:08:15I'm not sure I'm totally trained on
01:08:18when the right time is, but I mean,
01:08:20if you think it's really harmful
01:08:22to this child, you know if,
01:08:24and so we know that queer kids are
01:08:26more likely to be sexually abused and.
01:08:28You're not just by their peers,
01:08:30but by adults.
01:08:31There's so much violence that
01:08:33happens to career kids.
01:08:35If you think something like that is going on,
01:08:37then yes, I think they need to get involved.
01:08:39Obviously right.
01:08:39If it's psychological harm,
01:08:41I wish that were taken more seriously
01:08:43because that can be devastating
01:08:45and stay with you for a lifetime.
01:08:47But maybe talking to the child getting if
01:08:49there are other baby steps you can do,
01:08:51getting them support in other
01:08:52ways before you call CPS,
01:08:54but I would turn to my colleagues.
01:08:57I don't know how often this happens.
01:08:59I know there have been some
01:09:02controversial cases of CPS being
01:09:03called for various types of reasons.
01:09:06But I don't know if CPS actually
01:09:07acted on it or they said,
01:09:09you know this is OK enough
01:09:10that this child can make it.
01:09:12But this is also why homelessness
01:09:14is so high among queer youth.
01:09:15It's because it's not just some
01:09:17of their parents kick them out,
01:09:18they just say I'm leaving like
01:09:19this is an unhealthy environment.
01:09:21I would rather live on the streets
01:09:22and then what we see happening is
01:09:24often they turn to sex work because
01:09:26they're not able to get the type
01:09:27of you know employment, what?
01:09:28What employment can a 16 year old
01:09:30get and then they get you know
01:09:32more and more vulnerable through
01:09:33these sorts of things so.
01:09:35But we want to try to break that
01:09:37cycle of what's happening there.
01:09:39But and especially the case for trans kids,
01:09:41actually.
01:09:43So if we can interfere in certain ways,
01:09:45maybe.
01:09:45But the first step might be talking
01:09:47to the parents and seeing if you
01:09:48can get them on board and seeing
01:09:50if you can get it to be at least
01:09:51a more neutral environment,
01:09:53if not a supportive environment.
01:09:55Sorry, that wasn't the best.
01:09:57It's an honest answer.
01:09:58I mean it's it's not an easy question.
01:10:00I mean, it strikes me that the you
01:10:02know that the easy easy question is the
01:10:05question of physical or sexual abuse,
01:10:07then that's that's pretty clear
01:10:09that you have to get CPS involved.
01:10:10And then you say, well,
01:10:11so a house where the child
01:10:13is insulted by the parents.
01:10:15Does that mean you get CPS involved?
01:10:17Well, that's going to be
01:10:18a threshold case I think,
01:10:20and different people are going to
01:10:21draw that threshold in different
01:10:23places in a place where the kid
01:10:24is constantly subject to abuse
01:10:25to the point where he's suicidal.
01:10:27One would say that.
01:10:28Now, if the parents can't be
01:10:30guided away from this,
01:10:31that the kid needs to be separated.
01:10:32But there are so many there's
01:10:33there's a huge Gray zone in there.
01:10:35Different people will find a
01:10:36threshold in different places.
01:10:37I think there's no shortage of kids.
01:10:40Queer and otherwise,
01:10:42who are are pretty miserable at
01:10:44home and are and are treated poorly
01:10:47even in the absence of physical
01:10:49abuse and and I think for the
01:10:51overwhelming majority of those,
01:10:53this isn't in any situation where
01:10:54the state gets involved and it's,
01:10:56you know,
01:10:57I think the education of all of
01:10:59us as parents is hugely important
01:11:01in that regard.
01:11:02The parents can be made to see
01:11:04how they can do better.
01:11:05I think that's that's a huge part of it.
01:11:08OK, it seems as though.
01:11:11There are some very clear cases
01:11:12of kids who identify as female
01:11:14though born male and vice versa.
01:11:16But what about kids who don't
01:11:18clearly identify as trans but
01:11:20have body dysmorphia such as a
01:11:22teen born female who identifies
01:11:24as nonbinary and is interested in
01:11:26top surgery but is not interested
01:11:29in transitioning per se?
01:11:30How can providers and family
01:11:32be supportive of the patient's
01:11:34autonomy but also help clarify
01:11:36if surgery is appropriate?
01:11:38Yeah, no, that's that's a good a good
01:11:41question and an important point to raise
01:11:43that we have different categories.
01:11:45And so trans folks,
01:11:47either gender identity does not
01:11:48match their assigned sex at birth.
01:11:50But non binary folks.
01:11:51It also doesn't match,
01:11:53but in a different way.
01:11:53They don't identify as the formal
01:11:56opposite gender they identify sort
01:11:57of neither gender and This is why.
01:11:59Again, the kids voice is so important
01:12:02because some trans kids or some
01:12:05nonbinary kids experienced severe
01:12:07dissmore lobbies morphia, others don't.
01:12:09And this is where we have to have
01:12:11those conversations to find out.
01:12:13Is this bothering you?
01:12:14Is it not?
01:12:15And decide what is the best
01:12:17step forward and there isn't.
01:12:19It's not like again a clear path
01:12:20like you take 2 aspirin and call
01:12:22me in the morning and then the
01:12:23next day I'll take two more.
01:12:24This is what works for this
01:12:27child is does this child need
01:12:29top surgery but not hormones?
01:12:31Does this child need no
01:12:33surgery and no hormones?
01:12:34It's really dependent upon the child's
01:12:38wishes and what the child needs.
01:12:39So I think it's just having
01:12:41these conversations and letting
01:12:43the parents drive it.
01:12:44I'm sorry the patient drive now.
01:12:45Yes,
01:12:46I was just thinking of a case,
01:12:48but some of my clinical colleagues
01:12:50I just wrote up about a trans
01:12:52kid and her parents were trying
01:12:54to put her on hormones and she
01:12:56didn't want to go on it and but
01:12:58they they were struggling with
01:13:00this idea that you know what.
01:13:01But if you're a girl then you
01:13:02need to be on hormones and
01:13:03you need to look like a girl.
01:13:05And she was saying but that doesn't
01:13:07feel right for me like I can identify
01:13:09as trans and still look masculine.
01:13:11That's OK to me,
01:13:12so I think it's just also
01:13:13recognizing how fluid all of this is.
01:13:16And educating the family that
01:13:17there isn't this linear path.
01:13:20You know what occurred to me is
01:13:22you're speaking is is how often
01:13:24your typical general pediatrician
01:13:25might face something like this.
01:13:27Face is something like this,
01:13:29and it strikes me that that my
01:13:31first impulse was to say, well,
01:13:33it would be so rare that that one,
01:13:35as with any problem we face.
01:13:37I mean, I find that that things that I
01:13:39see a lot I get good at taking care of
01:13:41things that I see really infrequently.
01:13:43I never really get comfortable
01:13:44taking care of and not really
01:13:45quite sure I know what I'm doing.
01:13:46And So what I do then,
01:13:47as I say, well,
01:13:48I only see this once a year.
01:13:50I gotta talk to somebody who sees it a lot
01:13:52more and to find out how they handle it.
01:13:54And the same, maybe you're here,
01:13:55but the numbers you gave about
01:13:57the kids in high school suggest
01:13:58that a pediatrician within his or
01:14:00her practice has probably got,
01:14:02you know, several kids who are
01:14:03dealing with these things.
01:14:04Is that a fair statement?
01:14:07And then the question is,
01:14:08do you have on your practice and don't
01:14:10even realize it because you haven't
01:14:12asked how many are there like that.
01:14:15Here's someone,
01:14:16the person who asked about
01:14:17talking about surgery babies.
01:14:19By the way,
01:14:19she then came back and said you
01:14:20would dress this beautifully.
01:14:22Thank you and another individual
01:14:24comment that on the regret
01:14:26issue that less than 1% regret
01:14:28having affirming surgery.
01:14:32So thank you for giving us that.
01:14:34Thank you now. Here's a here's a
01:14:37question that's I'd be interested in.
01:14:38What you have to say.
01:14:39I'm not sure what I have to say here,
01:14:40and if someone else said Yale could
01:14:42perhaps answer this better than I,
01:14:43but I'm interested in
01:14:44Texas on where you're at.
01:14:46What is the curriculum like in medical
01:14:48schools about gender affirming care?
01:14:50How greatly does it vary
01:14:51between region of school?
01:14:54It drum it varies dramatically dramatically
01:14:57depending on location. On school.
01:15:00When I was at a previous job in a more
01:15:04liberal area and this was ten years ago,
01:15:06just to be fair, I wanted to introduce
01:15:08transgender care into the curriculum and
01:15:10the response that I was told is that the
01:15:13students aren't mature enough to handle it.
01:15:16And I said, well,
01:15:17some of the students are trans.
01:15:18They're clearly mature.
01:15:19They're you know, in their 20s at least.
01:15:21But I think it was more discomfort with the,
01:15:24you know, the people there.
01:15:26The faculty with this topic.
01:15:27So we didn't include it for I.
01:15:30Don't tell them I rebelled a little bit and
01:15:32put it in the curriculum in certain ways,
01:15:34so I think it's a lot of the faculty
01:15:36discomfort that's not being taught here.
01:15:38We do teach some of it, however,
01:15:40given all the things going on in Texas,
01:15:43public universities have been asked
01:15:45for Freedom of Information Act to get,
01:15:48and all the information of where
01:15:49we treat teach this sort of stuff.
01:15:51So all of our syllabi have to be
01:15:53sent in so someone could review it.
01:15:56Use it.
01:15:57And their campaign to limit trans
01:15:59rights so it is being monitored here,
01:16:02but it really just depends.
01:16:03I don't have.
01:16:04I don't know if there's good studies
01:16:06going that's pheasant,
01:16:07so let me go straight.
01:16:08Someone thought that the medical students
01:16:11weren't mature enough to talk about.
01:16:13That's a little scary, all right.
01:16:16So how do we reconcile all views
01:16:18versus new with professionals
01:16:20in the medical community?
01:16:23And I actually have a thought about this,
01:16:24but I'm interested in your thoughts first.
01:16:27Yeah, I mean there's always
01:16:28going to be each culture change,
01:16:30and it's it's hard, you know.
01:16:31But I think educational sessions like
01:16:34this can be really helpful and in an
01:16:37environment like this where it's low
01:16:40stakes where you know you can ask
01:16:41whatever questions we try to have
01:16:43sessions like that where people can
01:16:44just ask whatever questions they want.
01:16:46That's part of the LGBTQ group here at
01:16:48my institution because a lot of people
01:16:50feel nervous about asking those questions.
01:16:52They feel stupid that they feel
01:16:53ignorant or or biased in some way,
01:16:55but just having that resource.
01:16:57To them and just again normalizing it.
01:17:00You know people sometimes now put
01:17:01in their signature they're pronouns,
01:17:03and then some people put a leg and say why.
01:17:05This is useful to do this,
01:17:06and people can then click on it and say,
01:17:08oh, it's useful to include my
01:17:09pronounce For these reasons.
01:17:11So I think just continual education
01:17:13and continual normalizing it is is
01:17:15one way to help move things forward,
01:17:17but I'd love to hear your thoughts Mark.
01:17:18Well first and I was ovation,
01:17:19which Lisa knows this but and that's
01:17:21where the others is that when we started
01:17:23this before we started this meeting,
01:17:25I asked Lisa question because I wanted to
01:17:27be sure that I wasn't being offensive.
01:17:29Change and it had to do with
01:17:30the use of the term queer,
01:17:32which as an old guy when I was young,
01:17:36growing up that term was only
01:17:38used to be cruel. It was not.
01:17:40It was not used in the academic setting
01:17:42and it was not used by the gay community.
01:17:44Perhaps it wasn't.
01:17:45I was unaware of it, I don't know.
01:17:47But my point is that that when I heard
01:17:49it mostly when I was very young,
01:17:50I heard it used as an insult
01:17:52and that's no longer the case.
01:17:54As you say, they have that the term
01:17:56has been taken back if you will,
01:17:57or taken over.
01:17:59By the LGBTQ community and
01:18:01and I recognize that.
01:18:03But whether or not it was
01:18:05appropriate for who?
01:18:05Who could use that term,
01:18:06when appropriately and fairly without
01:18:08being insulting with part of that was
01:18:10just feeling comfortable with you and saying,
01:18:11listen,
01:18:11here's something I don't think I I'm,
01:18:13I'm up to speed hunt so help me with
01:18:15this because of how I use this,
01:18:17but I my answer to this question
01:18:19actually is where this is good because
01:18:21you wonder what good are us old guys?
01:18:22And this is where us old guys
01:18:24can actually do some service.
01:18:26Because and I've coined a term
01:18:28in my teaching.
01:18:29Of moral arthritis,
01:18:31and we get this as physicians in particular,
01:18:36in that we get more.
01:18:39It gets more and more difficult
01:18:41to be flexible.
01:18:42And when you, when,
01:18:43when I'm teaching a 24 year old medical
01:18:46student, listen, you should not do X.
01:18:49And here's why.
01:18:50The 24 year old medical
01:18:51student here is that right?
01:18:52Well, that's a good argument.
01:18:53OK, we go back and forth and she decides.
01:18:55OK,
01:18:55I'm not going to do X when I'm
01:18:57talking to a 54 year old physician
01:18:58and say you should not do.
01:19:00X and here's why.
01:19:02Well,
01:19:03now he hears this and he thinks,
01:19:04Oh my God,
01:19:04I've been doing it for 35 years or 30 years.
01:19:07And now you're telling me I shouldn't?
01:19:09And does that mean I'm a bad person?
01:19:11Set me now as a bad doctor and
01:19:12this is where it's a little bit
01:19:14helpful to have an old bioethics
01:19:16professor because I can say,
01:19:17you know what I used to do
01:19:19ex all the time too.
01:19:20You know what I thought when I was a
01:19:23young physician that this a baby like this.
01:19:25It was a surgical emergency.
01:19:28Do you know what this is?
01:19:29What I did this but it's OK.
01:19:30We've got to have some moral
01:19:32flexibility and and rec and
01:19:33the key to that is recognizing,
01:19:35I guarantee,
01:19:35and I guarantee to every 30
01:19:37year old who's listening that
01:19:38you're wrong about a lot of stuff
01:19:40and you'll figure out when you're 60 that you
01:19:43were wrong about it when you were. It's OK.
01:19:45So as soon as you realize I'm going to I am
01:19:47wrong about a lot of stuff your whole life,
01:19:49it's less painful to acknowledge you've
01:19:51been wrong about a particular thing,
01:19:52even if you've been acting on that,
01:19:54there are, I mean,
01:19:55and we get this in medicine.
01:19:57Aside from the bioethics we get this in
01:19:59medicine in general that for most things.
01:20:01We don't treat them the way we
01:20:03treated them 30 or 40 years ago.
01:20:04That's OK, we learned.
01:20:06Was, you know, as as you know,
01:20:07better you do better.
01:20:09As a wise woman once said.
01:20:10So as we learn more,
01:20:12we change and it's got to be the same thing.
01:20:14With these bioethics things.
01:20:15And this is where I think it's
01:20:16helpful when someone say,
01:20:17really, you know,
01:20:18you used to take money used to
01:20:20take free dinners all the time
01:20:21from the from the drug companies.
01:20:23Yeah, I did too,
01:20:24you know,
01:20:25but I'm starting to think maybe
01:20:26we shouldn't be doing that because
01:20:27of XYZ and that sort of thing.
01:20:29I like that term moral authority. That's
01:20:32right, it's like I gotta
01:20:33write it down somewhere.
01:20:34I think it may have appeared
01:20:35something I wrote maybe not.
01:20:36I've been using it in lectures
01:20:38for for in recent years.
01:20:40Anyway, that's my take.
01:20:42I want to get one more question in at least,
01:20:44and this is from Sarah Hall,
01:20:46who is one of our associate
01:20:47directors of the bioethics program.
01:20:49I appreciate your point about reversibility
01:20:52concerns being disproportionately
01:20:53salient when it comes to gender and
01:20:56reproduction related procedures.
01:20:58I perceive this to be a reflection
01:20:59of the fact that our patriarchal
01:21:01society frequently does not
01:21:03grant true autonomy to women and
01:21:05queer folks to the same extent
01:21:06it does to assist hetero men.
01:21:10Can you?
01:21:11Talk a bit more about this and
01:21:13how it might be reflected in
01:21:15other areas of healthcare,
01:21:16such as reproductive rights,
01:21:18specifically negative reproductive rights.
01:21:22Yeah, great point.
01:21:23It's just had cisgender heterosexual is
01:21:27the the short term that's had there.
01:21:30And I think you're absolutely right.
01:21:33I mean, I think this reflects the
01:21:35patriarchal structuring and which we
01:21:36expect people to act a certain way.
01:21:38And when they don't, you know we kind
01:21:40of threaten us too strong of a word,
01:21:42but we say you may regret this.
01:21:44Like all women want babies,
01:21:46you know you're going to want babies or
01:21:47all girls want to grow up to be little
01:21:49girls like you're going, you know.
01:21:50And I think this is true in
01:21:52other areas of health care.
01:21:53Like you pointed out,
01:21:55reproductive rights for sure.
01:21:56A colleague of mine has written
01:21:58a whole book on abortion,
01:21:59regret and how that has been used.
01:22:01The law to limit abortion rights
01:22:04even though we know that very few
01:22:07folks regret their abortion the vast,
01:22:09vast, vast majority 90 I don't
01:22:11know the exact number.
01:22:12Percent say this was the
01:22:14right decision for me,
01:22:15and if they do have any negative feelings,
01:22:18it's usually like I wish I
01:22:20hadn't been in that situation.
01:22:21But I made the right decision for me.
01:22:23And so we see this in all
01:22:25different areas also, just.
01:22:28You know in women's healthcare where
01:22:29women are are being thought that they
01:22:31don't know what they're talking about.
01:22:33So for a lot of health conditions
01:22:35where women are misdiagnosed or
01:22:36undiagnosed for for many years and it
01:22:39takes them seeing X number of doctors
01:22:41before someone says you know what I think I,
01:22:43I believe you this idea that
01:22:45like we just don't trust women
01:22:47to make their own decisions.
01:22:49You know when they report their
01:22:51symptoms that no, you know it's it.
01:22:53Don't worry, it's not your heart.
01:22:55It's just your indigestion.
01:22:56Or you know, no, you didn't.
01:22:58Like your register just
01:22:59been out gardening too much,
01:23:00these sorts of that I'm using.
01:23:01Obviously some hyperbole here,
01:23:02but this idea that we just we don't
01:23:04trust women and that and we don't
01:23:06trust queer folks either, right?
01:23:07We don't trust them to report
01:23:09these sorts of things,
01:23:10and we don't trust black folks
01:23:12because they like the list
01:23:13goes on of marginalized groups,
01:23:15and I think that pervades all
01:23:17areas of healthcare.
01:23:19And is why they often aren't
01:23:21believed and often get poorer care.
01:23:23And then why they don't feel like they
01:23:25want to share things because they're
01:23:26not believed when they do share things.
01:23:29And so it prevents them
01:23:30from seeking future care,
01:23:31so I don't know if that fully
01:23:33answered that question.
01:23:33But I think it's a really important point.
01:23:36Thank you very much.
01:23:39I'm going to try and get two
01:23:41more two more points comment that
01:23:43I'm going to try and go quickly
01:23:44here that are recent speaker.
01:23:46Let me just see pull this up
01:23:48because I want to make sure I yes
01:23:50a recent speaker on transgender
01:23:51stated that this gets to our point.
01:23:53Quote up to 40%.
01:23:54Decided to reverse their
01:23:55decision sometime an adult life.
01:23:57What are your comments?
01:23:57I think you've kind of commented.
01:23:58You think that's a much overestimated.
01:24:02Well, I can send you some of the
01:24:03literature that shows that again,
01:24:05there were some flaws there,
01:24:06like people didn't report back to
01:24:07the study were then considered as
01:24:09detransitioning even though they just
01:24:11didn't continue to participate in the study.
01:24:13So I think there were some real errors
01:24:15there and that gets misconstrued.
01:24:17Thank you, OK, and here's this will
01:24:20be the last question. Do you feel
01:24:22there any particular considerations?
01:24:24Especially that clinicians may overlook
01:24:26for supporting kids while they're
01:24:28exploring their gender identity before
01:24:30they fully realize their identity.
01:24:32You know, EG kids who think they may
01:24:34be gay or bisexual, trans, etcetera,
01:24:35but aren't yet sure and therefore
01:24:37are hesitant to discuss this with
01:24:40other any particular considerations
01:24:41or guidance you might give.
01:24:44Yeah, and so I think this is where
01:24:47just normalizing this and having this
01:24:49conversation young and starting to
01:24:51talk about these sorts of things.
01:24:52So one little thing you can do is you know in
01:24:56your office if you have pictures of families,
01:24:59have a queer family out there
01:25:00have different types of families.
01:25:01So then if the kid asked, oh wait,
01:25:03that kid has two daddies.
01:25:04Oh, I didn't know that was a thing.
01:25:06Oh great it is. Or, you know,
01:25:08have a rainbow flag and then they can.
01:25:10I love rainbows.
01:25:10What does this mean?
01:25:12Just normalize it?
01:25:12Make it part of your everyday.
01:25:14And I think that will set the
01:25:16tone that this is a place where
01:25:18they can go and be comfortable.
01:25:19And also you know.
01:25:21Try to respond in a positive and
01:25:23open way which I know you all do.
01:25:25But you know sometimes we can be
01:25:27a little surprised by some of
01:25:29these things and back and then
01:25:31close people down there and then
01:25:32afraid to talk about it again.
01:25:34If they get a response that
01:25:35they weren't anticipating,
01:25:36which they might get from their parents,
01:25:37right that if they bring this up,
01:25:40their parents might shut
01:25:40down and they think oh,
01:25:41this is something bad to talk about.
01:25:42So again,
01:25:43if you approach it because they might
01:25:45be too nervous and just say hey,
01:25:46have you identified,
01:25:47do you see yourself as you know
01:25:49a girl or boy something else?
01:25:51What would you like me to call you?
01:25:52What name do you prefer?
01:25:54And you do that for all kids.
01:25:55It's because my name is too right.
01:25:57It might help them.
01:25:59That's great, thank you so much.
01:26:00You know Lisa, given the hour.
01:26:03I'm just going to say that this was a.
01:26:04This was a marvelous session.
01:26:06I think a lot of us learned a lot.
01:26:08I know I certainly did.
01:26:10This has been really helpful
01:26:11and the time went by so quickly.
01:26:13But before we close out our two things,
01:26:16one is I see behind you all these pictures
01:26:18of all these wonderful places you've been.
01:26:20You were telling me before
01:26:21we started the session,
01:26:22but of course the one that's
01:26:23missing is sunny New Haven.
01:26:25So someday soon, when the world
01:26:27is a little bit nicer for travel.
01:26:29That we're going to get you to heaven now.
01:26:31Next time you do one of these,
01:26:32I want to see a picture of that's
01:26:34right of Cedar St behind you.
01:26:37But in the meantime,
01:26:38we'll thank you for doing this long distance.
01:26:40Thank you very much and I want
01:26:41to give the opportunity.
01:26:42If you have any closing
01:26:43thoughts you want to share with
01:26:44us. Yeah, and it's been a pleasure.
01:26:46Thank you all for participating.
01:26:47I think the two take home messages really,
01:26:49are you know how important it is to be
01:26:53supportive and to listen to kids voices?
01:26:56Because often they do get,
01:26:57you know you don't know you're going
01:26:58to change your mind when you're older,
01:27:00so those two takeaways.
01:27:01Thank you so much.
01:27:02Really appreciate it.
01:27:04Doctor Lisa Campo engelstein.
01:27:05Thank you very much.
01:27:07We will see you again sometime and
01:27:08thank you all for joining us tonight.
01:27:09We'll see you in a couple weeks.
01:27:11Thanks Goodnight bye everyone.