The Checkup with Doctor Mike - The Science Of Transgender Healthcare, Puberty Blockers, & Conversion Therapy | Dr. Jack Turban

Episode Date: June 19, 2024

Follow Dr. Jack Turban and buy his new book "Free To Be: Understanding Kids & Gender Identity" here: Instagram: https://www.instagram.com/jack_turban/ Twitter/X: https://x.com/jack_turban Free To Be: https://www.simonandschuster.com/books/Free-to-Be/Jack-Turban/9781668017043 00:00 Intro 01:18 The Basics 24:20 Defining Your Gender 28:45 Treating Gender Dysphoria 32:04 Cognitive Behavioral Therapy 45:32 De-transition 57:09 Alternative Explanations For Gender Dysphoria SUICIDE 1:07:201:07:17 Misogyny of Gender Identity 1:11:43 Affirming Gender 1:19:20 Treating Children / Puberty Blockers / Autism 1:35:16 USA vs. Europe / Cass Report 2:05:27 Exceptions 2:14:34 My Gender Identity / My Teenaged Patients 2:27:52 Transgender Athletes 2:49:40 Bathroom Laws 2:51:35 Two Spirit / Alternative Gender Terms

I think about how afraid I was to come out as gay when I was younger, and I didn't until college, but it felt way safer. And it was a lot safer for me to come out as gay than a lot of these kids to come out as trans. Surveillance video, the moment a man beat a trans woman to death. God created men, male, and women female. Confused kids being subjected to irreversible treatments. They're making it sound like kids are rushed into medical interventions or the doctors are, like, forcing puberty blockers on them.

Are doctors rushing patients into this? Let's welcome Dr. Jack Turbin to the Checkup Podcast. Dr. Turbin works out of UCSF as a leading expert in child and adolescent psychiatry. He's known for his extensive work on the mental health of transgender youth and his advocacy for evidence-based health care. He's also the author of a new book titled Free to Be Understanding Kids and Gender Identity. In this conversation, I wanted to focus on something. topics that have been just under-discussed or discussed poorly given heavy political or ideological

polarization. Focusing on the science only, we go in-depth covering gender affirming care, puberty blockers, transitioning during childhood, transgender athletes, anti-transl legislation, and so much more. Join us as we uncover the crucial truths about mental health, identity, and the path to inclusive care. Let's start off by setting the table and getting some explanation. for certain terms that we're going to use throughout this conversation, because what I found is a great part of the disagreement and discussion that has taken place largely surrounds misunderstanding. Semantics. Semantics, vocabulary, nomenclature. That's actually a lot of science. So we're going to be using a whole lot of terminology throughout the conversation. I want

folks to be aware of it. And this is a good lecture for me, because despite being a family medicine doctor that sees patients of all ages, of all demographics. I never had a really good quality lecture on transgender care. And I feel like this is a great place to start for doctors, non-doctors, because it's going to be pretty universal in the explanations. So when we're talking about an individual who's struggling with either their sex, gender, gender identity, can you take us through the levels of that? Yeah. I think there are four, terms that are important. So there's sex or sex assigned at birth and it has a bunch of different definitions, right? So you could use sex chromosomes as your definition. You could use

external genitalia. You could use internal sex organs. You could use hormone levels and that creates all this confusion. So we usually just go with what's on someone's birth certificate while recognizing that there are complexities where those don't all align for everyone. Yeah, it's interesting that we have not yet found a conclusion? On which term we like? Yeah. Why do you think that is? I think it's just that there are all these different variables and for most people they align, right? So most of the time, it's okay or not a huge deal to conflate those different domains of sex. For most people, their sex chromosomes predict their gametes predict their external genitalia. But if you work in gender medicine or if you work with intersex people, it's just

important to recognize that those aren't all the same for all people. Is it wrong then to say since it is concordant for the wide majority of people to say that that is the norm and then there are conditions that fall outside the norm but we can still use vocabulary. Norm feels harsh because it's kind of pathologizing I think but we can say it's most common. Can we totally fair. I know we get very worried about creating pathology or labeling pathology, why are we so afraid of being outside of the norm? Whereas in certain aspects, we celebrate being outside the norm, in other aspects we're afraid of it, or maybe it makes us feel bad about ourselves, what do you think drives that? Yeah, you're just a nice person, I think. So, right, that's how I think too. So this comes up

all the time with should gender dysphoria be in the DSM. So gender dysphoria is technically a mental health condition in the DSM. The reason we have it there is there are a lot of people who are really psychologically distressed from their gender identity being different from their sex assigned at birth. And then we want them to be able to get mental health treatment and gender affirming care, et cetera. So it's in there largely for insurance purposes. However, people weaponize that all the time and then say being trans is a mental illness. It's bad. We shouldn't affirm people. We shouldn't treat people as their gender identity, which is not what we mean in the DSM.

And when I see it in there, I think, well, you shouldn't pathologize gender dysphoria the same way you shouldn't pathologize bipolar disorder or depression or schizophrenia. But then, you know, a lot of people would come back in me and say, are you living in the real world? We do stigmatize all of those things. And so it creates a real problem when we do label things

as pathologies. You know, there shouldn't be stigma attached to it. But in the real world for patients, there just is. I absolutely see the stigma and that's something we fight back against it on the channel so often. Does the fact that stigma exists

mean that we shouldn't call it a pathology? Do you have a specific example? Well, like you mentioned bipolar disorder. To say that this is a pathology, one that people could benefit from treatment for the pathology, stigma surrounding the pathology, certainly wrong.

But to call it a pathology, is that technically inaccurate, medically inaccurate, wrong, ethically by any means? So a big thing that happened in psychiatry is we got a lot of flack for calling things pathology that people didn't think were pathologies. Can you give us an example of that? I don't know what you're going to say, but... Gender dysphoria is a good example. It actually came up a lot with different substance use.

So I think it was the nicotine lobby. I mean, this is an example where we should call it a pathology because nicotine is addictive. psychiatry got a lot of backlash for calling a lot of things that people commonly do. What about sexual preference? Well, maybe not sexual preference. Homosexuality is what I thought you were going to reference. But then the way they kept that in later, which is kind of the same with gender dysphoria, is saying like if you have egotestonic homosexuality, if you're upset about your homosexuality, that is a pathology, which on a certain level, yeah, we don't want people to be upset. So ultimately what they did in the DSM-4 was they added this

criterion to almost every single diagnosis that you need to have impairment and functioning from your condition. So for gender dysphoria, you have to be distressed about your gender incongruence and then also have some sort of distress around that that causes impairment and functioning. And I think it's logical to call that a pathology. But again, the problem is it just constantly gets misinterpreted that people think what we're calling the pathology is the fact that the person's trans, not the sequelae that are coming. from. Sure. And I think then in common tongue, we start using medical terms, not in the way that they were tended to be used, which happens very frequently with our vocabulary. That's why

vocabulary needs to shift. And that's why I think it's valuable that we kickstart the conversation because this is the biggest nightmare in general medicine. Is there so many times where we have a technical term or the way we use certain language, that's not how the general population uses language. and then it just creates a ton of confusion. Right. So we have sex being either chromosomes, gametes, but in the end, we end up with birth certificate. Let's do birth certificate.

Yeah, birth certificate. And usually the birth certificate is representative of all those things unless you fall into a unique category of a medical condition. Exactly. Next, gender. Where does gender fall in that spectrum? So the way I use gender, and people use it a million different ways, but I use it as a shorthand for gender identity.

So one's psychological sense of themselves and their identity in relationship to masculinity and femininity. It sounds like an easier definition than it is. And so I think of it as having three parts. The first part being like a transcendent sense of gender identity is what I call it. It's just that feeling of being, you know, male or female in a way you can't put into words, like almost like an emotion.

You just feel male or you feel female. And I think people feel that to varying degrees, like most different mental health measures that we look at. Then there is how you relate to gender roles and expectations. I think of that as like your social gender identity. And then that has a million different domains too, right? Because we have, we put everything in these male and female social categories like colors and toys and if you're assertive or if you're emotional, et cetera. And those things are all super fraught, right? they get into stereotypes.

So that's the hardest one to talk about are people's social sense of their gender identity. And then the third part is how you relate to your physical body. So your primary sex characteristics are the sex characteristics you're born with,

like external genitals that we talked about. And then secondary sex characteristics are things that come from puberty. And so how you feel about those parts of your body is also part of it. And as you can imagine, these things are all really complicated

and intertwine. But your gender identity is how you conceptualize yourself. in relationship to all of those things. Would you say gender identity is binary? No, right? Because it's these, not only are there these three categories, like your transcendent sense, your social sense,

your physical sense, but within those, there are so many different things, right? So within, and it gets so complicated. Because how you relate to gender roles and expectations is different culture by culture. You probably don't relate to every single, like, masculine social characteristics. right? I don't know that I've met anyone

who relates to all of the things that they're given social group or society considers masculine or feminine. So that one's like infinitely complicated. And then what we know from working with trans patients is that even

the physical one can be kind of complex. So some people might be really, really distressed by their chest but not so much by their genitals for instance. Because it's reasonable to say based off that definition you could take someone into a different year, a thousand years ago or perhaps in a different part of the world

and they might feel differently about their gender identity based on the culture they find themselves in. Yeah, and it might even change for a given person across their life, right? So I give the example, and it's not just trans people, right? It's just gender people have gender identities also that are really a complex mix of these things.

So I'll give the example, like a 18-year-old woman probably thinks very differently about her womanhood than, you know, when she's maybe later in midlife and has three children. I had a psychologist across for me not too long ago, Dr. Alima too, and he talked about how it's important to have less things that we consider our identities. And he wasn't talking about gender specifically. He was talking about I identify as a doctor.

I identify as a psychologist. I identify as an Indian American or whatever these different identities were. And he thought that the more identities we had, the more pathology that then can be created. Do you vibe with that notion or do you feel like that's an overread of the situation? What's the pathology example from that? You would oftentimes have to overact in order to stay true to your identity. So if someone challenges your identity as a doctor, you can get offended and create anxieties and depressive symptoms as a result. someone challenges your identity as a man, it can create all these symptoms. So the less identities

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Goldfish have short memories. Be like goldfish. I guess I could see that, but I don't necessarily think that you need to be so rigid about every part. of your identity. Like I was saying, like your conceptualization of your masculinity

could change over time and that's okay. And I think also just different people, I don't know if that's a realistic thing to ask people, right? Because we,

everyone has things that are important to them as part of their identity. I don't think you can tell them to just make that not part of their identity. Well, I guess the question more specifically is

what is the value in thinking about our identity often? or just thinking about it in general? I don't think you have to necessarily, but there probably are times when you do. In which situation would that happen? You probably think about your doctor identity

when you're at the hospital. It's important. You probably think about your gender identity when you go out in public and people are treating you a certain way based on how you express your gender, for instance. And for the individuals that are going through a gender identity situation,

where their sex that was on their birth certificate does not match up with what their gender identity currently is, that can become a mental health issue. Sometimes yes, sometimes no. So there are trans people who have a gender identity that isn't in alignment, if you will, or it's incongruent with their sex assigned at birth who are doing great.

There are a lot of people in my book who are doing amazing. So Nicole Mainz is in my book. She had gender dysphoria in the past. She was really distressed with her body not aligning with her female gender identity. But she got puberty blockers and hormones. And now she's a TV star. She was the first trans superhero on TV. She was just on yellow jackets.

She just had a book come out. And she is not depressed. So, right, for some people, they're trans and they don't have mental health problems. And then for other people, they do. particularly, and often that distress is from societal stigma or from that dysphoria, if you will, that comes from your body not aligning with the way you feel in terms of your gender identity. So if you are in a situation where your sex and your gender identity are incongruent, there has been the term gender dysphoria, gender incongruence being presented.

What do those two terms specifically mean and how are they different? So gender dysphoria is in the DSM. It's the psychiatric diagnosis, and it means that you have a gender identity different than your sex assigned at birth, and you've had it for six months, along with psychological distress that causes functional impairment of some kind. A lot of trans people were pointing out that they didn't have impairment in functioning. They were doing really well in large part because they were on gender-faring medical interventions, and technically, because they were doing well, one could say, oh, you don't have gender dysphoria, so you don't qualify. for these medical treatments that you're taking, so you'd have to stop them. And so the ICD moved towards this term

of gender incongruence that took away that distress criterion. That's so weird that that happened because if I have a patient who's hypertensive and I give them anti-hypertensive medication and they're normatensive now, they have a normal blood pressure, I would still call them a patient who has hypertension just on treatment.

Probably, yeah. I mean, the way I think about gender dysphoria also is if you read it, I think there's an interpretation that if the person anticipates that they are going to have more gender incongruence, like if their body's going to start developing in a way that doesn't align with their gender identity and that

would create distress, then you could meet the criteria. But I think there's another reading that people are concerned about. Got it. And then where is the term transsexual come into the conversation? Transsexual is pretty old school. We don't really use that term so much.

although I'll say... Why has that happen? So there are some people who do still personally identify with that term to specifically mean a transgender person

who's had gender-forming medical or surgical interventions. Okay. It's not a lot of people who still identify with that term largely because it was

weaponized and stigmatized for a long time and most people relate more to the term transgender now. Okay. So some people might use

transsexuals as a distinction for people who have sought out medical or surgical interventions. Transgender, people also use differently. So some people use it to mean you have a gender identity that's opposite your sex assigned at birth. I think most people's gender identity is more complex than that,

but I'm not going to tell somebody if they feel like their gender identity is binary that it's not. And some people truly feel that way. And so they use transgender to mean opposite in that way. I would say most people now use it as a broader umbrella term for anyone whose gender identity doesn't strict. align with their sex assigned at birth. So a lot of non-binary people would consider themselves transgender.

Others will not, you'll notice that it's really hard to define the terms because people use them differently. But I think for our conversation, let's use transgender kind of in the broad umbrella term, because that's usually how I use it, to mean anyone who's not cisgender. Okay. And the idea of someone being cisgender is also technically inaccurate based off your definition, am I right? because there are so many ways that gender could exist

that what does cisgender actually mean? Yeah, I think of it as a shorthand. And there's a big generational divide also. So that is another reason I wanted to write the book. Because I think often parents and kids are talking right past each other when they're talking about gender. So a lot of young people have this broader conceptualization of it, but older generations weren't taught to think that way

and they don't think about it that way. I think the way a lot of older generations, think about it is they use kind of transgender or cisgender as a shorthand. So if you take all of those factors and the vast majority of them align with your sex assigned at birth, you might call yourself cisgender. If you look at those and in some, you're like closer to the gender different than your sex assigned at birth, maybe you identify as cisgender or sorry as transgender. And how does that fall into the categories when one individual perhaps in your three defining characteristics of gender identity.

If someone believes that they are involved or enjoy a lot of the things that the different sex would enjoy. So the classic example that's given is someone is a tomboy. They're a girl that is at birth, a girl who loves playing male-esque sports by tradition, perhaps likes male dominant activities, which even saying that is not really technically accurate. It's kind of just our cultural definition. And then maybe even is homosexual in that regard from a sexual preference standpoint.

By the way, sexual preference is the right term to use when I say. We usually use orientation. Sexual orientation. So from sexual orientation perspective, how does that differ from someone who views their gender identity as incongruent? Yeah, both of those people exist, right? There are people who feel overall cisgender and break a lot of gender norms and identify cisgender or tomboys. I think one thing that's misinformation is people think we're like sitting those kids down and saying you're transgender, you should take testosterone, which we would never do. And then there are other people who have that physical gender dysphoria, right, where they're distressed about their bodies and maybe they also have that like transcendent piece where they just really feel, in a way that's hard to put into words.

And those are two different kinds of people to make it even more complicated. There are trans people who are tomboyce, right? So there are trans women who don't like a bunch of traditionally feminine things. Like they don't like makeup. They don't like ballet, like whatever. But they still have this deeply felt sense

of their like female gender identity. So they'll have two of the three categories more in line. Potentially, yeah. Yeah, that makes it really complicated. It is complicated. I'm also wondering what impact upbringing has in a situation like this because I wasn't raised by a generation that talked necessarily about gender identity. So it's not something I ever put a lot of thought into or emphasis into.

And now with generations talking about this more openly on social media, on television, in schools, Does that change one's identity as it builds off of a foundation genetically and then creates scaffolding, if you will? Yeah, I think it changes the way people ascribe language and think about it. So I think of that transcendent sense as being biologically determined, mostly because of these twin studies, where we compare people who are monazygotic twins, so the same DNA, people who are dysogotic twins, different DNA. And then twins are generally raised in the same environment. So these twin studies are thought to separate innate biological factors from environmental factors. And those studies find that if you're an identical twin, your twin is in your transgender.

Your twin is way more likely to be transgender than if you are a fraternal twin. How much is way more likely? No, it does. I'm curious when it's a monozygotic, what is the rate at which there is both being transgender? So they do some math that comes out to, they think it's like 70% increased chance. Biologically determined for gender identity. Interesting. And then in the multiple scenario, when you have two zygotes, what happens there?

Like if you, so the way they do the math is they compare the rate in the monozygotic twins with the rate in the dye zygotic twins and that's how they get the 70%. Oh, God. But I have to look up what they exact. So they're comparing twins to twins, not twins to general population. Correct. Yeah, because you want to see, do identical twins of trans people, are they way more likely to be trans than non-identical twins of trans people? I think the simpler way of putting it is identical twins and siblings.

Yeah, they try and do for turtle twins because they want them to be more closely related, right. But that's almost like in a similar comparison for my simple mind to follow it. So that's interesting. So there's a 70% genetic background to someone's thought of how they view themselves from a gender identity standpoint. So I would say those, like two transness, if you will, is the best way I can put it. And because that's something that's there when you're born, that's what I think of as this like hard, because you don't have language at that point. So I think of that as being your feeling transcendent sense of gender, you're born with. But you could imagine that then you build on that through life experience and

that's going to be really different depending on the society you grow up in. So this is another thing that throws people for a loop. So there's been this huge increase in kids who identify as trans, but you have to look at how they're defining transness. So they're not all identifying as binary and having physical gender dysphoria and wanting gender-faring medical interventions. So there are a ton of kids who the way they're describing their gender identity is way more about the social part. So I have a lot of kids who identify as non-binary, but they are totally happy with their bodies and don't want gender-faring medical interventions. But for them, it's really more like a way that they express that they don't relate with all these societal expectations that we think of as masculine or as feminine. and they're ascribing language to that

to describe themselves in a more nuanced way. But it's a different kind of kid, right, than the kids who have that physical gender dysphoria and what medical interventions. How do you measure or ask the transcendent portion of gender identity? There are a couple ways. So first we just describe it

and then there are a few different ways I've seen it manifest for people. So sometimes people draw themselves as a certain gender and there's this like oh wow like this is me in a way i can't put into words or sometimes people will use a new name and pronouns and it'll feel really like euphoric like gender euphoria you'll hear sometimes or people will use their birth name and pronouns and it'll just feel really wrong in a way that's hard to put into words and then some people it's not necessarily any of those but they'll say like i don't know how to tell you this but i just feel

male or I just feel female and we spend all this time educating them usually it's like with a big eye role because they're very aware but talking about all the ways you can be in the world right you can be cisgender and defy gender roles you can be transgender and feel like you need medical interventions you can be transgender and feel like you don't need medical interventions

um right I think there's this misconception that kids are confused or like don't know those things but we very explicitly sit down with them and talk about all of those things and it's very rare that they look at me and they're like dr turban i didn't know you could be trans without medical interventions or i didn't know i could be a tomboy the few times that it does get a little bit more complicated is if you have a patient who say has autism that is severe intellectual disability or different reasons that they may have more cognitive rigidity that they maybe haven't thought about these things with as much nuance. And so that's part of the reason that the W-Path guidelines, the big guidelines that we follow recommend that there's this

mental health evaluation prior to starting any medical interventions, both because you want to make sure that you really understand this person's experience and that they know everything they need to know. And then also because if they need supports besides gender-forming care, right? Sometimes the kids have anxiety or depression or bipolar disorder or PTSD that you want to make sure you're giving them all of those supports also and all these non-medical supports. We don't talk about that nearly enough. Sure. So the best predictor of a trans kid having good mental health is if their parents accept them.

So as much as we focus on these medical interventions, which are linked to better mental health outcomes, if I can get their parents to love and accept them and be able to have an open conversation and really see and understand them, that makes a huge difference. So that is a huge focus of the work, making sure that they're not being bullied, making sure that their community accepts them. It's really kind of like a broad package of gender affirmation that we're offering. It's a holistic care model. How does a child know or present by saying,

I would like to be, or I am trans and I would like medical intervention versus I don't want medical intervention? How would they know that without you educating them? Because you said they know. They know. Well, you said, like, a lot of times you'll sit down to educate them about the different ways to be trans or their transness, and you sometimes feel weird doing that because you feel like they know.

Oh, like, how do they know that tomboys exist and can be different than trans? Well, not necessarily tomboys, but, like, the idea that they could be trans and have medical intervention or not have medical intervention and still be successful. Because frequently this has talked about, I don't know how accurate this is from a percentage standpoint, but there are children who believe that unless they get medical intervention,

they are not being treated for their condition. Pumpkin is here at Starbucks, and we're making it just the way you like. Handcrafted with real ingredients like our real pumpkin sauce and rich espresso, sprinkled with pumpkin spice. It's full of real flavors you'll keep coming back for. Made just for you at Starbucks.

Bank more oncours when you switch to a Scotia Bank banking package. Learn more at Scotia Bank Bank Banking package. Thank you.com slash banking packages. Conditions apply. Scotia Bank, you're richer than you think. They're not being treated for their kid. Well, I guess if they were a kid who's really distressed about physical gender dysphoria, like their body not aligning with their gender identity, and I'm not addressing

that, then they're right. You know? Like if they have physical gender dysphoria and also. generalized anxiety disorder and I'm doing CBT for generalized anxiety disorder but ignoring the fact that they are constantly distressed about their physical body then that's true I'm not really addressing their problem so are there ways to address gender dysphoria without medical intervention so not the gender dysphoria itself right so I can treat the other co-occurring conditions in an evidence-based way.

Like, if they have generalized anxiety disorder, I can do CBT for anxiety. If they have major depressive disorder, I can give them an antidepressant. But those things don't fix this fact that their body doesn't align with their gender identity that's causing distress. And this is another thing that I think gets weaponized

and turns into misinformation is people say, do therapy for the gender dysphoria. And it comes back to this other question of like, what is the gender dysphoria? Is the gender dysphoria that you are trans? Or is the gender dysphoria, the sequelae of being trans? And what people are often implying by saying do therapy for the gender dysphoria is to do therapy for being trans. And so we published a study in JAMA psychiatry back in 2019 where we looked at people who were exposed to that practice. So people where we had 27,000 trans adults. We looked at only those who had spoken to a professional about

their gender identity, and we compared those where the professional tried to make them cisgender to those where the professional did not. And for those who tried to force the people to not be trans, they had a greater odds of every bad mental health outcome we looked at, including suicide attempts. So there's not, and there's no evidence that that therapy works either. So it's both associated with bad outcomes for the people who continue to be trans, and there's no evidence that it makes you not trans. So there's not a therapy for the being, trans. Right. Because that is essentially conversion therapy. And conversion therapy does not exist. And in fact, when a medical society or a medical organization says psychotherapy should be

part of someone's treatment who is seeking gender affirming care, it doesn't mean that they're trying to convert you out of gender affirming care. What the psychotherapy is is usually doing this comprehensive psychosocial assessment that we start with that is trying to understand their gender history, understanding if they have any co-occurring conditions, et cetera. And then also helping them deal with the stigma that they face, right? So if they're being bullied, we address the bullying. If they have started to have internalized transphobia, that happens all the time, right? Especially recently.

So I have kids who are reading the news and the news is saying that being trans is a mental illness or it looks like state governments are targeting them or saying that they shouldn't use the bathrooms that align with their gender identities because they're sexual assailants, right? All these awful things. That starts to seep into your mind and cause anxiety and depression. We can treat that with cognitive behavioral therapy. But again, we're treating more what we call like the minority stress and the sequelae of being trans rather than the fact that they are trans. And again, if they have physical gender dysphoria, like if they are distressed about their body, not a lot of with their gender identity, and I'm only focusing on their internalized transphobia,

that I'm not addressing everything that's going on. Is, like in cognitive behavioral therapy, the way that I understand it is there are certain things from an outside perspective that make us feel a certain way. And sometimes we have to either talk back to our feelings or write back to our feelings. And someone can have negative emotions about their physical appearance. Someone can have negative emotions to how someone else treats them. And part of what CBT does is help someone cope to develop flexibility in their thinking. Is that a fair assessment of what CBT is aiming to do? It is. And some people have pointed out that that can get you in trouble with minoritized patients in particular. So John Pichankas at Yale published

this great paper talking about all the pitfalls you can run into with CBT. For instance, if somebody experienced a bunch of harassment and discrimination, even violent victimization for being trans, you wouldn't, and so they have this idea, people are going to attack me for being trans that's causing them distress. And you challenge that thought that's causing anxiety and you sat them down and said, there's no violence towards trans people. Like, let's kind of re-structure that. that kind of gets you into trouble. So there's been a focus recently on how can we adapt CBT specifically to not hit some of those pitfalls

from my experience with CBT and I've gone through CBT myself personally as well as seen patients, many patients go through CBT. A lot of it is trying to be as rational as possible. So to say that if you're in a transgender or a different minority community and you're not experiencing negative outcomes,

like diminishing that? I feel like that's not part of CBT. It almost would be discounting reality. Is that fair to say? Yeah, it gets a little more. So there's one thing in minority stress theory called anticipatory anxiety, where if you were somewhere

where you experienced all that harassment and discrimination because you were trans, and then let's say you move to the Castro in San Francisco, where it's way less likely that you're going to have that victimization, there is still transphobia in that environment. So if we were to sit the person down, it is true, right,

that you are less likely to experience that here. But if you were to kind of classically do like a CBT thought log and challenge that idea, you could potentially be doing harm by kind of sending this invalidating message that transphobia doesn't exist when it still does. So there's some nuance.

Yeah, absolutely. It seems like it needs to be tailored appropriately. And misuse of CBT is equally as bad as not performing CBT, if not worse, because you're trusting the person to be helping you who's giving you the CBT treatment, right? Yeah. But a lot of people don't, if you, like I have found it difficult myself to administer CBT sometimes for patients with minority stress. Let's say I have a patient who is trans and they were walking around their neighborhood.

and somebody walking past them pushed them. And they feel that that person pushed them because they are trans. I'm looking at that situation. I don't really know, right? It could be that the person pushed them because they're trans or it could be... Charitable thinking that that person was like in a rush and pushed past them. But what do I say to that patient that's going to be helpful? Because if I kind of lean too hard on this idea that maybe they actually were safe, that could feel super invalidating.

Can you be open to both scenarios? If I go entirely into the other one, then I could potentially be setting them up to like always be anxious in situations or maybe they shouldn't always be anxious. And yeah, you could kind of give credids to both, but then sometimes that just leaves the person really confused. Well, because the idea of it to me is that it should be a flexibility mindset. Like the comparison that flags in my mind is someone who came from a war zone and perhaps has anxieties for being in a high danger spot. Whereas if they come to me and they're like, I'm in a war zone, I'm very anxious. I wouldn't then tell them their worries are irrational.

Because they're in a war zone. They're in the military. It's a reasonable level of anxiety that they're feeling. But then if they come back to New York City, and they're feeling the same way. I can then say, depending on the neighborhood, depending on the circumstances where you find yourself in, only you can be the judge of that.

That's not my place to judge whether or not this area is more dangerous. How do you judge whether this is dangerous versus this is not and kind of work through that process? Yeah. I think it's just a lot easier to do that with kind of wartime, kind of veteran-type PTSD, because I can be pretty confident that they are safe from that here. Whereas with stigma and really stigmatized groups,

it's really hard. And there's gunshots often. It might not be as simple. So like, you know, they might hear a loud noise. You're like, how likely is that it's gunfire? Well, depending on what area you're in, it could totally be gunfire. Right. And this is where CBT gets tough, right?

Very tough. Because a lot of CBT is also about exposure therapy. Right. So what you want the person to do is go, right, they have this idea that if they do a certain thing, something bad will happen. So the classic example is I had a shark bite and now I'm afraid to go to like a lake just because it has that association. Of course. And so it's pretty easy to tell the person, let's do an exposure where you go to the lake and you see that you aren't attacked by a shark and then you feel better after. But for instance, I have patients where I'm trying to challenge their internalized transphobia.

And so maybe I want them to go somewhere and come out of the closet to experience that people accept them and love them for who they are. And they might not get that. But they might not get it, you know. So it's similarly difficult that if you were trying to, I mean, yeah, if somebody had PTSD from gunshots because they were deployed and they live in a neighborhood with a lot of gunshots, that's a really hard CBT to do. And so that's kind of a similar situation of what we. see with some of our trans patients. Yeah, I could see that being difficult because trying to lean into that situation saying, okay, what if it's a gunshot? How likely that gunshot is at you? What can you do to stay safe? How valuable is it for you to do that? And that thought exercise can go wrong in a lot

of different ways where, especially if the patient feels a lack of trust for, you know, a whole set of reasons, especially if they've been mistreated in the past. Or if you mess up the exposure. Yes, like if you go too far too fast. Or if you want them to go have the experience that it's safe and then it's not safe because the reality is just transphobia is awful and they are dealing with that all the time and it is kind of always present in there. Right. So I guess let's rewind a little bit backwards to my upbringing and I'm just using myself as an example. How does one's upbringing impact their view of their gender identity? Like is it fair to say, that now, because gender identity is more openly discussed, still stigmatized, but more openly

discussed than it was 30 years ago, that children are more likely to question their identity. Is that a fair statement to make? Or am I think so? Yeah, I think they're more likely to think about it. I think there are two things going on. I think in the past, we mostly saw these binary trans kids who had really, really severe gender dysphoria because it was so scary to come out. No one was talking about this. They had never seen another trans person. The only trans people they saw on TV were, like, people who were getting murdered. And so the kids we saw were the kids who had that really strong, like, transcendent sense of a gender different from their sex society at birth and had really severe physical gender dysphoria.

Like, they couldn't be closeted. Like, that was so much more intense than societal transphobia that they came and they saw us. And so, and they were really brave, right? there were a lot of kids where it was really intense but they just couldn't get past that. I'm so impressed with these kids, honestly. I think about how afraid I was to come out as gay

when I was younger and I didn't until college would have felt way safer and it was a lot safer for me to come out as gay than a lot of these kids to come out as trans and so it's a combination of super brave kids and just their gendered asphory being intense.

And so now that things have gotten a little bit, well, they were softer. Now it's getting worse again. With a little bit less stigma, I think more kids were coming forward who had that physical gender dysphoria. And at the same time, because we were expanding that notion of how we think about gender, we were also seeing more kids who in the past one of maybe even thought about this. You know, like they don't have intense physical gender dysphoria. They don't have this super like intense feeling around their gender. But because they were prompted to think about it, maybe they're the people who say, you know, like,

I don't totally relate with these masculine and feminine gender roles in society, so I am going to, to tell you the way I feel about myself, adopt they, then, pronouns, or identify as non-binary. Do you feel that there is a world where if we can flip a switch and make the world super accepting, remove all stigma, that gender dysphoria is no longer the same diagnosis? what would it be in the sense of those who are trans face a tremendous amount of bullying judgment lack of acceptance into culture and there is a notion that that is a large driver of their negative feelings and their negative mental health outcomes is it fair to say that i think it's two

things i think it depends on the person again of course but for a lot of people, it is both that societal stigma of people not accepting them for being trans and also their physical gender dysphoria. Got it. And it can be complicated and those things can get kind of tied up in each other. But, and this is impossible to answer because we can't like achieve that sadly. But I think working with patients who've had that really intense gender dysphoria, that's not only there when other people are around, you know, like people who often...

It's not an external thing only. Yeah, like it's also, I won't shower because I'm so distressed about me seeing my chest myself because this is not who I am. And when we talk about psychotherapy within gender affirming care, is it reasonable to try CBT for, as not a treatment to convert someone, but as a treatment to reduce some of that negative feelings surrounding one's physical dysphoria? Like the idea of that they're so scared to take a shower because they don't want to see their body parts

that they don't believe is part of them. Is there a world to do CBT or some kind of other psychotherapy to help with those negative feelings? Or is that you feel? I've not found it to be super effective. So I think there's this misconception that it's like this either

or medical interventions or mental health treatments based on the hate mail I receive. I think a lot of people don't really realize that my clinic actually doesn't offer any medical interventions, right? I run a mental health clinic where I give psychiatric medication management and CBT and all of these therapies that you're talking about. Of course.

I will say I've not found a lot of success in getting those feelings to go away or be easier with CBT. I found CBT to be helpful if the person also has depression or also has anxiety or if they're being really hard on themselves or if they're internalizing those transphobic ideas, those I think I can work on. I can give them some skills that aren't really CBT to work through that really intense anxiety around their gender dysphoria,

you know, like deep breathing or whatever, but I don't think I've ever seen a case where they're like this fixed it. Thank you. I've seen other psychiatrists talk about that they have seen therapies like that be useful in those conditions and perhaps as a way that if we don't institute medical therapy and let's say for certain populations we only do psychotherapy, that those feelings can potentially go away either on their own or with the help of psychotherapy. And it's not the fact that that person

becomes converted. It's just their negativity surrounding their body or their gender identity go away. Is that a reasonable take or no? I've not ever seen it. any data that that's true and it's not been my clinical experience. What is the current state of what they call desisting? Really complicated topic. So people, back to definitions. Yeah, we should define this one. So detransition has been defined a million different ways.

So in some studies, they use it to mean the person stopped a medical intervention, but people stop medical interventions for all sorts of reasons, right? if you were on estrogen and you got a scary blood clot, maybe you don't want to take estrogen anymore. Maybe you took testosterone for a period of time and your voice deepened and you developed facial hair and you're good. You know, you just don't need it anymore.

Maybe you lost your insurance. Maybe people were awful to you when you transitioned and you're going to go back to just presenting as your sex assigned at birth because it's easier. So, right, it could be you stopped the meds for a million reasons. It could be your gender identity changed.

It could be you developed regret about your transition or regret about the medical intervention. What we see all the time is people will take a study of detransition and change the definition they used in the study to say like 20% of people regret their gender affirming medical care when really is 20% of people stopped their medication for whatever reason. Right. And detransition is really complicated. So we've written a couple papers on this. And this is specifically starting and then stopping medical intervention. So I'm going to give the example of

a change in reporting your gender identity. Change in reporting your gender identity. So like saying you're trans and else saying your cisgender for instance. Okay. Change in like gender expression. And so we wrote two papers on this. One was in for the nerds in the audience. One was in the Journal of the American Academy of Child Adolescent Psychiatry. Another one was in JAMA Pediatrics, and we set up this like internal external framework.

So your gender identity or your sense of self could evolve into you feel non-binary, for instance. So we had a patient that we talked about in this JAMA pediatrics paper who felt like a trans girl, took estrogen for a period of six months, and then felt actually I'm non-binary. The estrogen was helpful for me kind of coming to understand that. but I'm going to stop it because I'm actually okay with how my body is right now. And there wasn't a lot of external pressure, at least that we could identify for that person that resulted in that change in how they conceptualize themselves.

Then there could also be external factors like you transition and you get harassed or you can't find a job or you're afraid you can't find a relationship. And it turns out that's really common, even among people who are currently living their lives as trans. So we did this study. we published an LGBT health and looked at the same 27,000 trans people and something like

13% of them had detransitioned at some point in the past because of some sort of external factor to make it even more complicated because nothing is ever simple in this what we know from minority stress theory is those external factors that external stigma

becomes internal factors right like as you're exposed to stigma about trans people you start to develop internalized transphobia or you start to develop shame around it. So there's the other possibility that you feel trans and then you enter an environment, say it's an environment that's very religious and says that being trans is invalid or there are these trans exclusionary radical feminist groups who feel that trans masculine identities are just a manifestation of internalized misogyny or that trans feminine identities are really just like cisgender men trying to invade

women's spaces. If you're told that constantly, constantly, constantly, you might think, oh, I'm not trans. That was my internal misogyny, for instance. And there have been at least a handful of cases where people were actually very, they were trans men, and then they identified as women and were very vocal anti-trans activists, and then said, you know, my gender dysphoria actually didn't go away. And then went back to, like, the initial transness, if you will. So it's a really kind of messy field to understand. Is there also a fourth option where they genuinely believed they were trans? And it turned out the reason they felt that was they had another mental health condition.

They felt terrible. They sought a definition for why they felt the way that they felt, a reason for why they felt the way that they felt. And they saw on a website through one of their friends, someone in their class and they associated with it went through either just psychological treatments or medical treatments and then said oh man this wasn't right for me so there was one study that was published in archives of sexual behavior i think it's a really hard study to interpret but i'll tell you what they did so they put an anonymous

survey online the person who did this study was the same person who coined this term rapid onset gender dysphoria that maybe we'll talk about later. That's a very charged separate topic. So there are concerns from some people that this researcher is kind of trying to develop this idea and kind of like pushing that narrative. But so read the results through that lens potentially. But she put this anonymous survey online and said if you detransitioned defined by you started medical interventions and stopped them, please fill out the survey.

The reason I think maybe some of the people who filled the survey actually were real and it wasn't just like political operatives taking the survey is... Where was the survey given? The internet and like online forums for like detransitioned people. Interesting. Which are tough spaces to do research. For instance, like there was a subreddit are detrans. I'm so old for not understanding Reddit better.

Yeah, I'm the same. But this is... There's clearly a participation bias or pre-transing. selection bias of some kind. Yeah, definitely not a probability, say a poll. But, so for instance, like that are D-trans subreddit, why am I so old?

I think that's what it's called. Somebody, there were a ton of things in there where it had like, I think, over 10,000 members at some point, but if you read the forum, people were saying these are clearly people who are just trying to be bad as eyes our existence. So, yeah,

that's why I say, be thoughtful looking at the study. But there were some people in that study who said, I stopped my medical interventions, but there was actually some good who came from it. So I'm thinking, okay, those probably weren't total bad actors, but hard to know was everyone. And there were people in that study who said that their initial trans identity was from something else. So some of them said it was from internalized misogyny. Some of them said it was from having a sexual trauma and wanting to flee potential re-victimization. I don't know that any said it was like from their depression.

That's one, it's hard for me to see like how like I'm depressed. Was there a body dysmorphia component? I don't remember that being one. We should talk about that more. Yeah, we will. And so at least for those people, they said that was true for themselves. I think it's really hard to know exactly what their experience was. Was that true that their gender identity really was from those things?

did they enter these online communities that gas let them into thinking that those things were true and are they going to later come out as trans again as we've seen some people have when they initially said things like that I think we don't know it has a lot of these

parallels with the ex-gay movement of all these people who said they went through therapy for being gay and their gayness was about something else and then some of them even like became conversion therapist and then decade later said, you know, none of that was true. I try to take it at least a little bit at face value in case it is true. So we have incorporated that into our assessment before starting medical interventions. Interesting. How so?

So the way, again, really sensitive because I don't want to be the one gaslighting them. But what I tell them is, you know, if you're going to start testosterone. Describe what you mean that you don't want to. I know what you mean, but describe the gaslighting that you're worried about. impacting them. Yeah, I don't want to be like pushing this idea on them that their transness is from internalized misogy or their transness is from that it's not real. That it's not, that it's not, that it's secondary. Well, I want them, I'll tell you how I frame it for them. So what I say is I want you to know you may have encountered this idea already that there's this

idea out there that trans identities are a result of internalized misogyny or if they have a trauma history, really sensitive conversation, right? But I want you know this idea is out there. There's not concrete evidence that internalized misogyny or trauma make you trans. However, I would hate for you to take testosterone for a period of time and then encounter that idea for the first time and be like, oh, can I swear? Of course. And be like, oh, shit, like what, that's horrifying. I had never thought about that. Is that true for me? That is an awful thing to hear for the first time after you've been on testosterone. I'll say often with the trauma part,

a lot of times the trauma came after they identified as trans. So I've had examples of patients, not very frequently, but who have, when given that idea that transness could be from internalized misogyny, thought like, oh shit, when I hear my voice, it sounds feminine and I hate that is that internalized misogyny

and then they went back and have thought about it more and what I've asked them is okay so you hear your voice and think I hate that what are the thoughts after and I've never had the thoughts after be like because women are bad at math

or because women can't be doctors or because being a man is in society better than being a woman It's been more like, oh, because I'm male. And it kind of came back to gender dysphoria. So we're extra cautious, so we incorporate that into the assessment, but I've not had a patient where it was the case that they felt that they're,

after talking through it, that their gender identity was from one of those things. But it could be a thing that happened super rare. We don't know 100%. But we also don't know if that online survey was real, so it's just tough. Right. It's hard to judge off one single paper. What I've read, I specifically remember a Psychology Today article that talked about how currently... Psychology today. I know.

I write there, too. That's what I'm saying. Hits and misses. It's a blog. Yeah. But I'm going to present the notion that the writer mentioned in that there is in the current state of things, with the increasing rates of the diagnosis of being trans or gender dysphoria, there are two schools of thought. One is that we have more awareness of the issue.

We're more comfortable in making that diagnosis. People are more comfortable coming out, even though it's still not easy for most. The other school of thought that there is a potential social contagion, for lack of a better term, that is happening where there are potentially even, what they say, clusters of groups of people, developing these same symptoms surrounding gender dysphoria.

First of all, my first question is, do you believe that these two thoughts of schools exist? The schools of thought exist? Do people think those things? Do people think those in the psychiatric community? I don't think a lot of people actually by the rapid onset gender dysphoria things being a prevalent concern. Well, that's a very specific.

Also, this is kind of what my next point was. It comes back to terminology again. Yeah. So social contagion, what do you mean by that? Because you could say the decrease in stigma is a social contagion. You could, right? You could say, like, giving people the language to be able to describe their gender identity as a social contagion. But social contagion is a really loaded word. That's why I thought you were kind of alluding to the rapid onset gender dysphoria thing, because social contagion implies that the transness is a pathology. Well, the gender dysphoria, the feelings about one's gender identity could be pathology, and I guess that's what is up in the air when we're talking about different pathologies. I think people are often using it, though, to say, like, the being trans is the pathology? Well, the idea, how I've seen it discussed by psychologists and psychiatrists, and there are not many of them, because it's a very difficult subject to talk about,

and usually most people are not well-versed enough to talk about it, and even some who are talking about are not well-versed enough to be talking about it, have positioned it in a way where someone is having negative mental health symptoms. And in seeing their friends, in their groups, in their circles, go through psychotherapy support, going for medical interventions, struggling with their gender identity, and assume through either self-diagnosis or novice diagnosis, like their friend

or their loved one, put that diagnosis on them that perhaps they have an issue with their gender identity. That's the kind of social contagion that I feel like I'm talking about when I'm talking about the two schools of thought. Yeah.

Which I feel like is different than the rapid onset gender dysphoria. Well, I think the point I was making is that notion came out of the rapid onset gender dysphoria. paper. So me it's worth describing it a little bit. So it was that same researcher who likes the anonymous online surveys. So she put an anonymous online survey. This paper felt a little sketchier. She put an anonymous survey on four websites. One was transgender trend.com. One was

fourth wave.com, which is a reference to fourth wave feminism, of which there's this small group of trans-exclusionary radical feminism. One was, I think, like gender critical, professional so these websites that seemed biased and she asked people on those websites did your kid become trans all of a sudden and did they have mental health problems right before and were they spending a lot of time on social media talking to LGBT people right before and all those people said yes and then she said do you believe in gay marriage I think and they said yes and so she used that to say they were liberal I think it's important to point out that there are plenty of people who believe in gay marriage who are not so supportive of trans people the big problem with this

study is that they didn't ask the kids themselves their experience or their mental health professionals. Right. Because and this is in my book also I present this idea to a lot of trans kids and they said of course the parents thought it was rapid onset gender dysphoria. For instance

when I was little I I'm a trans like this person is a trans girl I was wearing a tutu and my dad freaked on me and so I butched up and started playing football and hid every feminine thing about myself and then eventually I went to high school

and I met some LGBT people and it was the first time that I felt like I could talk about this thing that I was hiding and then I went online because I wanted to see other people like me and then eventually I got the bravery to tell my parents and I interviewed that person's parents also and that mom said it seemed like he came out of nowhere

and then eventually in talking to my daughter she explained this history that she was hiding it from me for a long time and so that was one issue with this, you know, like, idea that people become trans from social media because they're mentally ill. And then also,

she said, yes, I looked super depressed before I came out because I had to hide this thing about myself and I was full of shame and it was awful. Another thing has been this sex ratio question. It's like the bane of a lot of people's existence. So it is true that there are a bunch of gender clinics that have reported

that they've been seeing more people assigned female at birth relative to assigned male at birth in recent years. And so this idea went around, it's kind of misogynistic, honestly, that there's social contagion happening for transness or gender dysphoria, and that birth assigned males or females are particularly susceptible to pure contagion because lady brains are sensitive. It's like very offensive. And so, right, we're seeing the shift in the sex ratio because they're social contagion among birth assigned females because they're more easily influenced. And so we wanted to look at that question and we were looking at the YRBSS data. That's the CDC's big study

of high school students. And so we looked in 2017 and 2019 and looked at the sex ratio of people who in the general public said they were trans and it was actually really close to one to one. I saw that. And so I think if there were the social contagion for transness where birth-signed females were particularly susceptible, we'd see that in the general population, right? Not just in the gender clinics. The reason I think we're seeing more birth-signed females

in the gender clinics is that the medical interventions we have for trans men work better than the medical interventions for trans women. So testosterone works pretty fast. We can offer menstrual suppression really quickly without the whole comprehensive biopsychosocial evaluation because doctors prescribe OCPs to patients all the time.

Astrogen takes a really long time to work and it's really, really slow. And so that's been the other question about the social contagion thing. It has become such a big thing that people talk about that it

snuck its way into the latest W-pass standards of care. So the latest W-pass standards of care say that if somebody's understanding of their transness didn't develop until after puberty, then you should extend the diagnostic process. And also that one of the things you should assess for

is you ask both the kid, parents, right? You do like a multi-informant assessment to see how are people around you going to react when you come out as trans or you transition. And if they were to say, I'm going to be super popular and it's going to solve all of my problems. That would be a flag that we would explore. I've seen it exactly zero times, even in the Bay Area.

So, long story short, I don't think there's good evidence that there's this like pathological social contagion for transness. I don't think the evidence is really pointing to that in a strong way. But again, because we're, this is an area of medicine where we're more cautious than probably any other area of medicine, it's another thing that's made its way into our assessments. Got it. Dr. Jonathan Haidt, who's been a guest on the channel, is actually going to be the next guest on the podcast for an unrelated topic, talks about how social media

disproportionately impacts young teenage girls or even like 12-year-old girls, 13-year-old girls, disproportionately as it impacts boys. Logically and scientifically, he talks throughout his books about how, why that happens and how boys interact with social media is different than the way girls interact with social media, that boys, the way they bully is different than the way girls traditionally bully. And a lot of these are stereotypical, but they follow a trajectory, at least

of averages. So he admits that there is these sex differences in the way the sexes behave, at least with their use of social media. You mentioned that you feel when we say that surrounding trans issues, it might be misogynistic or wrong to say that the female brain is more susceptible to being influenced. Do you feel that there's no differences between the two sexes in terms of behavior? I've not seen any convincing data that birth assigned females are uniquely susceptible to peer pressure. I've heard it constantly as like a trope, but I've not seen convincing data that it was true. I'd be curious to see what he presents.

Yeah, I think he presents the data of the rates of self-harm and hospitalization data surrounding self-harm. It's obviously not causative, right? If anything, we're showing correlations here. But in one of our initial conversations when we talked about doing this podcast, you mentioned that there's some feminists who disagree with some of the notions or science

that you've discussed openly in your practice and on social media, can you tell me a little bit about that? Yeah, this has a long history that's awful. So a lot of it comes back to this debate of is gender identity, nature, or nurture. And so John Money was this huge figure in sexology or gender medicine, whatever you want to say. And he popularized this idea that gender identity was entirely a social construct. The really famous story with him is that there. There were these identical twins where one had a mistake during circumcision and had his penis burned beyond repair.

And so the parents came to this famous doctor, John Money, and John Money said, gender is a social construct, do a vaginoplasty on this child and raise this child as a girl. And the child will identify as a girl because gender is a social construct. That kid ended up having gender dysphoria, her whole life. John Money hit it and covered it up. They came out at least a decade later. That person had a really bad outcome. And it was kind of this big realization that, okay, gender's not entirely a social construct. And that unfortunately then kind of hit the feminist movements because they had been

citing and using a lot of John Money's work as evidence that you shouldn't treat men and women differently because gender is entirely a social construct. You shouldn't treat men and women differently in a discriminatory way, but it's not because gender is entirely a social construct, right? There does seem to be this biological basis of your gender identity, like that John money experiment seems to show, with a million caveats. And as those twin studies seem to show, and so there's just been this tension. The other thing that happened was that idea was popularized after World War II. And so I talk about a lot of this history in my book that after World War II, there was a big reaction against eugenics, right? People didn't

want to say that different things were biologically determined. There was way more interest in Freud's ideas that, you know, everything was a result of the environment. And so we got all these ideas like the schizophrenogenic mother that said that schizophrenia is from having a cold distant mom. And there was the refrigerator mother theory that autism was from having cold distant mothers. And both of those examples, eventually we had something like twin studies or genetic studies that showed us there was a strong biological basis. But there's been this history evolve, where there's a period of time where for a lot of

political reasons, we wanted to think that everything was socially constructed or from the environment, and then we've been seeing over time a lot of these things just do have to do with biology. Probably both. Definitely both, right? But so kind of, right, because there's, at least for gender identity, there seems to be this, again, transcendent sense that's biologically based. And then you build on it with complexity. So then gender identity is not totally a biological construct. It's not totally a social construct. It seems to be like a biological construct that you then build on with social influences. What would you say the differences are between gender identities from a biological standpoint? What do you mean?

So you said that there's a biological difference between gender identities that exists that people have pushed against. What are those differences? So that's what I think that transcendent sense is, that the feeling of masculinity or femininity. I almost think of it like an emotion sometimes, just like this feeling that's hard to put into words. And then if you're asking, like, are there sex differences between the brain? I hear Gina Ripon like over my shoulder yelling at me. So she's a really famous neuroscientist who's got.

through all this literature where for a long time people tried to argue male and female brains are different and then use that to attack women, frankly. And so she's gone back and said a lot of that stuff's not very convincing. A lot of it's based on like sizes of different structures. I think she called it modern day phrenology, which is a good point, honestly. And then also pointed out that people treat men and women differently so it's possible that those differences we're seeing in brain structure and function are actually a result of how people are treated rather than innate biology, but that's like, yeah, the sex differences in the brain field as a whole other controversial area. How does, since in that standpoint, she talks about how the way we treat

certain individuals can lead to different outcomes, can our interventions as medical professionals lead to specific outcomes in patients where they wouldn't have happened otherwise? Yes. So can you give me some examples of how, How do we have checks and balances, I guess, when we talk about adolescent psychiatric care surrounding transgender or gender affirming care in particular? So this comes up often and I guess I want to start by pointing out that there's also a big ethical issue here potentially that in this, right? Because the question is always like if you affirm someone, are you increasing the likelihood that they'll continue to identify as trans? I think a lot of people would, trans people in particular would take issue with that, that it's implying that being trans is.

a bad outcome. Certainly people historically have argued that they want to save people from stigma or they want to save people from needing medical interventions, et cetera, but it's kind of shaky ethical territory, but it has still been discussed. And so I'll take you through the different stages of development. So people have asked that question for social transition for pre-puberal kids. They're really, really young kids who say they want to use a new name and pronoun and then their parents let them. And there was this paper in 2013. Deansma at all, where they looked at associations between kids who came to gender clinics who identified as translator with a bunch of variables. One of the variables that was associated

with this persistence was if you socially transitioned. People went to town with that one and said the social transition is making people persist. Of course. But it's a chicken and the egg question, right? Like, did the social transition make them persist? Or did the kids who socially transitioned were the ones who were actually trans to begin with because in those studies there were a bunch of kids where people went back they weren't trans to begin with they were like tomb boys to your earlier point

or cisgender boys with like feminine interest like dolls or whatever so no one talks about this paper but Christina Olson is amazing she's a MacArthur Genius Award winner she's at Princeton she has this study called the Trans Youth Project where she looked

at this chicken and egg question does your degree of gender incongruence So the degree to which you don't identify with your sex assigned at birth increase after a social transition and she found no. But rather, your degree of gender incongruance at time point one predicts

if you're going to go on to socially transition. So in the chicken and the egg question, it's the egg. Whichever one you choose to represent. Whichever one you think is first. And so then that question has also been raised at these other stages of development, right? So puberty blockers,

It's really hard to study that in puberty blockers because you would have to randomize people to blockers or no blockers to see if the blockers change the persistence rates. We don't have that data. What we have is people who start blockers, it's very rare that they don't proceed with gender affirming care.

So in the Netherlands, they published a big study. Let's, before we go into blockers, because I want to gently get our way there versus get into the middle of it and then people would be like, wait, where are blockers coming from? The one point that I know you wanted to discuss, and I think it's very valid, is there is this notion in many people's minds where they hear someone say that they have physical discordance

with their gender at birth, or their sex at birth, rather. And someone sees that and says, what is the difference between that and someone who gets plastic cosmetic surgery? So if someone wants to get cosmetic surgery and has negative feelings about their body part and gets plastic surgery for it, how is that different than someone who has a physical discordance or incongruence with their biological body parts? Yeah, it's just a kind of like false equivalence issue, that they are different things. And what we see is that with these gender-faring medical interventions, people do a lot better.

I'm not a plastic surgeon. I don't want to... Well, let's talk specifically about that because I think it's such a valid point because when we talked about it last time, my understanding is that those who get plastic surgery many times

maybe don't necessarily have a diagnosis of body dysmorphic disorder, but getting more and more surgeries is certainly not helpful to them. Yeah, what I was going to say is I'm not a plastic surgeon so I don't want to trash their data. They might actually have data

that people are quite happy with their plastic surgeries. I think their satisfaction levels are generally lower than gender affirming care, but I think they... I don't know, I would have to fact-check myself on that one.

I would say that for the general public, maybe, but that's not the population. But you're asking specifically about, like, repeated surgeries. Well, I'm talking about specifically someone who struggles with body dysmorphic disorder where they dislike their body so much that it's going to a point of being unhealthy.

Oh, I got you. I think you didn't say BDD the first time. probably did it, yeah. So in that scenario, I thought I represented by saying they're going multiple times unnecessarily, but I should have been more clear. So an individual that's going for plastic surgery over and over again as a result of BDD, that person's not getting a benefit. They're actually potentially harming themselves. Much in the same way, someone who struggles with body image because of anorexia, if we affirm the anorexia and say, okay, don't eat, we're actually doing them harm.

Yes. In this case, with someone who has physical incongruence with their physical appearance and their gender identity, by affirming it, we could be helping them. Yeah, they're just different conditions, right? So in anorexia, if you affirmed someone's anorexia, they would die.

With gender affirming care, what we find is when we offer those surgeries, they do have mental health improvements. With BDD, what we see is they don't feel better after their surgery, but they just are different conditions. One thing a lot of people don't realize, this is a bit of an aside, but I work in an eating disorders clinic also. And we actually don't get into it with patients with anorexia telling them,

like you're not overweight or challenging their body image. That is generally not effective. Really, what this gold standard treatment is something called family-based treatment, where it's really just about re-nourishing them, where their parents take over control of their eating and monitor them and as they re-nourish their mental health improves. Also, you also can have gender dysphoria

and like a BDD type picture. So there are sometimes patients who have their gender affirming surgery and then do get really fixated on wanting more and more surgeries and those are patients where we usually step back and we don't clear them to have repeated surgeries because you're noticing there's this pattern that they're getting really

it's not the majority of patients by any means but I've seen it a few times that they get like just really fixated on perfection and changing. The perfection of wanting repeated, repeated surgeries and needing it to be perfect and the surgeon can't achieve that perfection so it creates a problem and so certainly for those patients

we stop. That makes sense. For the subject of treating adolescents which is the majority of your practice, all of your practice? 60%. I work in an adult, psychiatry clinic too. Okay, so the majority of your practice. For those individuals, currently the way that the endocrine society guidelines are pre-puberty,

there is no medical intervention. Am I correct? I understand that? Then undergoing puberty, there is the potential for medical intervention. For adults, it's a different set of rules. Correct. So even within adolescence, it's a little bit more staged. So before puberty, nomadic interventions, once you reach the early stages of puberty, 10 or two,

you could consider puberty blockers. And then historically, you wouldn't start gender-affirming hormones like estrogen or testosterone until 16. Everything's more complex than we initially state. So that was the guideline for a long time. What endocrinologists were noticing is a side effect of puberty blockers as you fall behind on bone density. And so there were some kids who came out as trans very, very young and socially transitioned when they were, say, six or seven, and then they started their first puberty

blocker at 10. They last a year or two. This person has been on multiple puberty blockers and they're 14. And they were looking at the doctor and saying, all of my friends are going through puberty and I'm not, and that sucks. And then the endocrinologist was looking at their bone density and noticing they're risking their bone density more and more. And so they acknowledge in their latest guidelines from the Endocrine Society that you could consider hormones earlier around 13 and a half on a case-by-case basis to protect bone health

and that potential social stress for those types of kids who are really upset that they're having to go through puberty much later than their peers. Do you institute medical interventions like puberty blockers in your practice? No.

So mine's a, my clinic is a mental health clinic. And so I just happen to only see trans kids. It's like the one time where it works out. It's like a nice equity thing. Like the trans patients can get in to see a psychiatrist faster than other patients because our clinic exists. But we treat the full range of mental health conditions.

We do a lot of psychopharmacology. We're just treating other things like ADHD, anxiety or depression. We will do the therapy sometimes if those kids are needing puberty blockers or hormones. So we do these mental health assessments that then they would go. go to the endocrinology clinic that would actually prescribe the puberty blocker or hormones, and then we continue to follow them to make sure everything is going well. Why do you think, or maybe you know the answer to this already from research, is there so often comorbidities in association with gender dysphoria?

Yeah, the most common comorbidities are anxiety and depression. It's a little complicated because often it's from their gender dysphoria, or people treating them awful. And we sometimes have patients who were treating for anxiety and depression and gender dysphoria. And so let's say I put them on Waltbutrin or a Nessusri for their anxiety.

Sometimes that doesn't help and then they start estrogen and their gender dysphoria gets better and then the depression goes away and it turns out that I was not being used to the whole time. Okay. But it's complicated. Yeah.

Right. So it could be multifactorial. or it could be single of a different sort. Yeah, but we treat every patient on an individual level. Right. Right. So there are these population level associations where there's more anxiety and depression.

But I'm just treating people for what they individually have. Right. How does autism play a role in this? Because I frequently see it's cited in different articles. How does that tie in with gender dysphoria diagnosis? You're probably really tired of me saying things are common. No, but it's complicated. This is why we have, everything is complicated.

This is why this is not a 90-second sound bite. Yeah, that's good. So, the autism thing, there was this idea, there still is, that autism is overrepresented among people with gender dysphoria, and that gender dysphoria is overrepresented among people with autism. I forget what year we did this, but we looked through all of those studies, and we weren't totally buying it. the studies of people with gender dysphoria,

they gave them these autism screening instruments called the social responsiveness scale or the autism quotient that don't establish a diagnosis. And we have other research that shows that if you have anxiety or depression, as many is like 80% of kids with anxiety and depression

who don't have autism will score in the clinical range on these scales. Because they're not validated? They're just not very specific. And so it didn't really establish that those kids all had autism. Because we know that they're really high rates of anxiety and depression for these kids. So it wasn't surprising that a lot of them were scoring positive.

The other thing that was kind of fishy was the Dutch published a study where they looked at the rate of them screening positive for pre-puberal kids. And it was pretty much the same as the general population. And then when they looked at it in the teens, that's when all of a sudden there were more kids with autism. But you don't develop autism in your teens, you know. But you develop anxiety and depression in your teens because that's usually when these kids for the first time are having a lot of bullying and stigma. etc. So is it because of the instrument that you think this is an issue? I think that was the issue with a lot of those studies. Yeah. And then the other set of studies looked at kids with autism and they used this thing called the CBCL that says,

do you feel like you're the other gender, zero never, one sometimes, or too often? And they combine the ones and the twos and called that gender dysphoria. But people of autism have slightly more rigid thinking. And so for instance, I've had a couple patients who had like a stereotypical interest, let's say like a boy with autism who likes knitting, he'd be like, yeah, sometimes I feel like a girl, but it's not a kid who is gendered dysphoria, you know? And so we weren't totally buying it. However, the reason we were looking at it was that what was boiling down into the popular press was that these trans kids, trans people just have autism was like what the headlines became. And that,

that autism gives you these repetitive, restrictive interest, and they're just, like, obsessed with gender, and that makes them trans. And so we went through that letter to trans, that there's really not evidence for that. That being said, one percent of kids have autism, one-ish percent of kids have gender dysphoria or trans. So they're going to be kids who have both,

and it is a unique thing, right? Because their experience of the world and gender and social norms and their rigid thinking does require a special approach. approach for supporting them in their gender. And so the latest W-Path guidelines actually recommend that anyone working with trans youth does have training and experience with autism to be able to support those types of kids. And there's a great researcher named John Strang who has dedicated his career to figure out

how do we specifically support kids with autism who are gender diverse? In order for children to get access to gender affirming care, and I say children speaking of a broad range of ages here. There has been a school of thought that says there should be a lot of questionnaires, there should be a psychoanalysis done beforehand, there should be some, I guess, not necessarily barriers, but checks in place before we institute certain treatments.

Some people think that this is very valuable because it prevents children from going for treatments they don't need. Some people view that as a barrier, a true barrier to getting care. you're very evidence-based, what does the evidence say? Should we make it that there are these very strong checks in place, or do we actually just delay the process for children who need treatment? So the current guidelines are that you do these comprehensive mental health evaluations

before adolescence access treatment. So that's what we do. And that's what the research is, because that's what we do. And so some people say, like the only evidence-based thing to do is to do these mental health assessments before offering gender-affirming care. Some people have pushed back on that a bit, and again, they're not doing this

because you have to follow the standard of care right now, but they've said, like, maybe this could evolve in the future because it's possible, like, yes, all of the research is on that, but that doesn't mean that that part of the treatment is necessary. And they've pointed to what happened in adult psychiatry where we used to require these mental health assessments for adults, And it turns out we were doing a lot of harm because the assessments were not appropriate. So psychiatrists, if they felt that a trans woman's makeup wasn't good enough or her clothing didn't look sufficiently feminine, they would refuse to let that person access gender affirming care.

And so there's this really sensitive history, understandably, in the trans community against these assessments. And so the question has been raised, are we doing harm by requiring the assessor? for youth both are we like recapitulating that stigma that they were doing an adult psychiatry and also it takes time to do those mental health evaluations and for pubertal suppression in particular those kids might be actively progressing through puberty that can't be undone and might cause severe gender dysphoria and so by delaying their access to treatment we could be doing harm um so i don't think we have an answer for could our outcomes be just as good we without the assessments, that is not answered, but all of the current data is showing benefits

of care is based on doing the assessment. So that's why the current guidelines say you have to do the assessments. Got it. Now, I feel like we've done a good job covering the state of puberty blockers as it is. What is the current pushback that you're seeing in media, in social media, or maybe even in academia surrounding puberty blockers and children? So it's not so much in academia, honestly. I think people are pretty comfortable with puberty blockers because we've used them in pediatrics for a long time. The political environment is a disaster, right?

And my emails are a disaster as a result because what people are saying in Twitter and what politicians are saying that they're making it sound like kids are rushed into medical interventions or the doctors are like forcing puberty blockers on them when the reality is. let's take that question point by point. Are doctors rushing patients into this?

No, if anything, the trans community and my patients are mad at me because we're slowing it down, right? By putting those checks. We're doing these mental health evaluations that are intensive and lengthy and delay their access to care. We're certainly not pushing it on them, if anything, we're making it harder for them to access it. And it's really hard to even get in to see us, right?

So my clinic's a little bit lucky that we have a shorter wait list, but a lot of the medical clinics for puberty blockers or hormones, they have a wait list of a year or longer. There aren't a lot of psychiatrists or therapists like me who know how to do the mental health evaluations. So in most places it's really hard to get in to see someone. So you might wait six months to a year to get in to see someone and then get your assessment done

and then wait another year before you even get into the clinic. So this whole notion that kids are like showing up and immediately getting blockers or hormones is just not realistic. And the idea of banning care, where is that coming from? Yeah, it's not coming from medicine. You know, it started with a chiropractor, actually. I don't want the pro-chiropractor people to come after me,

so I'm not going to say a lot. But it was from a chiropractor non-medical doctor who is like a strong political consternary. conservative who introduced this legislation that would have made it illegal. I remember when I saw it, I thought, illegal to do puberty blockers? To do any gender-referring medical interventions for people under 18. So even psychotherapy? No, no, medical. Oh, medical. Okay. Yeah. So I remember seeing that and thinking, this is wild. And I read an op-ed about it in the New York Times just because I wanted people to know this was happening and was concerning. And I remember thinking,

like, okay, this won't go anywhere. That was very wrong. And so this became a huge, priority for a lot of right-wing politicians, and then they've introduced legislation in more states than I can even keep track of to ban gender-ferring medical care, and have developed really effective political rhetoric, right? Like, you constantly hear them saying, and they'll name their bills this. Like, the bill will be called prevent mutilation and sterilization of children. That sounds scary, right? And so people get all riled up, and then they're in favor of this legislation and we as doctors with the exception of you are really bad at communicating with the public. I need to do better in this topic as well. But just in terms of like communicating with the

public and educating lawmakers and like having people know the evidence behind that should be informing legislation, doctors are historically awful at that. And so it just took off. I was one of a few doctors, you know, I at least had experience writing op-eds, but I quickly was flooded out because every politician with a big platform was out saying things that weren't true. Speaking of gender, is it gender reassignment surgery? Is that the correct terminology? Some people use that. We use gender affirming surgery. Gender affirming surgery. Is that done in adolescence ever? So the only surgery that sometimes is considered, for adolescents is gender-affirming top surgery. So for people who are assigned female

at birth and have very extreme chest dysphoria, you can consider surgery to remove chest tissue. It's obviously a huge decision, right? The mental health professional would have to be on board. The surgeon would have to be on board. The parents would have to be on board and you're weighing all the risks of surgery, which is many against the risks of mental health equality of these patients might be having. But there are cases where kids are so... But that's not a common. It's not routine. Yeah, but it happens. It's not because they make their bill about that when that's not the majority of cases, far from it. Yeah, I mean, it's not super, super rare because there are kids who have really, really severe chest dysphoria and do get surgery. So that's

the surgery that I will say sometimes happens in adolescence. Gender affirming genital surgery, not really considered before 18, except for there will be, and it's kind of, outside of some of the guidelines, because the Integrance Society guidelines say to wait until 18. But some doctors have said, you know, there are these patients who are 17 and they're going off to college and do we want to be really rigid about this 18 age or should we let them have their surgery the summer before college so they can have their recovery and not have school disrupted. So I've not had patients personally who have had the surgery below 18, but I've at least heard of cases where that has happened.

Right. It's understandable to me, given the nature of politicization in the United States between red states and blue states on certain matters. Why is there a discordance between gender affirming care with the United States and let's say some of the Nordic nations or the UK, for example, why isn't there more of a unanimous consensus? Yeah.

Yeah, so this has been another political strategy, I think, honestly, that, and I see that, because I do expert witness work sometimes from educating the court about like these medical interventions when there are challenges to these laws banning gender affirming care. And what I often see the lawyers for the state trying to say is like, look, all of these liberal nations in Scandinavia are banning care. We're just doing what they're doing. but those Scandinavian countries don't ban care. And it's not true that it's not politicized in Europe. It is politicized, maybe not as much as it is here. But there are political movements related to gender-affirming care. And some of those nations have done things like restricted care just to clinical trials

or made it a lot harder to access care. What most of them have said is you need to do this mental health evaluation before considering medical interventions, which is what we do here. anyway. So I don't know that it's totally fair to say that there's like not a concordance because the standards of care here are to do something that's very similar to what they're saying to do in a lot of these European countries. I think the difference is they have been saying to only do it in the context of clinical trials. Most gender clinics in the U.S. are at academic medical centers and a lot of us are doing research. But I don't think there's a consensus in the U.S.

that it should only be restricted to clinical trials because we recognize that the practicality of that would create a lot of issues, right? We already have wait lists that are a year or longer. A lot of the clinics are closing. They're wait lists because states are banning care. A lot of the clinics are closing and people are kind of moving to other states.

We have kind of this crisis of being able to access the care where I'm not sure it would be feasible to only have it in clinical trials. I'm not fully convinced it's going to be feasible for these European nations to do it exclusively in the context of clinical trials that my understanding is they've not actually set them up

so I'm not sure what's going to happen with people actually being able to access care. But if you read their statements, they're often saying like there are cases where it seems this is necessary so we're not banning it but they want there to be this cautious approach

with the mental health evaluation. For the report that came out of the UK, the cast report, it's largely it's not fair to say it's being misused by a lot of people. It's being misused to be stigmatizing to the trans community. It's used to

muddy the waters of scientific discussion. And the takeaway that I got from reading the cast report as well as the interview with the lead author and some of the op-eds that were written by authors of that study is that trans-trans. gender, gender affirming care, is very valuable. The specifics of each of the individual treatments need more research as to age where we start, which treatment we choose, how long follow-up is, whether or not it's in a clinical trial.

But nowhere, even in the cast report, did they say we need to ban gender affirming care. Is that a valid takeaway? I'm still working my way through it. It's a big document. So it's 388 pages. And so our team is going through all that and also all the systematic reviews that they used is the basis for the report.

But certainly there are sections of the report that say that there are patients for whom it seems this care is needed and a good idea and it should still be offered. And yeah, a lot of it is a call for more research and making sure that we're being really thoughtful in how we deliver the care. I think that's true about it. Part of the feedback Hillary Cass made about the current state of evidence that when it comes to puberty blockers specifically is that the evidence by which to institute puberty blockers is not as strong as she would like for irreversible medical treatment. What's your take on that

assertion? Yeah, I don't think of puberty blockers as irreversible treatment. Certainly in the sense of their blocking of puberty, that is reversible. So if you stop the medication, endogenous as puberty will proceed. I think the cast report is very confusing to read, and I'm worried about it because I think a lot of policymakers are going to misinterpret it or misuse it

because it's not very consistent in how it applies language in differentiating technical language from lay use of words. So, for instance, in the systematic reviews for puberty blockers and gender-affirming hormones, they actually rate a lot of the studies on the mental health benefits as moderate,

some even as high quality. But then in the non-peer reviewed like big 388 page report, it says, you know, it's low quality, it's poor quality, all these different terms that are very different, that are both not exactly what the systematic reviews say, and those words of

quality of evidence using these rating scales for medical interventions, those are terms of art, right? So there are many medical interventions that have low or moderate quality on these very technical rating scales that we offer routinely, like almost all neonatal ICU care

falls into that category, but the general public doesn't know that. So I do worry that people are not being responsible with explaining exactly what those terms mean. I don't think anyone's going to disagree with her that more data would be good. I think what I do disagree with is that people have looked at the report,

said, look, she said it's poor quality, therefore it's bad, we shouldn't offer it. ban it and that's what keeps coming up. That is absolutely a true outcome of what's happening. She talks about one of the indications that we currently have for puberty blockers being to quote unquote buy time for an individual to make a choice. But she believes that it's not a true by time situation because such a high percentage continue to getting masculinizing or feminizing hormones after blocking puberty. Do you believe that it's still valuable as a tool to to buy time?

For some patients, yeah. You know, I think the buying time idea was interesting. I don't know that I ever fully bought that that was the only utility of them. The utility is we have these kids where their puberty is progressing and their mental health is deteriorating really quickly

because their body doesn't align with their gender identity and they're feeling awful, right? And their mental health is really getting worse. Yeah, I guess buying time is an interesting way to phrase it, but it's useful because it puts their puberty on hold that's making their mental health deteriorate.

And it does let us talk to them more to explore their gender identity and think about next steps without that kind of impeding dread of, oh my God, my body is changing and I can never undo this without surgery, if at all. So I think of them as more as important for like stabilizing mental health.

And yeah, I mean, I guess by time so they you're not having these irreversible medical, or irreversible puberty changes, but buying time is kind of a funny thing to say because you're also stopping, you're treating something that's going in the wrong direction. Right. Her reasoning why she doesn't believe the by time applies is because if 98% end up pursuing hormone treatment that you weren't really buying time, it's just a progression in the treatment, which essentially means you're starting treatment

when you're starting puberty blockers, you're not actually buying time, which is sort of what you're saying. And that is kind of how we approach it, right? Because you can't just, it's not like a patient comes in and you can just start a puberty blocker to then start figuring things out.

You have to do the comprehensive mental health evaluation before you can start the puberty blockers. So you actually have to figure out a lot of things before starting that, including fertility preservation. So, right, we, if you were to start puberty blockers and then stop them,

that's what we did in precocious puberty, all the time and you could it seemed fertility was intact by and large but because what we actually do in gender care is we have the whole fertility conversation before they even start the blocker which is a big difficult conversation because a lot of these kids the fertility preservation process exacerbates gender dysphoria um so yeah and most of the kids do go on to gender affirming hormones and most of the assessment to decide if this was a good idea happened before even starting the medication. So I think that's to an extent true.

But in the studies of puberty blockers, it's not 100% of kids who go on. It's the vast majority. But, you know, there are at least two studies. One found 1.9% didn't continue on. One found 3.5%. But it's really interesting what happened with those few kids. So in one study gave us very little information on what happened.

There's another study by Brick et all where that was the 3.5% of kids didn't go on to hormones. one of them evolved into a non-binary identity and felt okay with their sex assigned at birth. So maybe for that person, you know, there was a therapy thing where they were really still working to understand themselves. One actually still had gender dysphoria,

but the medication was stopped for like unspecified psychosocial reasons. But it didn't seem that any of them regretted the puberty blocker, which was interesting. She talks about that starting puberty blockers at age 13 would essentially be the same as starting the entire hormonal treatment because of the 97, 98% continuation rate.

And her notion was that there is a potential risk that we don't yet know because of the length of current research that we have that we don't know how this impacts development into the mid-20s, into the 30s. Is that true, A, and B, how value is it to be thinking about that? We don't know nothing. So for instance, there was this landmark study by DeVrie at all, the Dutch group where they followed 55 adolescents who got puberty blockers

and then hormones and then gender affirming surgery in adulthood. And they've done quite well. We've been using puberty blockers for gender affirming care for decades now, actually. And so we do have patients who have been on them for a long time. I have patients who started them and now are at Ivy League colleges. So could there be some, like, minor impact on their cognitive development, maybe? But we don't know that for most medications because, first of all, there are infinite cognitive domains you could study. So it's impossible to know for every medication if they impact different cognitive domains.

Usually the way we think about medications that are FDA approved, and if there's, like, a bad long-term outcome is we have these post-marketing surveillance studies, right? where if there's something scary happening, it gets flagged. And so that happened for puberty blockers for for idiopathic intracranial hypertension, where it seemed like a lot of kids who were getting blockers had that condition. That was getting reported. So the FDA looked into it. And then it turned out it was not a real issue.

They compared to those who got blockers to those who didn't. And it wasn't actually an increased risk. It just seemed, you know, some people happened to get it. And so it signaled to the alarm. So I think it's important that we not treat these medications differently than other ones. So I was a little bit surprised to see her say that because if anything, these have been more studied. So we looked at, not we, another group looked at executive functioning using this Tower of London task after puberty blockers and found that executive functioning was not negatively impacted by puberty blockers, which is more than we know for a lot of medications because we just don't have unlimited resources to look into every single cognitive. outcome for everything. Is it fair to say that because these medications are using hormones that are

part of the development process, that we should treat them differently than medications that are not part of the development process? I guess I would say like at the very least, you should treat them like other psychiatric medications that impact the brain. So like give me an example of something like that. So lorazidone is a medication that was FDA approved for pediatric bipolar disorder based on a six-week trial, and we do prescribe that relatively routinely. We don't have decades and decades of follow-up data, but we're doing what we do with all medications where the FDA established that these medications are safe for use in pediatrics, that there aren't any really scary things that happen when you start taking them. And now they're marketed.

and people are using them and then if bad things happen on them that gets reported to the FDA and if they detect something in post-marketing surveillance then that is looked into so I'm all for more research and looking to see how these kids

do longer term but I think the thing that concerns me is that's turning into let's ban this treatment without people realizing that's not what she means or says yeah and also just like the logic not making sense there so if you want

five to 10 years of follow up data to not ban a medication, then you have to ban every medication that was approved by the FDA in the past five years, right? Because it doesn't have all that data. So yeah, I'm not saying that she says that, but her words and the impact has unfortunately been that. Does, is there a world where through gender affirming care from a psychotherapy perspective can be a sole treatment for those with just. gender dysphoria? I certainly have patients who don't want gender affirming medical interventions.

And a lot of patients who are trans who don't have like that physical gender dysphoria. And so they don't get medical interventions. Sometimes we go through that mental health assessment and they learn all about the medication and they think that's actually not for me. But again, I think the thing to be careful about is that doesn't mean there's an evidence-based talk therapy for the gender dysphoria, which usually what we mean by that is the distress about their mental health. Sorry, they're distressed about their body not aligning with their gender identity. There's no evidence-based psychotherapy to fix that. This is actually a question I have. I have patients of mine

that are adolescents or even younger that create pathology or diagnose themselves with pathology when they're experiencing normal physiology. So they have something bad happen in their life and they feel sad about it and because we are more open to talking about mental health conditions and maybe their friends are that they then diagnose themselves or self-diagnosis.

Is that something you're seeing or are concerned about? That happens in psychiatry in some really interesting ways. So not so much they're feeling distress and so then they think they have gender dysphoria.

It happens with like dissociative identity disorder all the time. This has been a big thing in psychiatry that I finally accepted that now there are just two different dissociative identity disorders. There is the DSM's definition, which is you had repeated childhood trauma and you develop this condition

where usually you have kind of like a dissociative fugue kind of thing you don't remember later. Like you get really distressed and then you start acting like another person and then come to later. There's another DID that exists on the internet. And this is the idea that you have these alt

It has a whole language. Like you have altars and a system, and it's usually not actually distressing. Like, an example would be somebody says, oh, I was in class and I was really bored. And then I became like my sailor moon altar and I flew around the room and it was awesome. Or sometimes it's like there's a part of themselves that they don't like or don't feel comfortable with. So I've had patients where they feel. like anger isn't an acceptable emotion and so they call their anger like a different

person and so I have not found it productive to get in fights with them about whether or not they have DID. So I've just explained to them you know there's this kind of DAD and there's this kind of DID with yours should we talk about it the one time I do kind of intervene

is if right there's like a shame component so like if you think anger is bad and so you're saying the anger is not you like let's address where that shame is coming from So stuff like that definitely happens. I think autism is another example. ADHD is another example that people have talked about

like these non-specific symptoms, meaning you have a certain diagnosis and that actually doesn't line out perfectly with what the diagnosis is in the DSM. But gender dysphoria, not so much, honestly. It's more we've had patients where like their definition of, I guess in that way, maybe it's kind of similar.

Their definition of transness is a little different, right? So, like, a patient who adopts, they, them pronouns, and describes themselves as non-binary, and it's largely because, let's say, like, they don't like the gender roles assigned to them because they were assigned female at birth, and they're identifying as trans. I get, right, that's really different than a kid who, you know,

can't go to the bathroom or can't shower because they're so distressed about the gendered out. aspects of their body. What is the risk of no medical treatment for gender affirming care? It depends on the patient, but for some patients, there's just a really clear worsening of their mental health, for instance, from their endogenous puberty progressing. Is that temporary or is that long-lasting? It seems to be long-lasting.

So, right, the one way we can look at this are these. So there are two types of studies. So they're the longitudinal studies that look before and after the medical interventions or puberty blockers and generally have found for hormones, usually mental health improves. For blockers, mental health seems to either improve or just stabilize and not worsen, which is also good because usually what we see is their mental health worsens from puberty progressing. And then there are cross-sectional studies that compare those who got the treatments to those who wanted the treatment but didn't access them. So we had a study in pediatrics where we compared adults who wanted puberty.

blockers but couldn't access them to those who accessed them. And those who accessed them had lower odds of lifetime suicidal ideation, for instance. So the risk is just various forms of internalizing psychopathology usually, which means anxiety and depression, which often leads to suicidality. So it's interesting to hear you say that for one main reason. You could be a teacher, you could be a parent, you can be a politician, you could be a primary care physician. And I hear you say that there's moderate quality or at least good quality evidence with a strong recommendation

that puberty blockers will improve mental health outcomes or at the very least stabilize them. At least when you have done it under current guidelines where you've done this comprehensive mental health evaluation where you've already kind of determined that this is a good patient population. The benefits outweigh

the risks. Right. And then I hear the interview on BMJ, British Medical Journal, which is a very respectable medical journal with Hillary say the exact opposite. What is a primary care physician, a politician, a parent, a teacher supposed to do?

What was the opposite thing that she said? That giving puberty blockers currently does not have high quality evidence to improve mental health outcomes. But if you read her report, it says there are circumstances where you should do it because the patients need it. Right.

So I guess I don't know how to reconcile her statement. Her circumstances that she talks about are very rare. and I'll give you one of the ones that she brought up during her interview where you have male sex at sign at birth

with an early history of gender incongruence who would have a lot of damage who socially transitioned early who would have a lot of damage to their mental psyche undergoing male puberty because they've been living

in what she calls stealth to their classmates. So they're biologically sex at sign at birth male. They've been living socially transitioned as a girl. And by going through male puberty, that would be very harmful. And she believes the evidence there is clear that puberty blockers and hormonal treatments later down in line makes sense. But for the majority of the cases, she believes the evidence is not as clear.

And that's her statement on it. So how do I, as a primary care physician, make, I guess, sense of that, where I have a respectable medical journal telling me one thing and then a medical expert also telling me something different. Yeah, I think you're in a tough position. I'm not saying this to sympathize with me. I'm just genuinely saying, what do we do here? Like, from a practical standpoint.

I mean, I personally don't think, that certainly is a kind of patient that would warrant medical intervention. I don't agree that that's the only patient. who would ever warrant gender-affirming medical care. With all due respect, she doesn't work with these kids, so she hasn't seen the other types of kids where we're doing the risk-benefit analysis with the help of the parents, with the kid,

explaining these treatments in detail, understanding all the risks, and then sitting all together and realizing, okay, we know all of these risks. This could impair my fertility. This could impact bone health. But I'm also seeing that my kids' mental health is deteriorating, and they're really, really distressed about their progressing puberty

and in weighing the risks and benefits for this patient, everyone's in agreement, right? The doctors, the parents, the kid, that this treatment makes sense. I'd be curious to see... I'm more speaking about the evidence rather than... That's the next thing I was going to say. So I'm curious to hear how she got to that conclusion that the evidence base is only good for kids like she described,

because those aren't the only kinds of kids who are in the studies. Interesting. Yeah, it's hard for me to... And certainly the systematic review didn't look at that question at all. Again, it's so hard. Imagine, like, for me, as someone who's trying my best to understand this,

how can we expect a listener to know the best treatment or the right pathway for their child? Like, I sympathize with parents now or legislators. What do we do here? How do we fix this? I mean, I think you should take your child

to a reputable expert who works in this area who follows the clinical guidelines? I don't know, I mean, I've not listened to all of her interviews. I don't know that she said like if you are a family

in the United States don't go to a gender therapist to have an assessment. That's absolutely not what she says. She's speaking so, she doesn't make recommendations in that regard. She makes statements

about the quality of evidence or the lack of evidence or the preponderance of evidence. This is where I take issue with her a bit because I do think she keeps taking these, at least I've seen her several times in the report, either not be consistent with the results of the systematic review where they label the evidence moderate or high quality. Like she somehow translates it to low quality over and over again. Or not

explaining to people that that's a term of art, right? That that means level of evidence. And then I don't know that I've heard clarity from her on what she wants people to do, actually. And those, in these situations you're describing. I think she wants ultimately that gender affirming care should continue. This population has been largely hurt by our medical system because what happened at least in the UK is everyone got pushed to one clinic that had no ability to care for that many patients. Totally overwhelmed. And as a result, patients ended up suffering.

So she believes that we need drastically quicker data to help support. our methods that she feels are largely expert or contenses driven, and that she believes if we are going to be doing puberty blockers, which some instances it makes sense to do, it should be followed very thoroughly through a clinical trial. What she means by clinical trial, I don't yet know. Again, as you described, you haven't seen them set it up yet. So is this just meaning that they're going to just follow this person and categorize this data to use in further research? Or are they to be directly comparing this person to another person in the clinic, I think that's TBD. Yeah, I mean, I think I share her dream that we could follow every patient closely in a clinical

trial and have a ton of data on them. That would be great. I don't know how realistic that is and the reality of clinical medicine is you have a patient sitting in front of you and you have to do something. And so I would want to hear from her what she thinks you should do if you have a patient who doesn't have that didn't come out to their parents when they were five, right? They came out to their parents when they were 14. They missed the window for blockers and they want gender affirming hormones and they have really severe anxiety and depression and are distressed about their genders for it and they want that treatment. Is she saying we shouldn't do that? I actually don't know her answer to that question, but that's a scenario I face regularly. And we have

a pretty involved process for making the decision, right? We have this comprehensive mental health evaluation that includes all of these things. Like, again, if the kid were saying, I'm going to be super popular at all. My problems are going to be fixed by taking estrogen, then I'm not going to jump to starting the hormones right away. I'm going to want to explore and kind of understand what that's about. That's a very clear example. I think even in my limited work with adolescents in their mental health, I rarely see conditions or be as straightforward is that where they're like, the reason I'm doing this is for X, Y, and Z. It's a lot of exploration and even their confusion over what's happening. I think that's why it's case by case, right? Like sometimes

it's super clear, sometimes it's more in the middle. And when it's in the middle, we spend a lot more time. It's also not my experience that any parents are like rushing for their kids to get Jennifer medical interventions. And the parents are the ones ultimately deciding. I've had parents like want to continue to talk about this for like a year or longer before making the decision. So you're right. It's not always easy. But I guess I've just, the discussion and what sometimes the cast, the way the cast reports being translated, I don't want to put this on her necessarily, is it's turning into a lot of this black and white thinking without saying like, okay, so what do you do with this actual patient who's in front of you where you have to make a decision?

Yeah, I think not to put words in. someone's mouth, but I think based off my reading and hearing of what they've said in the past is if you decide to pursue puberty blockers, it could be reasonable based on your medical expertise, but that should be in a clinical trial format. What that means for them for a country versus what it means for us means two different things. Yeah. And I'm never going to say that it's bad to collect more data. Like that's great. I work in an academic medical center where we're constantly collecting a lot of days as long as the patients are open to having their data. And I'm collected, which sometimes they're not, and then we don't.

I think she would just say that the informed consent would be different for her than it would be maybe for someone who views the data as more higher quality. I wonder how it's different. Just in terms of explaining that, if we're going to do puberty blockers here, I could see this working, but the evidence isn't clear versus an individual who might see the evidence as better and say, odds are that the puberty blockers would help. I guess that's a question for you. How do you introduce the topic of puberty blockers for patients?

Or you wouldn't, but... No, I would if I was doing the mental health evaluation for it. But I think it goes back to this misconception that people are like rushing the kids into medical interventions. But right, if I have a kid who it's more complex and not like the evidence base where they truly didn't realize their transness until like three months ago and they have autism or they have autism

or they have PTSD or they have other, like, really complicated mental health concerns that I'm going to explain to the parents, like, this is a complicated situation. These are the things I want to look into before starting. But don't the current guidelines from the Endocrine Society, at least when I looked at them, that if an adolescent presents with the questioning of their gender identity, it's fair to start puberty blockers at that moment? No. That's not the current guidance?

No, you have to have the mental health evaluation first. and the mental health evaluation will say we'll check for comorbidities or other issues checks for comorbidities checks for anything that could inform their ability to provide informed because they're minors it's assent not consent um you want to know their gender history if there's anything that's not typical for the types of patients that we see got it so those things would be screened out beforehand because like um i saw an interview with a physician talking about how that is generally what is done, but that there are certain situations if someone doesn't have access to

psychiatric evaluation or psychological evaluation, that they then still allow them to start the puberty block of process. But you say that's against guidelines. Well, that's not what's recommended in the guidelines. But that, I mean, I'm not aware of that happening, but that does happen in medicine, right? That, like, in resource poor places, they do things. things that aren't in line with guidelines because they're in a situation where they don't have

another choice. I guess if you were in a place where there are no therapists that know how to do this, and you have a kid where you're a doctor who's really worried that they're suicidal, for instance, and you think they need the puberty blocker, then maybe you would operate outside of guidelines. You're obviously putting yourself at malpractice risk, and you could be, right, there could be consequences to that, but that's why doctors train for a long time because sometimes they need to make those difficult decisions that are based on their clinical expertise and their reading of the data and the situation.

Right. What currently do the guidelines state that someone needs to have from a licensing, a specialty perspective in order to institute gender affirming care? I have to look back at the exact list of guidelines. I know that I meet them. Okay. You have to be a licensed mental health professional

for like a recognized mental health profession. So you could be a psychologist or a licensed clinical social worker. This is to do the mental health evaluation. Correct. You need to have experience in gender care. So this is, does it have awesome experience? Does it have to be a medical doctor or it can be a psychologist? It can be a psychologist or social worker.

Got it. And then from a... They have to be licensed though and have training in gender and autism and in a list of a few other things. I think maybe it's in there. that you have to know how to use the DSM, for instance. Which is, I don't know, there are any of them who don't, yeah. And then from a puberty blocker standpoint, is this something a primary care physician

can institute or no? Oh, that I'm not as sure if they list specific qualifications you need to have as the endocrine provider. Because I don't give them. But I will say from looking at the world, so usually it's either a pediatric endocrinologist or an adolescent medicine doctor. Those are the two specialties that I see. got it

generally we'll prescribe them what would you like to see primary care physicians do better when it comes to the trans community what I like them to do they're also in a tough situation sadly because what I would like them to do

is get the kid to specialty services right probably what would be helpful is that they had a little bit more training on knowing when a kid needs to be referred to specialty services because that creates problems sometimes. Like they'll often refer

very young pre-puberal kids to a medical clinic. And then if that is somehow missed, then like a whole appointment is taken up for a kid where you tell them you come back. Because we don't do medical intervention in a young person.

Yeah. But below the age of what? 10? You have to be in 10 or 2 of puberty. Got it. Okay. varies by age being 10-ish. for that kid it probably would have been better if they referred them to a gender therapist because then they can start doing

kind of like exploratory therapy with the caveat, okay, this is another term that is a problem. So exploratory therapy, I would say I conduct exploratory gender therapy that sometimes I have patients who come to me, to your point it's not entirely clear that they want to better understand themselves

and their gender and learn more and explore. Can you help me understand my gender? identity? Yeah, do you want to come? Yeah. No, but can we do it now? Or is this like totally inappropriate? I think it's okay. Okay. This is not a patient relationship. Of course. This is for fun. This is for educational purposes. Yes. Not for fun. Tell me what your question is. When someone says they have a different gender identity than their sexual identity at birth, I want to be able to better understand what that means so I'd like to better understand my gender identity

so how would I go about that I guess if you are my patient theoretically but you're not my patient I would want to hear more about like what led you to want to come see me to get you thinking about this so I guess there's something that you're worried about I want to become more empathetic knowledgeable to those who struggle with their gender identity

You were not a good referral. You should have read my book. Because you're not distressed. So patients usually don't come to me if they don't have some sort of... So what is exploratory therapy, then? They have to have distress? They're distressed about something,

but they may not necessarily have gender dysphoria. Well, I have plenty of distress. But not surrounding gender identity. Of a type of patient who comes, for example, is someone who is not sure if they're trans, like they're kind of confused about it. and sometimes we talk through it and they're actually not. So I've had examples of patients who come and talk to me

because they wonder if they're trans or have gender dysphoria and then we talk through it and actually they are like uncomfortable with their body for some other reason or they feel unattractive and think like other people won't be interested in them and so it's making them uncomfortable with like the gendered aspects of their body is a little hard to describe because these cases aren't super, super common

but it happens sometimes and it's often like a very specific outcome but there are cases where people show up kind of wondering like what's going on with my gender and they want to talk about it. The reason I was saying we have to be careful about the term terminology is that that phrase has been co-optive, exploratory psychotherapy by conversion therapists. So there are people who are saying that they're sitting down to explore

gender and help people understand it. But what they're actually doing is trying to convince the person that they're not trans, which is very different. People often miss this point. So it's conversion therapy if your goal is to change their sexual orientation or gender identity. But it's not conversion therapy if you're trying to help them understand themselves. I guess another example is someone who comes in, and again, this isn't super, because kids are really gender fluent, at least in the Bay Area where I practice, right?

They know a lot about this. But right, you can have a patient with autism who comes in who is saying, like, I am wondering if I'm trans because I, like, listen to all these things that I like. Like, I like all these feminine things, but then maybe you explain to them all the different ways you can be in the world. Like you can be a cisgender person who defies gender norms.

You can be a transgender person who is really distressed about your body. For this person, it's sounding like you're not distressed about your body. Like maybe you're a trans person who doesn't have physical dysphoria. Maybe you're a cisgender person who just rejects gender norms. But sometimes people do need to be given that vocabulary and that understanding to explore and really understand themselves. I guess another example is that patient example of, I introduced the internalized misogyny idea and they were like, oh crap, like I actually

need to go think about how this relates to my gender. So that you could maybe call that a type of exploratory psychotherapy. You mentioned that because I stated that I don't have a distress surrounding my gender identity, it's going to be hard for you to help me with the exploratory part of it. Does that mean? Well, more just like it. I know jokingly. No, no, more in terms of like resource allocation when you were asking about like what primary care doctors should do is I want there to be more education for primary care doctors to know when to refer to the appropriate place because we are so strapped for resources.

For me as someone who is not in distress with their gender identity, can I better understand someone who is in distress with their identity by better understanding my own gender identity or no? Yes. Yeah, I totally think you should read my book. Okay, so. because I do think like being so this just my point is this isn't something you need therapy for this doesn't require professional attention but definitely I think you can be more supportive

to trans people and gender diverse people around you if you are like expand how you think about your own self and your gender so in the book I have prompts for people because I think the book is going to be a lot of parents reading it in particular who want to better understand their kids and so I walk them through these different parts of your gender identity and then have prompts to think about, like, okay, do I have a transcendent sense of gender identity? Like, do I just feel male in a way that that's different from how I relate to gender roles? What are the gender roles that I relate to? What are the masculine gender roles I don't relate to?

Now I am wanting to do gender therapy for you. So, like, what are some parts of masculinity that you feel relate to you or don't? I don't know. That's, like, the thing that I think most doctors struggle with when I have this conversation with them. We, and this is a pretty broad group of physicians, don't understand what gender identity means and how to properly evaluate it because we were never taught it. So is there a world where, because humans are such adaptive creatures, that I've adapted to my gender identity that was taught to me by my parents, by media, by culture, by my sex assigned at birth, and then by

doing exploratory therapy, I'm going to create some confusion within myself, or is that not brought about in evidence? Well, let's see. So some things can happen. Like, did you ever have an experience when you were young, where you did something that wasn't considered masculine, and then there was a negative outcome? Sure. Like, for example, I always viewed myself as part my mom and my dad right like when you think about oh do i look more like my mom more like my dad i always viewed my logical side being more of my dad because he was very practical very stern russian father and my mom was more emotional and understanding and maybe even had a higher emotional intelligence because of that more empathy than my father would have who's more rigid and practical

and i felt like i had some of those feminine tendencies and i could see how other people would view feminine tendencies in men as a negative, as a weakness. Did that ever happen to you? Like that you said, like, I'm emotional or... Not in any traumatic, memorable way, but I vividly remember seeing other people be treated negatively for it, and I thought how incorrect it was. Did it change how you acted?

Interesting. It allowed me to see the value in the way that I acted, in being different. But again, I don't know if that's just an adaptation. Yeah. So the reason sometimes this is useful, especially for parents, is often there is something.

And the parent, some parents are, maybe you would be cool with your kid being trans and be able to talk about it easily. Most parents can't. And it could be for a bunch of different reasons. One of the most common reasons is that they themselves experience something I call like gender threat.

where they did something when they were little that wasn't stereotypically associated with their gender identity and then they got bullied or harassed or something. And so they, at a young age, learned, like, I actually need to live in this rigid gender box because it was dangerous to not. And so they're kind of... They think they're protecting their child.

They think they're protecting their kid. Yeah. And they think they need to do that same thing. But sometimes it's not... They don't realize that. They're just freaking out. And then I'll talk to them, be like, why do you think this is hard?

Because a lot of times I'll have parents who just say, like, my kid can't be trans. No, my kid's not trans. Like, they're not old enough to know this. And then I'll say, like, okay, like, why? Like, why do you think

that that's the case that they can't know this about themselves? And they'll get, the person will get really emotional and then there's someone packing. Sure. Sometimes it's that, like, gender roles have had a really negative impact on their life. So this happens for women all the time, right? Like they've experienced so much

misogyny that if they have a trans son, it brings up like, oh my God, is my kid giving into these misogynistic ideals that I really, really hate, for instance. So I think there's a lot of value in unpacking those things.

This is so throwing my dad under the bus, but I'm going to do an imaginary situation where if I came out as trans to my dad as a child. I'm going to try and imagine what his thought process would be or how he would talk about it. And knowing what I know about him being very practical, I think he would say, like, great, I don't care. If I would say someone's bullying me about it, he would step in if that bullying became chronic. If it was acute and it was short term, he would say learn to deal with it.

But I don't think he would pay special attention. With a bullying. With a bullying, yeah. where he would say we need to put special attention let's really dive into this is that a problematic way of handling it is that how most parents handle it? I think that most parents handle it okay that they just say

okay great you are that but keep doing good in school or focus on something else oh I think most parents don't want to deal with it so I think most parents run away from it and the importance of dealing with it is depends on the kid so for some kids

it's not a big deal. But for some kids, they have a lot of like stereotypically feminine traits, whether they're trans or not. And then they're actually getting like viciously bullied and it's really impacting their self-esteem. And sometimes parents still want to run away from a scary thing to talk about. And that I think is where it gets. What if there was no bullying? And the kids just live in their life breaking gender norms? Yeah. Cool. Is it important then to discuss it? Like is it important for me as a primary care physician to bring it up. No.

That doesn't happen too often, sadly. Locust society is as shit as it is. Yeah. But I have some kids who are just chilling. Yeah. I've had kids who are fine and there's minimal bullying and their school's super accepting.

They live in Berkeley. You know, like everyone's being nice about it. And they'll experience like occasional bullying but it's not a huge deal. And then they're kids who are trans or non-binding. but don't have physical gender dysphoria, for instance. So I have kids like that

who aren't just training them for like OCD or something else that they have, but the gender piece isn't a big deal. It doesn't always have to be a big deal. Is there ever a world, and this is probably moving away from the trans conversation, but just in general from a gender identity standpoint, like if I was very sensitive about

someone challenging my gender identity as I feel it, and I would get very upset by it, is there a time where CBT is appropriate than to say why are you feeling so negatively hurt

by those statements like evaluating that not from a necessarily transgender perspective it could be gender congruent maybe usually when I think about this is more when I'm educating people

why trans people are so mad at them like parents in particular or school staff or why are patients usually bad at them? So certainly sometimes people are just really frustrated like you're not seeing me for who I am and that is upsetting but there

are often other layers like let's give the example that I'm a trans woman and I you misgender me you may all of a sudden become like

the bully from high school who like threw me into a lot of them. So you like displace that those feelings onto it. Yeah. Or you might be like my parents kicked me out of the house when I was little, right? Or worse. All these things.

Like you can bring up all that stuff. So I think it's sometimes helpful for people to know like that's part of why like not messing up name and pronouns is sometimes a little bit of a bigger deal. And if you mess it up like how to react So if you just, especially if you're a person's doctor and you mess it up, to just say like, I'm sorry I mess that up. Like, I'm here.

I'm on your team. I can understand why that would be upsetting. It's better not to like dwell on it forever because sometimes you're more like feeding your own guilt than helping the person. Then you're making them more uncomfortable and they don't want to be around you anymore. But just knowing like kind of how and why that is sometimes upsetting can help. Fair. So when should I, should in my general. adolescent annual physical exam.

Should I talk about gender identity, if at all? Um, I think it's probably not a bad thing. Like, do you do it as part of your heads? Is that what they call it? Well, yeah, I'm asking if you think it's valuable. Like, there's people who say yes. It depends on how you do it.

Other preceptors have said no. I think there are ways you could do it where it could be bad, right? Like asking in front of the parents for a kid, and you do that for a kid. kid who's closeted, you actually, like, create a whole problem. That would be bad. I could see value, I don't know, I would probably leave this to the adolescent medicine doctors or filling medicine doctors decide for themselves based on you have limited time, right? So what you screen for. But for my biased perspective, of mostly taking care of trans kids, I think for them,

there would be value for you to ask because you could be the only person in their life where it's the first safe place to talk about it. And maybe you have a good feel for their parents and you could kind of work with them and maybe get them talking about it and potentially really save that kid from, you know, like a decade of having to hide this thing about themselves and feeling really isolated and pathologized.

Yeah, like I have children who display perhaps behavioral issues at school maybe have withdrawn from social contact issues with family members and they say, like, I don't recognize my child. They're acting completely differently. In those instances, is it worth discussing gender with the parents, maybe outside of the room? First thing, yeah, like a sudden change like that, the first thing I would probably screen for is trauma. Like, for instance, I think there'd be other things you'd screen for first. But I think if you could do little things to at least let the kid know that if that's what's going on with them, they could talk to you.

So if you have like a little trans lag on your lanyard, that kid's the trans. kid was really good to notice that, you know, and maybe feel a little more comfortable saying like, please don't tell my parents this, but the reason this is happening is, like, I think I'm trans and I told my friend and they told everyone and now, like, I hate being at school

because a bunch of kids are mean to me. Got it. So that's valuable to know, when to refer is valuable to know, who to refer to, depending on the age demographic, is valuable to know. And also referring to

a therapist immediately because another thing that sometimes happen is a kid is a candidate for medical intervention based on their age or stage of development so you've appropriately sent them to the pediatric gender clinic. And then they sat on that gender clinic wait list for a year

and then they got there and they were told for the first time you need to go get a mental health evaluation. And now they're really mad because they have to go do that and then somehow get back into this clinic to actually get it. And that's a whole disaster as it is from our healthcare system standpoint, I can't even get non-gender regular

CBT treatments for even people who have good quality insurance. So it's very messy in that regard. That's the other thing that's often missed from this conversation, right? Is there's this notion John Stewart said it in a really funny way. He interviewed the Arkansas

Attorney General and she kept making it sound like kids are getting rushed into medical interventions and he turned to her and said, you're acting like a kid walks into a pediatrician's office and says he's trans. And the doctor goes, thank God, because I've been building my trans army and, like, throws a testosterone dart at them. The reality is, like, you're probably not prescribing a puberty blocker

or hormones for these kids, right? Like, you're the first person they're going to see. And then they're going to struggle for a really long time to even start this, like, careful, thoughtful process. It's very true. There are some societal, maybe non-medical or less medical situations that have come of this. I think one of the ones you've discussed,

and worth discussing today is about sports. What is your notion of transgender athletes participating in, I guess, how would you say it, in cis sports? No, like sports that align with their gender identity. Sure, sports that align with their gender. So I'm on the NCAA Committee for Competitive Safeguards and medical aspects of sports, so what I'm saying is me, not the committee or the NCAA, to be clear.

And that committee is not just about gender, right? Yeah, we barely talk about gender. Yeah, I think I'm like, I think I'm there for that a little bit, but I also am screening a lot of people for if they are being sketchy about taking stimulants for competitive advantage. Or like amenorrhea from over-exercising or something. Yeah, I mean, a lot of what we do is like when people are taking banned substances and still want to compete.

Okay, fair. Of which testosterone is one. Although I think, I don't have the numbers, but I think we get more people taking, cis people taking testosterone for a million different medical conditions that sometimes are less convincing than others than we do in trans athletes. But I have a lot of thoughts on this. And I'm glad this is a long podcast.

So we're going to start with history. So I'm really struck by this historical thing that happened. So in Colorado, there were a bunch of cities and towns that were passing laws that made it illegal to discriminate against LGBT people. And there were some political activists who didn't like that because they thought being gay was wrong and it challenged the social order, et cetera.

And so to stop that, they wanted to amend the Colorado Constitution to make it illegal for individual cities or localities to pass anti-discrimination laws to protect LGBT people. They came up with two strategies that might sound very familiar. The first one was to say LGBT people are dangerous to children because they're groomers.

You may have noticed that's back. The other one is that they saw that civil rights activists kind of hit a wall with affirmative action because white people were kind of okay with civil rights until they felt that something was being taken from them. So they came up with a slogan called equal rights, not special rights. Non-discrimination laws don't give you special rights. But that kind of didn't matter because they were just capitalized. on this feeling and they went all over the news and they kept saying the slogan and then it passed the amendment to the constitution passed for the state and then later was overturned by

the Supreme Court but I think that playbook is back right because the groomer thing is back and then the sports thing is interesting because it's really worked right there are a bunch of liberal voters who are freaking out about trans girls playing in sports and I think it's because it capitalizes on this notion that like something trans people are taking something from cis people, like they're getting special rights, they're getting a leg up, which is bat shit, right?

Like, have you met a trans person? Like, they're facing every hurdle in society. Most of them, like, sports are the last thing they're caring about. Like, there's no evil scheme for trans people to, like, take things from cisgender people. But so I think there's, like, a big political appeal, and that's why it's being pushed. because the Associated Press did a study

where they asked all the state lawmakers who introduced bills that would require trans people to participate on sports teams that aligned with their sex assigned at birth and they said, can you name a trans athlete in your state and none of them could?

Right? Which raises the question, what inspired you to introduce this legislation? And then, if I think, so put the political motivations and why we're even talking about this, aside and just thinking about the actual question at hand. So the theory for why trans girls should need to participate on boys' sports teams is that they've had testosterone and puberty,

and that gives them an athletic advantage. First of all, it's not true for a lot of trans kids. Like the kids who have puberty blockers, it doesn't make any sense, but all of these laws would still make them participate on boys' sports teams. And there is a bunch of data that cis men do better in certain sports than cis women but trans women are not cis men right and in fact there's research

that looks at their muscle mass and other physiologic parameters that they are kind of at a disadvantage compared to cisgender men transgender women because of hormones no before hormones probably for a million reasons right

like they they don't have well so we'll get to that So they have, as much as we talk about this testosterone advantage, that's just one part of what makes you succeed in sports, right? Like you have to train, you have to have resources, but trans kids have the deck stacked against them in like every other way aside from this supposed testosterone advantage. Like they have more anxiety, they have more depression, they're being bullied.

Like they're very distracted by other things that make it hard to compete and succeed in sports. Which is why they're underrepresented in sports participation in title. So you'll constantly hear people give one example of a trans person succeeding, right? Like Leah Thomas. But I don't think it should be that trans people can never win. Like I think what would be fair

is if they're winning proportional to how many trans people there are in the population. Well, that's strange. We're never looking for proportionality in sports. Because then certain leagues are being very discriminatory certain races then.

What do you mean? Well, there's like the NBA, the amount of white people's not representative of white people in the population. Which is another good example, though, right? Because decades ago, we had this exact same conversation about, not you and I. Decades ago. Had the exact same conversation about race. Like there was this idea that African American people had this supposed athletic advantage,

and so they had to be segregated in sports. And turns out probably a lot of that research was kind of sketchy. But right, if we're talking about fairness, right, there's this idea that's being propagated that trans girls have an unfair competitive advantage. But if that were true, shouldn't they be overrepresented in titles?

I guess it depends. I wouldn't necessarily say it's clear cut. Could that develop over time? I think it's possible. So that's kind of my point. So I think they don't have an advantage because they have all these other things that are disadvantaging them. So if in the future

like all the other things that made it hard for trans athletes to succeed win away like the stigma was gone and some testosterone advantage was revealed and all of a sudden trans women are dominating sports leagues and cisgender women aren't winning then I think that's when it would be

a more reasonable time to have that conversation but at a time where trans people are underrepresented in sports and it seems they actually if anything have a disadvantage based on the fact that we're not seeing a bunch of winners I just don't think this is a like honest conversation What happens in like combat sports

Where you have Like you'll say let's wait to see if there's an advantage But then someone can get really hurt Waiting for that advantage to be born out And then by the time it's born out We've hurt a lot of cis women But cis women get hurt from cis women in sports all the time Right

And there's no data that they're getting hurt more from trans women. Right, but you're saying there's a possibility that that might be borne out. Theoretical possibility. I don't know that I'm actually buying it. Because I think about your point about marginalized communities

and those who are mistreated by our society, they would have a disadvantage in sports. But with certain sports, we see marginalized communities thrive and do very well. But that's not what we're seeing with trans people.

Right. Not with all trans people. Because they're like the most marginalized. Well, that's like a weird competition. Yeah, I mean it's a weird competition, but right, it's true. I can't get behind this idea that's being propagated that like trans people have some special like advantage in society. But with the Leah Thomas example, like initially we're talking about those who were transitioning early had puberty blockers didn't have that puberty. puberty, so-called advantage. But in that case, isn't there, like, wasn't Leah Thomas participating in men's sports? Yeah, Leah Thomas isn't a person like that. But is it possible that Leah Thomas is just a really good swimmer? Well, if, like, not because she's, not because she's a great swimmer. That's not up for discussion. But, like, why is she not allowed to win? I don't know if it's, first of all, like, who am I to say what's allowed? This isn't my statement.

I guess my thought is why do we need men's and women sports? Well, I didn't create that. Well, I'm asking. Do we need that? Well, right, so there is convincing data that cis men do better than cis women in a lot of competition. So that's why they're separate.

However, I maintain that trans women are not cis men. We don't have data that trans women have this huge advantage in the way that it would seem that cis men would. And you're saying because of the mental health, the stigma, the marginalization. Yeah. Yeah, I would like to see how the data stacks up on that in comparison to other marginalized groups, just because that's what I would be looking for for a contrasting example. But I guess I would go back to like why are we fixated on separating sports in this way

when we're in a situation where there's not an overrepresentation. Like, if anything, it would make more sense to look at the other places where there is an over-representation. Like, that is more logical than looking at this group that's underrepresented in titles and participation. Well, I think it's largely cultural. Like, the idea of why we have different sex-based sports leagues, but not different race-based sports leagues. Like, why did that happen? Just because it would be messed up to have different race-based. It's kind of messed up to have a separate trans sports league.

Well, that's what I'm saying. If you come from space and you look at it, maybe one group of people, people say, why do they have different sexes compete with one another? This doesn't make sense to us. So I could see how an outside perspective, any kind of group differentiation could be viewed as harmful or negative. So if we're going to say there's an advantage to being a cisgendered male playing a sport, there's an advantage of cisgender male playing a sport against a cisgender female, I don't necessarily see physiologically how that advantage is lost in all. all transgender athletes.

Like I could see the ones that you're describing that went through puberty blockers. And I feel like that's what the Olympic Committee was trying to do. Trying to set certain hormonal parameters. I mean, that's what the NCAA does also is you have to be on, you have to have your testosterone suppressed

for a period of time to like a sports specific level that's based on like all other competitive leagues set there rules. I believe on your panel in Dartmouth, Dr. Rippon mentioned maybe there's a sports league in the future that stratifies people,

based on their testosterone levels, where it doesn't matter what your... I think I did tell her that doesn't totally make sense because... I agree, but I'm just saying. But the reason that doesn't make sense is because, like, your current testosterone level doesn't necessarily mean what it's been in the past. But, like, how do you...

I think maybe, like, I hadn't quite thought about it the way you're pointing out, but I think that is important of, like, why are some of these separations okay and some aren't? So, although, I don't know. And I don't have a good answer. There actually are a lot of problems.

So I think generally we think it's okay to separate men's and women's sports, although it does create a lot of issues, right? Like there's less funding for women's sports. They get less... If we were to do... They get a few sponsorships. They get less media attention, et cetera.

But, right, it would be really messed up to separate, to have different leagues based on race because there's a sensitive history of, well, I guess there's for women also. But right, it comes down to, like, think about what this does, to the trans people, right? So this is the other thing that sucks

is we have these like intellectualized conversations and right, the conversation we're having is so far removed from like the trans girl sitting in my office. So think of what happens to her. So she, let's say she's not out, right? Like she's, because she's afraid to tell people for stigma and she's running track.

What do you want her to do? Like you want her to be a girl all day and then like when it comes to the end of the day and she goes to track, She's going to go be with the boys. Like, that's humiliating and awful. After all these years of brewing KOR's original, we've learned one undeniable truth.

Any legacy is possible. You just have to start. Core's Original. How will you start your legacy? Celebrate responsible. Must be legal drinking age. I don't have a good answer. And I'm not saying that that's a good answer.

And I think if we're balancing, like, like, why is it so scary to have trans? The scary thing about trans people participating in sports is that they have some huge advantage so cis women don't win anymore or they're like hurting people at disproportionate rates. We don't have evidence that either of those things are true but it is very clearly evident that these kids,

if forced to have to go play on the boys' team would feel awful and humiliated. So like why are we... You know, it's like it's a lot like the Colorado thing. we're going to pass a law, say, like, attacking the LGBT people for this supposed advantage that doesn't even exist? So you're talking about it as an example of their feelings of how they feel of having to play on a boy's team when they don't want to, or they don't feel like they belong there. And I could totally empathize with how terrible that feels. Could I know personally? No, but I'm trying my best to empathize. at the same time I'm trying to empathize

with the cisgendered girl who's participating in the sport that was swimming for her and now she no longer can win but that's not true because they cisgender girls win against transgender girls all the time I meant in that competition right

because the people who competed in them has she ever lost to a cisgender girl probably yes and again are we making light of her struggle by saying well you win sometimes And because someone from the other side, right? That's sports. Sometimes you win, sometimes you don't.

But imagine someone's like that's like the trans person. Sometimes you win, sometimes you don't? Well, yeah, like if they were losing. The trans person would probably be like, yeah, just don't make me go play on the boys' team because that'd be humiliating. I'm fine losing sometimes. That's part of sports. And you know, the examples get really sketchy.

So like the classic example is people are constantly talking about this Connecticut case, right? So there were two transgender girls who were African American, which I don't think was a coincidence for why this lawsuit was brought, but they were running track in Connecticut. The Alliance Defending Freedom, which has been behind like every legal, social legal case that's been high profile, right? Like gay marriage, sodomy laws, abortion, anything, any trans case. They brought a lawsuit and they sued the Connecticut Association. of schools saying, you know, you can't let these transgender girls compete because if they compete, our cisgender plaintiffs can't win. That's what they said. They filed their lawsuit like a few days later at the state championships. The cisgender girls beat the transgender girls

that they had to throw out the lawsuit. And they ruined like sports for these transgender girls because they became a huge news story. They were all over Twitter. People were like circling their musculature and calling them men, they don't play sports anymore. I interview Andrea Yearwood, who's one of those kids in my book. And it's just so far removed from

reality, you know? Like, it's not honest. Like, they're just saying that these cisgender girls can't win, and then they do win, and then they'd ever talk about that case again. You know, like we're done talking about Connecticut because that just,

wasn't true. And Leah Thomas doesn't win every single race, right? But the people are capitalizing on this idea that trans women are like unbeatable. Right? I don't think that they're saying they're unbeatable. You just said like she can't you she like the sister gender girl's upset because

she can't win but she can win probably often does win. I meant in that one situation but if someone feels like you know in sports everyone is always up in arms if someone has a competitive advantage. Which there's always subcompetitive. Yeah, whether we're talking about Formula One, they did some illegal modification on their car versus someone taking a supplement

versus someone taking... Or some people are taller. Exactly. So everyone always will rush to make some sort of statement, excusing either their loss or whatnot. But if you genuinely feel that you're at a disadvantage because someone was born a biological male, I have to empathize with that person feeling their struggle that they feel their disadvantage. Even if they don't have data that they're at a disadvantage? Well, when we say they don't have data, what does that mean?

Like, if someone went through puberty and has... Well, because trans people aren't dominating sports leagues. Well, that doesn't mean that they're not at a disadvantage. If they were at this, like, advantage, wouldn't they be winning? More than there are... Why does that have to be true? Because if you have an advantage, you're going to win more. Well, you're talking about really just first place.

And I'm talking about someone beating you. for fifth place, right? Like finishing ahead of you. No, I'm just saying if you have... Like a fairness. If you have an advantage, then the trans people are all going to do better.

Well, even on average, they're going to do better. They're going to be overrepresented in the sports titles. I think that could be a possibility. But that's not true right now. But that doesn't mean it's not true, period.

Is that fair to say? Well, but then are we just grasping at straws? Well, no, because we're looking at other data points to suggest that, Just like how, if we don't have... What's the data point? That someone who went through male puberty has some sort of advantage

physiologically, stature-wise, bone density-wise, muscle mass-wise. And someone could see that as a disadvantage to them, whether or not that person wins or dominates the sports league. Is that fair to say? I guess I would just go back to the fact that like, first of all, that data is cis men compared to cis women.

And it's not showing that trans women have, right, because it's all about advantages. Like, it's not showing that trans women have an advantage over cis women. And I guess I would also come back to, like, isn't it kind of wild that we're even talking about this? Yeah. Like, what is this about?

Yeah. Like a classic example. So Utah, for instance, passed a law that would force trans girls to play on boys' sports teams. and the Republican governor, Spencer Cox, heard from a bunch of people who were like, that seems mean, right? That seems mean to the trans girls.

And so he went and he looked, how many trans athletes even are there? And I think they found four in the state, and one was a trans girl. The other three were trans boys. And so he vetoed the law and said, like, why are we having this huge focus on impacting these, like, four kids? It's like this doesn't make any sense.

This is like, he may have called it, like, legislation looking for a problem or something. And I feel like this is a conversation that's not, I don't think it's really about the sports advantage. I think it's about something different. I think there's a lot of cultural issues that present in very different ways. And because the topic of gender is so culturally tied, even the definition of a gender identity has cultural norms in it, right? So how it impacts people's cultures, whether or not we believe it to be fair or not, is going to be open to interpretation. There's no facts to how someone feels or whether or not they feel it's fair. Factually, it doesn't have to be a men's women's sports league, right?

But culture has set it up that way, and that's where we are, and that's why we're talking about it. So it is very messy. I'm not going to lie. And it's terrible that we're doing it at the cost of someone. And I think it's just mean. Yeah. Yeah, I think it's just mean and it's like divorced from the reality of the situation. And I think it would be really hard to sit down in front of a trans kid and tell them like, I think because all these things.

Like I get that I get that you're not overrepresented in sports. I get that you have all these mental health challenges. I get that you personally aren't even winning, but you need to go play with the boys. Yeah, I could see that being fresh. Yep. And right, there are people who are like real fringe and right wing who probably do still think we should like segregate sports leagues by race. And that's also tough. And I think this is similarly that.

What role do you think we play as physicians in helping politicians shape policy for sports teams or bathroom policy, which has gotten a lot of publicity in the news these days? I really think we should be careful to make sure our decisions are based on evidence, right? And I think that's what doctors and researchers are helpful with is we can bring research and evidence to these policy debates. So bathroom bills are a perfect example That the reason people say that you should have to use the bathroom that aligns with your sex assigned at birth Is because if we have trans inclusive bathroom policies there will be more sexual assaults That's what the argument is right But it's been studied and those studies are made never in the policy debates that you watch

So there's a study in pediatrics by Murchison at all that looked at trans inclusive bathroom policies and schools and they found that the schools that had the trans inclusive bathroom policies after adjusting for other variables had lower rates of sexual assault against trans students. It raises the question still like, okay, but what about the general cisgender population? What happens to their assault rate? And that was studied also. And what they found was that the assault rates for the general cisgender population aren't

higher if you have trans-inclusive bathroom policies. So it seems pretty clear. You should have the trans-inclusive bathroom policies. In general? I don't know. I don't know the full history, but what the political debate is now is there's an idea that if we didn't, that there will be more sexual assaults in bathrooms. Was that ever borne out by evidence in the past, do you think? I don't know. Not that I'm aware of.

At least with the trans inclusive bathroom policies, it shows, like when you let trans people use the bathroom that matches their gender identity, no. I don't know if there's data on just like gender neutral, like having a place only having gender neutral bathrooms. if it changes assault rates. I've not seen that. There was something I wanted to ask. One of my friends was applying to a job

at one of the major news stations and they were asking some general demographic info and one was about gender and on the Dropbox menu it had the conversation that we talked about today, non-binary, male, female, etc. Or maybe it didn't have male-female,

but either way. One of the things that popped up was something like Two-Spirit. help me wrap my head around what that means from a medical perspective. What two spirit means? Or like that there's like different groups of gender identities that I'm not familiar with. And it seems like there's a growing list. Yeah. Two spirits are very specific one that is from Native American communities.

So there's a long tradition in some Native American communities. I'm not a complete expert on this. But that it's culturally understood that they have people who, are not, like, in their social categories, fully male or female, and their phrases, two-spirit, for those people. It does bring up this interesting thing that it turns out. There are kind of trans, gender-diverse people across cultures, just call different things and throughout history.

So another classic example are, like, He'sra people in Indian culture that goes back for over a thousand years. But there are a couple different things going on. So that one's interesting because it's like a culturally contained. social category for people. But there are a million terms. Doctors can get really overwhelmed, understandably. And it's evolving, right?

Like demi-boy, demi-girl. I don't know if you've heard of these phrases. But younger generations are just thinking of gender in a more expansive way. And they've come up with more terms. Sometimes you just have to ask, be like, I'm old, I'm so sorry. I don't know.

Can you talk about that means? I could go research it if it's annoying for you to explain it to me. It's a nice way to say it. but right like there you could think like male and female that's how a lot of older generations think about it and then maybe you think male female non-binary but what if you're like here or what if you're here or as we're pointing out it's not even like a single line right because it involves how you feel about your body how you feel about social categories if you have that transcendent sense so people are just creating more nuanced vocabulary to describe those different things got it one thing

I would say that gets people and families and political debates up in arms is I think people feel like their definition of gender needs to be right and the other persons is wrong and I don't feel the need to have that fight. Like what I

was on that panel at Dartmouth with, I think Alex Byrne, is his name. He really wanted to define sex and gender as gametes and like if he defides himself based on the size of his reproductive cells, like more power to you, dude. I could care less. But please just don't like

go tell my patients who are trans, who are trying to like live their lives as women in a social category, like you're defined by your gametes because they don't identify by their gametes and who are you to like tell them how to define themselves. Isn't that their gender identity versus what their sex? Well, he says that your gender identity is your sex. Is your is your gametes, which like, okay. Because I thought that was just his definition of sex. He doesn't believe sex and gender are different. Oh, different.

Okay, got it. Because I believe that his point, why he defined sex that way at the very least, was because if you zoom out from us as humans in other species, that's how it. He wanted it to apply to plants also. Sure, like, by all means, but. But that's not something that's applicable to someone's identity. Don't that come tell me that I have to always defied sex by gametes, because if I'm running a clinical study, I don't have access to people's gametes. To categorize them, I'm going to go

on what's in their medical record, which is their birth certificate, which is why that's what we use. Fair. Complex topic. I think there's room for part two on this. Definitely. Yeah. Yeah, I think once this lands for people, they're going to have a lot of questions for us. I think part two could be answering some of those questions. I'm going to listen back to this conversation, continue to grow and become better for my patients because I think it's mandatory for us in the health care community. I think there's a lot of questions and not a lot of education. So I appreciate you making the time to go out of your way, very far out of your way to come to New York and do this work. Because if it wasn't for you,

honestly, a lot of people would not have the valuable information that you're sharing and you're literally saving lives in the process by doing this level of education. That's very nice of you. Thank you. And I guess if I want to leave people with one thing, is just that all of this is really complex. And if you are hearing people in the media, make it sound really simple, be wary. And try and dive deeper.

And it's a shameless plug for the book. But that's really what I try and do is take these ideas that have been represented as being simple and try and help you open them up and just think about them with more complexity. Well, just like I think we said on the first, it wasn't even the podcast then. it was the YouTube channel then nuance is a superpower and I think with this conversation we

desperately need more nuance less clickbait less attacks especially from the political space because that doesn't help anybody totally cool well thank you appreciate your time doc thanks