I'm Dr. Sophia Mata, and I'll be the moderator for this session. It's my great honor and privilege to introduce Dr. Jack Drescher for today's Distinguished Psychiatrist Lecture, Evolving Controversies in Treating Gender Dysphoria Youth. As moderator, I do have some bookkeeping items to go over. So at the end of the session, we will take questions and answers for the audience. And also, this is being part of the virtual presentation, so that I will also be taking some questions from the virtual audience as well, too. So I will be alternating between a live question and then also a virtual question. Dr. Jack Drescher is Clinical Professor of Psychiatry at Columbia University and a faculty member at Columbia's Division of Gender, Sexuality, and Health. He is a Senior Psychoanalytic Consultant at Columbia's Center for Psychoanalytic Training and Research and Adjunct Professor at New York University's Postdoctoral Program in Psychotherapy and Psychoanalysis. He is a Training and Supervising Analyst at the William Allenson White Institute, and he is a National Faculty Member of the Florida Psychoanalytic Center. He is an Elected Director-at-Large of the American Psychoanalytic Association and serves as a member of the Committee on Public Information and Committee on Gender and Sexuality. He serves as a consultant to the Sexual and Gender Diversity Studies Committee of the International Psychoanalytic Association and presently serves on IPA's Communication Committee. Dr. Drescher is Distinguished Life Fellow of the American Psychiatric Association and the past President of the Group for Advancement of Psychiatry and past President of APA's New York County Psychiatric Society. He presently serves as a corresponding member on APA's Council of Communications. He has served as Section Editor on the Gender Dysphoria Chapter in the DSM-5 Text Revision Process. He has served on APA's DSM-5 Work Group on Sexual and Gender Identity Disorders and served on the World Health Organization's Working Group on the Classification of Sexual Disorders and Sexual Health that revised sex and gender diagnoses in the ICD-10, sorry, 11. He has served on the Honorary Scientific Committee revising the second edition of the Psychodynamic Diagnostic Manual. Dr. Drescher's professional honors include the 2022 Sigourney Award for Work on Gender and Sexuality, the 2022 Public Communications Award from Columbia Psychoanalytic Center, a Distinguished, 2023 Distinguished Psychiatrist Lecturer at this year's APA, and the 2023 Pascal Normal Award for Excellence in Psychoanalysis from the San Francisco Center for Psychoanalysis. It is my honor and privilege to introduce Dr. Jack Drescher. Thank you. Thank you for that. Well, welcome. I'm going to, as we know, we're going to talk a little bit about evolving controversies in treating gender dysphoric youth. I'm not a child psychiatrist or child analyst, but became interested in this subject in my various iterations of my work with the DSM-5, the ICD-11, and the DSM-5 text revision, which I work closely with people who do work with these children and adolescents. So this is sort of my attempt in the last 15 years to try and understand some of these issues. I'll start with the question of gender. For many people, gender is binary. If you travel anywhere around the world and you're in the airport and you want to find a restroom that suits you, you might look for one of these two universal symbols with which you might identify to figure out which restroom you should be using. But sometimes binaries are inadequate, as in Scotland, where this man doesn't know which restroom to use because men wear kilts. So gender is not really about biology. Gender is about culture. As I've been giving this talk around, someone who saw the talk sent me these pictures from Qatar, for example. I'm not sure you could figure out yourself, if you're not from Qatar, which is the men's room or the ladies' room. But here they do explain it to you in Arabic and in English, if you don't know how. So as I became involved, starting with the DSM process, in the subject I'm going to talk about today, I really became aware that there was a big picture that I cannot see. This is the closest I could get to a big picture that I cannot see, six blindfolded scientists trying to describe an elephant. One of the things that really, I think, characterizes the way many people will talk about this issue, and you may even hear some of that in some of the questions and answers that usually come up after this talk, is that some people focus on one part. They think it's all about the tail or the tusk, but it's not. Part of the difficulty is really being able to think about this in a complex manner, which is the challenge we're going to try and talk about today. So I'm going to define some terms for you. There are many languages here. A lot of people don't know what many of the words mean, and so one of the tasks I've given myself recently is to help educate mental health professionals who know a little bit to learn a little bit more about the subject. Then I'm going to talk about some of the clinical controversies surrounding the issues of gender dysphoric youth, and then finally conclude with what I call putting on the brakes, what's happening in the socio-political arena surrounding gender dysphoric youth. So we'll start with some definitions. Start with sex. Sex is about biology. Sex is about your chromosomes. It's about your gonads, your hormones, and the appearance of your genitalia as well. Gender, however, is not about ... Although there are legal documents that use the word sex and gender as if they were the same thing. Some states' driver's license asks for your gender, but your gender and your sex are not the same thing. Gender is more your way you live, your ... What's the word I'm looking for? Your expression of yourself, whether it's as a boy, a girl, a man, a woman, or some other category, with biology and other psychosocial factors having some role in the creation of your gender. Your sexual orientation, now this is a very important point. Historically, sexual orientation and gender identity were treated as if they were conflated with each other. It's only in the middle of the 20th century does our literature begin to tease out the difference between a sexual orientation and a gender identity, which I'll also define. A sexual orientation is your erotic response tendency or sexual attractions. If they're directed to someone of the same sex, we call that homosexual. If they're directed to someone of a different sex, we call that heterosexual. If it's to both sexes, we call that bisexual. One of the problems, if we're working with trans populations, is that are we talking about their sexual orientation before or after transition? It's a very clunky term for this population. The literature has words like androphilic, meaning it's attracted to men, or gynophilic, attracted to women. A person could be androphilic both before and after transition. Another important point, which I will emphasize throughout, is that my gender identity, whether I think of myself as male or female, tells you nothing about my sexual orientation. We'll talk a little bit about that. Sexual identities is a little bit different than a sexual orientation. This is the subjective experience of one's sexual desires or attractions. I might have a homosexual attraction, but if I don't accept that aspect of myself, I might decide to become celibate and go into the Catholic priesthood. I do not adopt a gay sexual identity. You might want to call me gay, but gay is an identity. It's not a sexual orientation. Sexual orientation identities are how people subjectively experience their identities. The Center for Disease Control, for example, in tracking the HIV epidemic, does not talk about HIV in gay men. It talks about HIV in men who have sex with men, because it's a behavioral description that adequately captures what goes on during the epidemic, so the CDC understands the difference between an identity and an orientation. Sexual identity, how I think and feel about my sexual attractions, is not synonymous with the sexual orientation to whom I am attracted. A gender identity is an individual's identification as male, female, or some other category, and we'll talk about some of those other categories. As I said earlier, my gender identity tells you nothing about my sexual orientation. This was not ... Well, we'll go on. Transgender, this is not a scientific term. This is a colloquial term. It was coined first in the 70s to describe people whose gender identity or gender expression and behavior did not conform to that one typically associated with the gender to which they were assigned at birth. Now, there are other terms like gender fluid, gender nonconforming. I won't read through the list. I'm not going to define them for you, because actually, everybody uses the terms differently. I edited a guest issue of APA's Focus Journal on a special issue devoted to working with LGBT communities, and my committee, the Group for Advancement of Psychiatry, a room full of experts, were all writing articles, and I said, why don't we have a glossary so that all the articles don't have to keep defining what they mean, and the group could not agree on all the definitions, so we didn't have a glossary. The importance here, particularly the clinical point here, is that when people define themselves in this way, if they come into your clinical practice, it's okay to say, I've heard the term. I know that not everybody uses it the same way. How do you mean it? Because we're really talking about the adoption of subjectivities in the clinical world that we live in now, and so the best thing you can always do is to ask people, you know, what do you mean by that? Gender expression is a term that's increasingly finding its way into legal documents that refers to how people demonstrate their gender to others by a manner of dress behaviors and appearance. So if a heterosexual, cisgender woman decides that she likes to wear men's clothing, she may be heterosexual, she may be cisgender, but her gender expression is atypical, and so she, you know, there's some places where you cannot discriminate against her just because she likes to wear atypical gender-expressing clothing. Gender assignment is what happens at birth. Historically, people talk about biological male or biological female, but again, we don't know where the biology of gender, identity and gender, stems from. We believe, most people believe, you know, that the genitals that you're born with is an indication of what gender you will develop into, and that actually is true for most people, but we know that it's not true for everybody. So when we're talking about working with these patient populations, we talk about people as being birth-assigned male or female, or individual-assigned male, female at birth. The language here, again, is always changing. For example, natal female or male was once acceptable, we used it in the DSM-5, but it has grown out of use, and now we talk about BA, female or male, or birth-assigned. Disorders of sex development are conditions, inborn somatic deviations of the reproductive tract from the norm, or discrepancies from conventional biological indicators of male and female. Historically, we referred to these people as hermaphrodites. Even today, we refer to these people as intersex, having intersex conditions. There are members of the intersex community who do not like the term disorders of sex development, so they would like a less pathologizing term, so they have preferred differences in sex development. Both of them can be abbreviated as DSDs. Gender dysphoria is a term that's been around for a long time. It refers to a, before we used it in the DSM-5 diagnosis, it was a term for the distress that people, that accompanies one's incongruence between their experienced or expressed gender and their assigned gender, and it was the diagnosis that replaced the gender identity diagnosis, gender identity disorder diagnosis of DSM-4. In the ICD-11, on the other hand, gender incongruence is the name of the diagnosis, and I'll talk a little bit about why that is. The ICD-11 was approved by the World Health Assembly in 2019. It started being used in many countries around the world in 2022, not in the United States, and it describes the marked and persistent incongruence between a person's experienced gender and their assigned gender, and this is the diagnosis that replaced transsexualism and gender identity disorder of childhood in ICD-10. So gender reassignment, that's a little better. So gender reassignment, or gender confirmation, is an official and sometimes legal change of gender. It may involve something called social transition, which implies no use of medical or surgical interventions, change in clothing, change in name, change in pronouns. It may involve hormone treatment. Some people want, as part of their transition, to be treated with either masculinizing hormones or feminizing hormones, and some people want what used to be called sex reassignment surgery, today is referred to as gender confirmation surgery, which are the surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble that of the other sex. That might involve top surgery, which would be mastectomies in birth-assigned females, or breast implants in birth-assigned males, or bottom surgery, which is surgery to alter the appearance of the genitals as well. And it's important to keep in mind, and I'll talk a little bit more about it, not everybody has all the treatments, not everybody can afford all the treatments, so there's a lot of variation in the transgender community, and the patients you might see in this community are a broad range of clinical appearances and wishes and desires. It's also important, unless a child has an intersex condition, it's rare for surgery to be performed. It's not a common procedure. Transsexual is a historic term, it's a medical term for people who receive hormones or surgical treatments. It's a term that emerged in the middle of the 20th century. In this literature, it's talked about as being partial versus complete, so as I said before, partial would mean somebody had maybe surgery but not hormones, somebody had hormones but not surgery. If they had both hormones and surgery, it's called a complete transition. If the transition is from birth-assigned male to female, the literature used to refer to such a person as MTF, the community refers to such a person as a trans woman, and if it's in the other direction, it's FTM or trans man. And again, gender identity and sexual orientation are independent variables. This was an interesting historical point. If in the middle of the 20th century you were birth-assigned male, you were attracted to women, but you nevertheless had what we would today call gender dysphoria and wished to transition and you went to see a doctor who might offer those services, you could not, as a birth-assigned man, tell the doctor that you were attracted to women, because at the end of your procedure, they would be making a lesbian, and this was a very heteronormative practice in the middle of the 20th century, so these were things that people could not reveal to the clinicians. These are not the standards of care today, but this was a standard of care years ago. So this is a very famous trans woman who publicly transitioned from male to female, is publicly gynephilic in the sense that she was married to a woman before her transition and has publicly announced that she's still interested in women since her transition. This is the child of Sunny and Cher, publicly transitioned from a lesbian identity to a trans man, known to be gynephilic both before and after transition. I'm not revealing any confidences here, these are public figures. Cisgender, this is a term that the transgender community uses to describe people whose gender identities align with their assigned sex at birth, that is to say that if you in the audience are not identified as transgender, the people in the transgender community might refer to you as cisgender. It follows the kind of history we saw with the words homosexuality and heterosexuality. Maybe 80 years ago, if you were a heterosexual, you might not know that you were, because it was not a term that had entered into popular language. Cisgender is now gradually entering into popular language, you'll read about it in the newspapers. And it comes from the Latin cis meaning on the same side, trans on the other, and if you remember your medical school, organic chemistry, these are cis trans isomers. If you draw an invisible plane through the gray molecules, the two molecules, the molecule on the left, the two green atoms are on the same side of the plane, so that's the cis molecule, and the molecule on the right, the two green molecules are on opposite sides of the plane, and that's the trans molecule. There are a lot of scientists in the transgender community. Transphobia is a term patterned on the word homophobia. It includes a wide range of negative attitudes, feelings, or actions towards transgender people. Some see it as underlying much of the social stigma that we see against transgender people, which we'll talk about at the end of this talk, such as bathroom bills. The bathroom bill, which the first one emerged a few years ago, I think in North Carolina, was a bill that would force a birth assigned man to use the men's room, no matter what their physical appearance was. So that would mean that Caitlyn Jenner in North Carolina, if the bill had been sustained, would have to use the men's room. And we can talk about how those kinds of ideas play out. But transphobia is also seen to lead to fatal violence, which disproportionately affects transgender women of color as well. There are some other terms. These are community terms. Misgendering is the lack of recognition of the gender expression of a particular individual. So if you decide when you meet a trans woman to use male pronouns, and that happens accidentally a lot. I'm theoretically an expert, and I sometimes make those mistakes. But sometimes it's deliberate. Some people refuse to recognize a person's gender pronouns. Deadnaming, again, another term in the community, is the use of a person's pre-transition name and the refusal to recognize their post-transition name. I know some people in the community for whom that's not a problem, but for some people it's a very upsetting thing. And again, it can be accidental and happens all the time, or it can be deliberate when people do not wish to respect a person's subjectivity, for whatever reason that may be. Pronouns. Now, Facebook offers more than 50 gender options for pronouns, which I have no interest in memorizing, and I don't think you should memorize them either, because you could use your brain for other things. So I think the best thing is ask. Ask people, what are your pronouns? I sometimes get asked the question, I work in an inpatient unit. My patient is identified as female, is using a woman's name, female pronouns. But the insurance is in their pre-transition name. It's a male name, it's all over the chart. What should we do? I say, well, right in the beginning of the chart where you just told me that the patient prefers, presents as female, uses a female name, wants to use female pronouns, and we will do that through the rest of the chart. The insurance company won't sue you, and the patient won't sue you. It's simply a matter of being respectful of the patient's subjectivity. Gender policing. Now, gender policing is something defined as the imposition or enforcement of normative gender expressions on others. We are all raised to police gender, pretty much. I mean, if you just take a look around the room right now, you could register in your mind who is presenting male or female gender expression. This is just something that we're coded to do at a very early age. There is research by Kohlberg, having nothing to do with transgender issues, but having to do with how children learn. Around the ages of three or four, children learn about the world in binary terms. And the first binary that children learn is big, little. And the second binary that children learn is male-female. Can you hear me? Yeah, okay. And so, if we're in that airport bathroom I mentioned at the beginning of my talk, and you're walking out of, say, the men's room, and you see somebody walking into the men's room whose gender expression isn't prototypically male, you might say, I think you're going into the wrong restroom, you know? And so, these kinds of things happen all the time, and everybody's policing each other to a certain extent. Now, gatekeeping is a term that comes from the transgender community, which is a definition of what we call psychiatric evaluation. Because in the middle of the 20th century, if you wanted to transition, you could not do so without the permission of some mental health professional who had to testify that you were, quote unquote, a true transsexual. That is no longer the standard of care for treatment with hormones. Endocrinologists and some primary care physicians will now give adults hormones without any psychiatric or mental health evaluation at all. But the surgeons are not in agreement with this, and surgeons, because they don't want to, because basically the surgeons wish to cover their asses, require one or two letters from mental health professionals attesting to a diagnosis that would support the surgeons providing the transition surgery for them. The other place, excuse me. But, you know, and now as a psychoanalyst, the other place where you see gender policing take place all the time is in the realm of our countertransferences. Since we are all culturally raised to do a certain amount of gender policing, it is almost inevitable that in clinical situations we may find ourselves trying to police the gender expressions and activities of our patients as our countertransferences. And that's just something, you know, we all have countertransferences. I'm not using it in the strictest sense of the term, like it's something you should be rid of, because we can never be rid of our countertransferences. But it is something that we need to be aware of when it comes up in clinical practice. So now I'm going to move to some clinical controversies. The first one is, should there be a diagnosis? And this came up during the time we were doing the DSM and the ICD-11. So the DSM-5, and I was one of the people that the APA appointed to serve on the workgroup on sexual and gender identity disorders to revise the DSM-4. This was the first DSM that was done in the modern Internet age. So we had a lot of comments and a lot of buzz going on about this. Everybody was weighing in from a variety of different perspectives. And newspaper articles, you know, previous iterations of DSM were not out there in the public for comment and things like that. So we had a lot of interaction with interest groups who were interested. One of the things that happened was APA was accused of stigmatizing the expressions of gender variance as symptoms of a mental disorder. And just as homosexuality had been removed from the DSM-2 in 1973, people wanted the diagnosis out or to be depathologized. I would point out, if you don't know, that this is the 50th anniversary this year of the removal of homosexuality from the DSM-2. But while there were calls for removal, there were also calls for attention. We were hearing from advocacy groups who also represented interests of transgender people. For example, there were many people who were concerned that if we remove the diagnosis, you would remove access to care, which is to say every time you have to see a doctor for one treatment or another, whether it's a mental health professional or other specialty in medicine, you need a diagnosis code. And without a diagnosis code, you can't get that treatment. So these people saying, please don't take it out because there's already enough difficulty getting treatment for these patient populations. There were some people who suggested, for example, that we make it a V-code. Those of you who know, V-codes in the DSM are conditions which might come to the attention of a mental health professional, but they're not in and of themselves mental disorders. So the recommendation for a V-code, however, was the problem is that nobody reimburses for V-codes. So it doesn't solve the access to care problem. So that was not an option. Other advocacy groups came to us. This is a little-known fact. It's very common, for example, in the United States, if a trans woman is arrested for whatever crime and put in prison, usually she's put into a men's prison. And when she's put into a men's prison, some prisons refused, if she was on hormones on the outside, they refused to continue her hormone treatments for whatever reason. You can imagine what the reasons might be. And so they've been taken to court. And the groups that argue in court for these prisoners make the case that this is a medical condition that requires treatment. And if you deny them medical treatment in prison, this is considered cruel and unusual punishment, which in the United States is unconstitutional. And the arguments were won before DSM-5 based on these arguments. So this was another argument for retention of a diagnosis. So summarizing basically the challenge to the work group was how to reduce the stigma of having a diagnosis while maintaining access to care. So we voted to keep the diagnosis in. We thought that that was the lesser of two evils. One overarching diagnosis with separate developmentally appropriate criteria sets for children, and a different one for adolescents and adults. These are the diagnoses. We had suggested, the only recommendation that they did not accept from the work group was not to use the other and unspecified categories which have always been called the wastebasket categories, but are sub-threshold categories for making a diagnosis. And the reason was we said this way, you don't have to give somebody a diagnosis who doesn't want one. But I think in terms of what I call bureaucratic harmonization, every diagnosis in the DSM has these categories. So they're in the DSM-5 and the TR. So the text revision, I was asked to edit the revision of the chapter. That was not a revision of the diagnostic criteria. It was a revision of the text and updated academic citations. So the diagnostic criteria are unchanged other than changing the term natal, which appeared in the diagnosis in 2013, and changing that to birth assigned in the 2022 text revision. And this is a list of, on the far right, you have the name of the diagnosis. So these diagnoses actually don't really make their way into the DSM until DSM-3, based on research that was being done. The first two DSMs were just a list of names. They did not have all the descriptors that you see in the modern DSM. The diagnosis name changes with time. The parent category changes with time as well. We go from psychosexual disorders to disorders first evident in infancy, childhood, or adolescence. And finally, gender dysphoria, which has a chapter all its own, separated from the paraphilias and the sexual dysfunctions. And this is a very important point, particularly for the residents who, if they're telling you that DSM is the Bible of psychiatry, it's not a Bible. It's a user's manual. And because it's a user's manual, it changes with time as we, you know, as we, our thinking, our clinical thinking and research changes the way we think about the things that we're treating. ICD-11 is published by the World Health Organization, which is a branch of the United Nations. I was asked to join their work group on sexual disorders and sexual health in 2011. And again, we had similar questions. How do we manage the question of stigma versus access to care? And so in 2019, we recommended, among other things, that the diagnosis be removed from the ICD-11 chapter on mental disorders. Because the ICD, unlike the DSM, the DSM being very binary, you're either in or you're out, the ICD has more options. Every medical diagnosis that exists is in the ICD. You see a physician in any specialty, you get an ICD diagnosis. And so we could maintain access to care by moving it out of mental disorders, which solved two birds with one stone. And the new chapter's called Conditions Related to Sexual Health. And these are the diagnoses in the ICD, one for adolescence or adulthood, and one for childhood. And childhood diagnoses, both DSM and ICD, refer to prepubescent children. Because the children who develop gender incongruence or dysphoria before puberty are a different, are mostly a different patient population than people who develop gender incongruence or dysphoria after puberty. And there's some confusion there, which we might get to talk about. And again, there's an unspecified category as well. Now, mostly everybody was happy about the adult diagnosis. There were some articles published in The Lancet protesting the retention of a child diagnosis, saying that we were pathologizing these children. Previously, we were psychopathologizing the children. But we pointed out that the ICD contains conditions like normal delivery and menopause, which are not medical illnesses. And they have codes because they require access to care. And so that was what, and so that was how we solved that problem. We're happy, we don't, we didn't have to weigh in on whether or not people thought it was a medical illness or not. We simply had to just say we wanted it to be there because people need treatment. And here again, in the ICD, you can see, you know, that the diagnosis first appears in 1979, 1975 in the ICD-9. And the parent category keeps changing. And the ICD is used by most people in the world. So right now, if 2022 countries started using it, I think it's about 80 countries are now using ICD-11. We're not using ICD-11 yet in the United States. We just actually moved to ICD-10 in 2015, even though it came out in 1992. And there was a lot of resistance to that change because it probably involves a little bit like the Y2K problem. Hospitals and insurance companies would have to change a lot of databases to do this. So the two codes are incompatible. And it is uncertain when ICD-11 will be adopted in US. And I've chaired a couple of meetings with people on this subject. And I've decided that fixing this problem is above my pay grade. And I'm not getting paid for this anyway. So everything is above my pay grade here. So the second controversy is treatment of prepubescent children. So I became interested in this subject during the DSM because I had been working since the 1990s on writing papers about conversion therapies of homosexuality. And so what happened in 2008, the Kenneth Zucker who chaired the Toronto Clinic was appointed to chair the work group on sexual and gender identity disorders. And people on the internet were accusing Ken in his clinic of practicing conversion therapy. And I had never heard the term used in that way. So this is what got me involved in learning more about the treatment of kids. So as I got interested, I learned a few things. So one of the things I learned is about the phenomenon of desistance and persistence. Some people don't like these terms, but that's what the literature shows. There are 11 peer-reviewed studies since the 1970s that show the majority of children who develop dysphoria before puberty do not grow up to be transgender. They grow up to be gay and cisgender. And some kids even grow up, a smaller number grow up in the literature of people who are referred to gender clinics because these are only people being seen in gender clinics at the time. A smaller number grow up to be heterosexual and cisgender. And these kids are called desisters. And the children who do not grow out of it were called persisters and would remain dysphoric as they entered into adolescence after puberty. There are people out there, some trans advocates who don't like this literature. They refer to it as junk science or it's a myth because the studies, they say, rely upon overly inclusive gender identity disorder criteria to make the diagnosis. But one of the reasons, I think, has to do with the way people tell narratives because the research on desistance runs counter to a popular belief that people are born trans. So we'll say again to my younger colleagues, whatever you've learned in your residency, your analytic training program, we don't know why people are transgender. We don't know why people are cisgender. We don't know why people are heterosexual or homosexual. There are lots of theories. There is no science supporting any basis for saying I know. It's really important for us to learn how to say I don't know because there's too many people out there pretending they know things that they don't know. So because I became curious about this, I was invited by the Journal of Homosexuality to guest edit an issue of any subject of my choice. So I reached out to my colleague, Bill Byne, who we've done chapters in Kaplan and SADOC for the last four volumes on homosexuality and the last two volumes on gender identity. And we decided, Bill is also not a child psychiatrist, we wanna learn about this. So we reached out to seven clinics and they said, write us a paper that describes what do you do in your clinic? And don't argue with the people that you disagree with. This was a thing of concern to me at the time because the different clinics, they knew each other, but they weren't doing what I thought would be helpful, which is working together to find the best solution for all the kids, they just all had their own methods of doing things. So we heard from five clinics, one from Toronto, Amsterdam, and three American clinics. And we tried to synthesize what the research shows. So it's a heterogeneous group of kids that despite the tension they get in the media, the numbers are small, less than 1%. And that while still relatively small, the number presenting to gender clinics in recent years is increasing by many fold. The research shows that the majority of, again, published peer review research of the majority of these children at these clinics were referred to as the sisters. And the prospective studies show that the majority did not grow up to be transgender, but gay. And what was most concerning was that there was no way to tell in these kids who would be a sister or who would be a persister in that literature. And so it was, to me, we get back to our elephant from the beginning of the talk, this is really complicated. How do you do that? There was, it was pretty much consistently believed by all approaches that if it persisted into adolescence, it was more likely to persist into adulthood. And that the presentations and needs of the pre-putal kids were different from those of the adolescents and they required different clinical approaches for the two age groups. So what don't we know? There's a lot we don't know. We don't know what causes it. We don't know how gender identity develops in anybody, cisgender or transgender. We don't know the relative contributions of biology in the psychosocial environment and the development of a gender identity of any kind. We don't know whether the stress that trans kids experience is related to their psychosocial environment or to the dysphoria in and of itself or some combination thereof. And we don't know why some kids desisted and why some kids persisted. So as the APA was dealing with a lot of public pushback during the DSM-5 process, I had recommended to APA that since APA develops practice guidelines for many of the conditions we put in our diagnostic manual and since we had put this diagnosis in our manuals since 1980, it might not be a bad idea if we could come up with some treatment guidelines because otherwise we were like that Tom Lehrer song, I just shoot them up, I don't know where they come down, that's not my department, said Wernher von Braun. So we had put the diagnosis out there but took no responsibility for trying to explain to people what to do about it. So the bill was asked to chair a task force of which their report was published in 2012. And there was no controversy about the treatment of adult patients and yet older adolescent patients but again, the three treatment approaches, there was controversy about what to do about the prepubescent children. This was the controversy of that time. So the Canadian approach was an approach that basically tried to lessen the gender dysphoria to get the kids more comfortable with the bodies they were born with so that they wouldn't grow up to be transsexuals or transgender. The Dutch approach was a little bit different. The Amsterdam clinic now, they did what we call watchful waiting. There was no direct effort to lessen the gender dysphoria or any of the gender typical behaviors. Their idea was that let it evolve on its own and they would work with the families to try and help the families accept their gender atypical child's behavior but they did not think that the child should be socially transitioned but should just be allowed to see what happens until the child gets older and make a decision when the child gets older. So no immediate decisions. And then there's the gender affirmative approach which developed here in the States which took the position, well, there's nothing wrong with just affirming the child's gender presentation and the child would benefit from social transition and having everybody join in on helping the child socially transition. So this table tries to compare the three different approaches. The Toronto approach, as I said, discourages the cross-gender interest in play whereas the Amsterdam approach, the Dutch approach did not because they felt it shamed the child for their atypical gender interest. Social transition was not recommended for either of the first two but the gender affirmative approach said there's nothing wrong with it. If the child changes their mind, you just do a social transition back. Puberty suppression which I'll talk about was a technique that was used for all the kids because some kids did not desist until after puberty and so it wasn't clear, so it was a way to give the kids a little bit extra time before they did that. None of the approaches were interested in trying to prevent the kids from being gay but the Canadian approach did try to prevent transsexualism in adulthood. And an important point is that whatever everybody was doing, there were no random control studies. They didn't compare with each other so it's a problematic aspect of history. So puberty suppression, which is getting a lot of play in the news these days, is as you know, puberty is a critical developmental milestone. Many people don't know that puberty blockers were approved by the FDA in the United States in 1980 for the treatment of precocious puberty. Usually girls who started developing puberty age seven, eight, nine thought not to be good either for their physical or mental health. If you read the literature on puberty blockers for the use of precocious puberty, people are calling it a gold standard. They're not denying that there may be side effects to it but nobody is working to outlaw the treatment of precocious puberty because of puberty blockers. That's not the issue. It's not the medication. But puberty suppression was used by all three approaches, even the most conservative Canadian approach and it's endorsed by all three approaches. So the problem with puberty for many kids is that they either have severe reactions to their body changes or anticipated body changes. For example, if a child will persist in having gender dysphoria, they will not want to have the secondary sex characteristics which would involve even more medical treatment after puberty. So beard growth, Adam's apple, penis growth, the same thing, birth sign, girls who don't want to develop breasts, don't want to start menstruating. So this was a way to try, my reading of it is that this was a development in terms of exigent circumstances, that they were dealing with kids who were having a specific problem and this was an attempt to solve a problem in the here and now. The concerns, side effects, of course, a deficiency on bone metabolism, potential for mineralization, osteoporosis. That bone metabolism can be remedied by giving sex steroids, and keep in mind, some people who oppose these treatments call them experimental, even though the long-term treatment for precocious puberty is more than 40 years, and the long-term treatment for gender dysphoria is almost 30 years. And then there are social factors that are coming into play. Right now, 20 U.S. states, Washington, D.C., and Ontario have passed laws banning efforts to change a minor's sexual orientation or gender identity. That stands for, SOCE stands for Sexual Orientation Change Efforts, and GICE stands for Gender Identity Change Efforts. And just as a coda, Ken Zucker, his clinic in Canada was closed down among accusations of mistreatment of patients, but Ken sued them, and he got a public apology and more than half a million dollars from the clinic. It's a very difficult subject to be talking about. So finally, the third controversy I'll touch upon is the increased number of adolescents who are presenting to specialty clinics. So we're seeing changing demographics. This is a text from DSM-5 and the DSM-5-TR. More than about a decade ago, the sex ratio of people appearing to clinics was equal birth sign males, birth sign females, but we're now showing increased numbers of adolescents who are signed female at birth than signed male at birth, and also increased numbers. And no one knows why. A lot of opinions, lots of strong opinions, a lot of emotional opinions, but people who are critical of the research that exists for treatment don't have much research to say why they oppose, but that doesn't matter because this is not really so much about research. This is an emotional issue we're gonna hear. So because of this, the increasing number, a phenomenon which I call putting on the brakes has begun to develop. So we see people who are opposed to puberty suppression. Again, they use buzzwords like experimental, low level of evidence. There's an Oxford study that reviewed over 300 medical procedures. It turns out that only 10% of medical procedures done have a high level of evidence. So most medical procedures being done in every specialty do not have high levels of evidence. So this is not unusual, but it sounds bad. It really sounds bad. It's a good soundbite for the opposition of treatment, but it doesn't really describe what this means in terms of the grading systems that we use in medicine. There are people who feel that children should not be able to make these decisions, that they are incapable of understanding the long-term consequences, and they're probably right. I mean, I wouldn't disagree with that, but children don't usually make these decisions on their own. Most of these children are making these decisions with the permission of their parents, and we are assuming that the parents have some confidence to decide what their children can do. There are concerns about future fertility, and there's a lot of concerns about regrets, which I'll talk about. So there's a lot of people who don't think children should be medicated. I'm from New York. My hometown New York paper, which I've written lots of, I've had a lot of letters published. My sixth grade teacher would be very proud of me for having all my letters in the New York Times. But often my letters are in response to some anti-medication article in the New York Times, which include articles, like one recently, about the use of antidepressants in adolescents, because it's not approved by the FDA for use in adolescents, but it's used all the time. There's some people who don't really believe that gender dysphoria is a thing, that it actually exists. And, or, among, let me say, my psychotherapy, psychoanalytic colleagues, people who believe that gender dysphoria is always a symptom of something else, and that if you just work at the underlying and resolve the underlying psychological issues, with what some of them are calling gender exploratory therapy, you know, which sounds a lot like reparative therapy, but they don't call it that, but then, anyway. And so you hear psychoanalytic formulations about normal development, and the thing that, you know, that's getting to me is I keep getting calls from journals to respond to articles, you know, that are making certain kind of claims, articles I'm happy to share with the audience. And then there's some people who say there's, you know, that nobody should get any medical treatment, because the human brain is not fully developed until 25 years old, and in some people, 30. They must know my nephew, and. So. So. There was a panel here, actually, last year, not here, last year's APA in New Orleans, of some gender therapists who I asked them directly, I said, you know, they said they don't believe anybody should get medication who's a minor, only as adults, and I said, well, when do you believe adulthood begins? 21, 18, 21 to 25, and they wouldn't answer the question. So I think they don't believe in using any treatment at all. So that's it. So there's a phenomenon that's been called detransition, okay, which is stopping or seeking to reverse the gender-affirming medical interventions. It means stopping the hormones, and maybe even trying to reverse some of the surgical procedures that they had. Some people who have done this, even though they've detransitioned, they still continue to identify as transgender and non-binary, and I'm gonna show you some literature on this subject, and some may change their mind and re-identify with their birth assigned sex, and their estimates of regret are anywhere from one to 13%. So Lisa Littman has done a study, this is what I call a qualitative study of 100 people who've detransitioned, and what's the most interesting thing, of course, is that there isn't one reason why people do this. I just recently reviewed a piece for a journal that said that all of this treatment is iatrogenic, meaning it's caused by the physicians, but it's not iatrogenic in that particular sense. I mean, there may be cases where it is, but the reasons, the motivations to change are quite complicated. Some, in Lisa's study, there's a personal definition of male and female change, and they became comfortable identifying with birth assigned sex was a majority point. Some people, almost half changed because they had concerns about medical complications. I like to give the example of kidney transplants. There's a certain number of people who lose their kidneys because they're very uncomfortable living on immunosuppressant drugs for the rest of their lives, and although they may have been given informed consent about the drugs, actually living with those drugs turned out to be much more difficult than they anticipated. They stopped the drugs, they lose the kidney. Should we stop doing kidney transplants, or should we put people on immunosuppressant trial for a year so they see what it's like before they get a kidney? So, you know, I've been trying to invite people to think about these things the way we think about all the other things in medicine together. This is a sensationalized subject, but because of the sensationalization, we don't think about it the way we think about everything else in medicine. How do we integrate our thinking about it? Some people said it didn't help. Transition didn't make them feel better, so they wanted to go back, and some people didn't like the physical results. Some people discovered, probably in one of their therapies, that a trauma or mental health condition caused their dysphoria, because here you have people who know causes of gender dysphoria. Some people experienced external pressure, and some were concerned about payment for treatment. So it's not just about the doctors. It's really about a complex psychosocial subject. This is a Canadian study that did a qualitative study of 20 AD transitioners. Again, a wide range of motivations for people wanting to change. So this is, you know, we should not ignore, you know, in any specialty, the fact that sometimes we don't get the results we thought we had, and we need to do better. This is what, but when we need to do better, what we need to do is we need to invest more time and money into research and training. That's what we would do with anything else. This is not what's happening in some parts of the United States now. So, putting on the brakes. We'll start with Great Britain. So there was a lawsuit. The Tavistock Clinic in London had a gender identity service, which had a very long waiting list. As I said, the numbers had been increasing, and they had a long waiting list. And so in 2020, a lawsuit was filed against the clinic. There were two, we would call them, what would we call them? Claimants. The opposite of a defendant is a plaintiff. The plaintiff, thank you, sorry. Having a senior moment. So the Mrs. A was a mother of a 15-year-old autistic child who's on the waiting list, who had not received any treatment, and she had raised the issue of concerns about the child's ability to give consent. And the other plaintiff was a then 23-year-old woman who had been given puberty blockers when she was 16, given hormones at 17, had a double mastectomy at 20, but at 22, she stopped her hormones and identified as female. So the court ruled that minors under 16 cannot give informed consent, and those over 16 required court approval for medical treatment, because the courts are trained in deciding who requires a clinic. So fortunately, the appeals court has my sense of humor, and they overruled the ruling. It was for clinicians, saying it was, and this is a quote from their ruling, it was for clinicians rather than the court to decide on competence to do treatment. And it was appealed to the Supreme Court, which refused to hear the case, because basically the Supreme Court agreed with the appeals court decision. Sometimes the people who oppose treatment keep citing this case as if they had won something, you know, that they had stopped the treatment. They hadn't stopped the treatment, but what they did stop was the clinic. So the Tavistock Clinic received complaints from former employees. They were accused of making decisions that would have a major impact on children and young people's bodies and lives without a robust evidence base. So in September of 2020, the National Health Service, because the clinic was part of the National Health Service, launched an independent review. And the March of last year, the Cass Syndrome Report identified problems, but she didn't make her recommendations until July. And her recommendation was to close the clinic and to basically set up two regional health centers that would provide treatment. And also to set up, you know, relationships between researchers and whatever, what, how do they put, national provider collaborative with an integral research network established, bringing together clinical and academic representatives from regional centers. So she's saying what I'm saying, you need more research and you need, but what's really important here is that they're not stopping doing the treatments. They're just asking people to slow down the treatment and who can argue with the idea of doing, you know, careful evaluation before you help a person make a life-changing experience. I do that in my practice with people getting married or thinking of changing their jobs. You know, that's a normal thing that we do in treatment. So why wouldn't we do that, particularly with children? It's helped them do that. Other countries have also, you know, the Finnish, Finland, New Zealand, Royal Australian New Zealand College of Psychiatrists, Sweden, the French, they've all issued, you know, slow down things, but most important thing to mind that they're not saying you can't do it. Nobody has outlawed the treatment outside the United States which brings us home, home. So this issue became a very national interest starting in 2019. In my thinking, I may be wrong, but this is my reading of the story. This became a big story. Two seven-year-old children, birth sign boys, living in Dallas, Texas. The parents were divorced. One of the children announced that he was a she and mom took the child to the gender clinic in Dallas and the Dallas clinic recommended a social transition. Mom wanted to do it, the dad said no. They had joint custody, they went to court. The case was heard over a few months and 11 Dallas jurors voted to support the mother's wish to transition the child. Texas, but Dallas is not really like the rest of Texas. We know that. National news story, you know, everywhere. And there was immediate political, the governor of Texas promised to order the state's Child Protective Services to investigate the case and one legislator proposed a bill to define transitioning as child abuse. This is the beginning of what we're seeing now. The judge, feeling the heat, vacated the jury's decision and restored the joint custody so no decision could be made. And so, you know, I've done these talks in the past and I'll give you a list of this is going on. There's a long list of things going on since that time. So the legislation tracker shows that there's almost a 2,500% increase in anti-trans legislation, mostly related to this subject. And some bills seek to make gender-related medical treatments a criminal offense, a felony. That is, if you're a doctor and endocrinologist who prescribes it, you've committed a felony, you'll lose your license and you'll be subject to civil suits as well. And other bills seek to bar transgender youth from joining school sports teams consistent with their gender identities. So the legislation tracker says that 49 bills have been, states have bills introduced this year. 549 bills, 71 have passed, 62 signed into law, 102 have failed. So Oklahoma, felony charges, providing gender-affirming care to people under 26. I remember that whole thing about when adulthood begins. Arizona, guardians and teachers can override a student's pronouns. Wyoming, child abuse charges for following medical standards of care. Sports bans and locker room bills have been added on to the transition issues because it's not really about the transition issues, it's about trying to put the transgender genie back in the bottle. And Florida has even banned insurance coverage for transition services for adults because it's not really just about children either. So there's an ethical issue, which I've published in a couple of papers every time I've asked to respond, which is if at the risk of sounding binary, there are two kinds of kids, okay? There are kids who will benefit from treatment and there are kids who will not benefit from treatment, okay? And if we set up the system to slow down the process, we're definitely gonna benefit the kids who won't benefit from treatment, but we do that at the cost to the kids who might. So if I'm a child who actually has gender dysphoria that's not gonna go away, you tell me to slow down, you're doing this to me, you know? You're doing this to me because you wanna save that kid. You wanna save the cisgender kid at my expense. And I've served on ethics committees, so I know what an ethical dilemma looks like. And this is an ethical, and this is what we should be talking about. And when we have this discussion, it's a very different discussion, which is how do we find a balance? Well, how do we find the best thing for all the kids? So this is my view on the subject. So I'll conclude by saying, you know, when we think about gender, we can comfort ourselves with binary thinking, or we can learn, as psychoanalysts say, to tolerate the anxiety of uncertainty. That is, you know, one of the things that makes life complicated is some questions don't have easy answers. Psychoanalysts like to say, don't just do something, stand there, which means, you know, that it's important, you know, to learn how to tolerate the anxiety so we can figure out a better answer than the impulsive answer that takes place. So treatment guidelines have been published by the Endocrine Society. There's an international organization of experts called the World Professional Association for Transgender Health. I've written some articles last year responding to critics of transition treatments, which I'm gonna give you my email address, jackdreschermd at gmail.com. And I have a mental health listserv to which I am the only one who posts, so there's no chatter, just some stories I think people might find of interest. If you'd like to be on my listserv, send me an email, tell me who you are. You don't have to tell me why you wanna be on my listserv, just tell me that you're, you know, a professional or you have an interest in this subject. And I'm happy to add you. Thank you. Thank you. We'll go to the Q&A. If anyone has questions, please come up to the podium. And we have a few virtual ones as well, too. So we'll be going between the two. Hello. I'm a child psychiatrist working for the county. Which county? San Joaquin County. Minnesota. What's that? Minnesota? No, in California. Oh, okay. Sorry. The population, some of the population that I have, that come into the practice, I identify some sort of a trauma. And so, because their picture shows more of the dissonance and the dysphoria and the identity and the dysphoria with the identity. And sometimes, you know, as a psychoanalyst, sometimes you think on lines of dissociative identity disorders and the multiple personality disorders, or the borderline cluster. And, you know, so has there been any studies where identifying the GID population is their trauma piece? And how much does that contribute to the schism of their identity so that the model of treatment can focus more on CBT or DBT to unify this duality that emerges from some event that occurred, rather than a birth process? I'm sure there's a birth process to it, but then there's a trauma process to it. Are we addressing the trauma process of things? Well, so let's say you were coming into supervision with me, you know, and you had a difficult case. So what would I, so I would say, well, look, I said, I don't know. You know, we don't know what's going on with this particular child. I mean, it might be, your theory might be correct that that's what's going on. The DSM-5-TR requires that you make a differential diagnosis. There is a list of diagnoses that sometimes might present as if it were gender dysphoria. So you want to make sure it's not one of those other things. And so that's why we do evaluate, you know, that's why we, unfortunately, gatekeeping, that's why we do it. The problem, I think, that really sometimes comes up in clinical practice is, is the clinician willing to consider the possibility that the gender dysphoria might be an authentic thing in and of itself, even though all those other symptoms are there? Because that's really, I mean, a complicated question. I remember editing a paper many years ago. I edited the Journal of Gay and Lesbian Mental Health, and we did a special issue on inpatient populations and patients with more severe psychiatric disorders. And someone, you know, wrote up a case of someone who was psychotic, you know, but they also had then what was called gender identity disorder. And it was like, oh. I hadn't thought that that was a possibility, but to apparently younger colleagues, it was. And it is a possibility. So I think, you know, you have to keep an open mind about what the outcome might be. That is, you want to help a patient, if they're having a history of trauma, to work with the history of trauma. But you can automatically assume that the history of trauma is causative. It may be associative, but not necessarily causative. So that would be my open-ended answer to your question. I had another question about... There's a whole bunch of people there. Why don't you have a seat and come back. Okay. Let's go to a virtual question. So this one was thumbed up a few times. So there are some who believe that there is a portion of gender dysphoric children who are suffering from contagion, because this has become popularized. We have learned of contagion with suicide clusters and drug use. Is there any evidence of contagion for gender dysphoria? Yes. so there's Lisa Littman, whose detransitioner paper I mentioned, wrote a paper in 2018 on something called rapid onset gender dysphoria. And that's not a DSM diagnosis, and she described adolescents whose parents, it was a study of about 250 parents that she interviewed. And the parents reported children who presented with atypical gender identity presentations as part of friendship groups, that it wasn't just their child that was presenting with these symptoms, if you will, but also their friendship groups. And so Lisa did hypothesize this was something called rapid onset gender dysphoria, different from other cases in the literature. Again, there are no studies to show that this is happening. I have a colleague, David Lopez, I presented with him yesterday at the American Academy of Psychodynamic Psychiatry, who's a child psychiatrist in a wealthy suburb of New York, sees a lot of adolescents for whom gender difference is a presentation in their clinical presentation. David's view is that kids are now using the language of gender that they're learning as a way to really flummox their parents. And it works. It's actually a rather effective technique. So, for example, these kids in Lisa's study were not kids who were seen and diagnosed. The kids are telling their parents this, and the parents don't know what to make of it. I'm sorry? They're not dysphoric, a lot of them. They're not studied either way. So, we don't know what's going on. I can't say it's impossible, but somebody hasn't researched it, in a way by studying the kids to see what's going on. Hi. Thank you so much. It's always reassuring to hear your talks, Dr. Drescher. I am a child and adolescent psychiatry fellow in Miami, and it's been very difficult to tolerate the uncertainty of times right now because of the politics, shenanigans, and I'm... Could you speak closer to the microphone? I was talking to a colleague. We had a research project on how to improve care for transgender youth, and we were debating what is gender-affirming care in our role as psychiatrists is addressing writing on the patient's chart that they have a preferred pronoun. Is that gender-affirming care? What are the risks for us now? How to navigate that? I guess it's more eventing, but how to navigate that as psychiatrists? How to differentiate if we're providing treatment for depression or psychotherapy, and can that be qualified as gender-affirming care? Can that bring legal repercussions to us? And this is... For gender... I didn't hear the last part. What's the question exactly? It's if our roles as psychiatrists providing either medication management or psychotherapy, how is that... Can that be qualified somehow, or how is that qualified as gender-affirming care? And how can that harm us if that is becoming a felony to provide gender-affirming care? How to protect that, I guess. Well, for most of the... Well, thank you. Yeah. So how... If they're making it a felony, what do we do? Well, if they're making it a felony, we can't do it. I mean, that's why they're doing it. Whether the laws that make it a felony will survive the courts remains to be seen. But yes, if it's... The laws banning gender-affirming care are brought to you by the same people who are trying to ban access to abortion. It's not a coincidence. And so, what do you do if you live in a state that's banning abortion? I don't know if you know this, I mentioned Kaplan and Sadak, I went back and I collected all the earlier volumes of... And the earlier volumes of what was then called Friedman and Kaplan have chapters on the psychiatrist's role in abortion. For when abortion was illegal in most of the United States, psychiatrists could give a patient's a pass, but I don't think that we're in that stage now, we're in a very novel part of time. What do they say, may you live in interesting times? We're living in an interesting time and it remains to be seen how this will unfold. You know, we psychiatrists are notoriously bad at predicting the future, so... Okay, another virtual question. I'm a child and adolescent psychiatrist. Over the past several years in my solo practice and school consultation, I've been seeing an increase in the number of kids and teenagers, but especially in the autistic spectrum. Have you, in the research, found this to be the case as well? There is a lot of research that shows an association between autism and gender dysphoria. Why that is so is not known. I do sometimes get consults with parents who believe, you know, well, my child has been sort of on the spectrum since they were very young and they believe that that is the cause of their, quote unquote, confusion about their gender, but again, this is an area that requires research, but there is no known causative relationship. The problem sometimes with the parents wish, you know, like, you know, so if I treat the autism, then the gender dysphoria will go away? How does that work? That's what some parents believe. Thank you for the great talk, Dr. Drescher. Connor Zbirek from Sacramento. There was a great article on Harvard Law Review in March, Medical Disobedience. I don't know whether you had a chance to see it. I'll email it to you. It's a San Diego University law professor. He is talking about the conscience in medicine. After Roe, there were many people who wouldn't do abortions and medical personnel, and they had given free pass in law, and so he's arguing, so how about the other side now? And you know, because Roe is overturned, because of your conscience as a physician, you still would like to provide abortion. Because of your conscience, even though it's a felony, you would like to help adolescent transition, provide hormonal treatment. I don't know whether anybody approached you, given your position as an expert in these subjects, to advocate for sort of providing more balance in the legal system, sort of conscientious providers as opposed to conscientious deniers. I haven't been approached. It's an interesting question. I think there will probably be a case, you know, that will come up in one of the states that are banning abortions completely, or after 12 weeks, or six weeks. All right. Thank you. Another question. Many people have been accused of transphobia, a new form of bigotry. Raising questions or disagreeing with them has been met with canceling or accusations of child abuse. If accurate, why would we believe that parents are able to provide informed consent for the child in this sociocultural setting? I feel like there's more than one question in there. So I hope nobody heard me accuse anybody of transphobia today. Did anybody hear me accuse anyone of transphobia? I don't find that to be an effective way to argue for care. You know, I don't think scaring people about side effects is an effective way to argue against care. And I don't think accusing people of wanting to kill children and making them suicidal is an effective way to argue for care. I think there's a way to talk about the need to do that. So what I would like to recommend to people who are afraid to speak up is learn how to speak up in a way that is respectful of the people that you disagree with without accusing them of having motives that you can't possibly understand what they might be. For example, I saw a family, a mom and a child. The child came out as trans 10 years ago, and mom has a hard time accepting that. And I had stopped seeing the patient, but they asked for a family session just last week before I left. And they were both upset. I saw each of them briefly, individually, then saw them together. And mom won't use the pronouns or the preferred name. And it turns out that mom is terrified for what's going to happen to the child. And the child has a hard time understanding the mom's terror, because all the child wants from the mom is recognition of something that's very hard for the mom to do, because then the mom thinks she's giving the child license to be hurt. That's a complicated thing. This is a complicated subject. So I think, I mean, people have called me transphobic, but we all have, I like to say, we all have racism inside. We're embedded in racial ways of thinking in our culture. We all have anti-Semitic ideas in us, whether we act on them or think about them. We have homophobic ideas. Having prejudices and biases is normal. The issue is not what you think and how you feel. The issue is how you display and you behave yourself, despite having these feelings. That's my psychoanalytic perspective on bias. Hello. I'm a transgender person, and when I hear detransition, I feel like it's a very, like, cis concept. And a lot of these lectures are very binary, where gender, I mean, from the transgender population, we feel that it is a spectrum. And the term detransition, I think, leaves very little room for people who, for instance, might want to take testosterone to change their voice, but want to appear androgynous. And I feel like it has been used against the trans population as, like, weaponry, because it's, like, considered bad, detransitioning. But I think the trans population has a different idea and concept than the cis population about, like, what is detransition, and that it is more acceptable and part of our journey. And I don't, I mean, I feel like there needs to be more room for that in discussions like this. But how do you feel about that? I agree with everything you say. I think when I, the two studies that I tried to cite really talk about the multiplicity of motivations for people to change their mind. And I think, you know, there are people, for example, who have detransitioned. The New York Times ran an article last week, which I put out on my listserv, about people who are, you know, sort of like, just used to have ex-gays who would testify against gay marriage, you know, who were, you know, that's what I'm looking for, funded in their travels around state legislatures by, you know, conservative social groups opposed to gay marriage. And now we have detransitioners doing the same thing. And there's even one person who was doing that for a while and now regrets it and is probably talking out about the political manipulation of people's complicated life experiences. So yeah, I think, you know, I think really that we're at the beginning of a conversation that needs to be had. And, you know, people say things behind closed doors that they don't say in public. And we're now saying things in public that need to be said. And it's not pretty, you know, but I don't think anybody should be canceled. But I just think that we should be talking, which is why people are trying to stop the talking. You know, there are people who are trying to prevent people from talking about things. And the reason they want to do that is because they know that talking about homosexuality for the last 50 years, since APA removed it from the manual, we now have gay marriage. That didn't happen overnight, but it happened with conversations, many of them which were quite ugly. So I think we're sort of where we were with gay marriage 50 years ago around trans issues. And my main regret is that my optimism, I don't know why I'm optimistic, is it will get better. But my regret is that in the here and now, people will be hurt by this. I've had a number of people, so I'm going to take two, because one of them is easy to answer. I have asked for copies of the slides available for download and also for those virtual participants. I'm happy to share my slides, PDF of my slides. And then what is your estimate of the percentage of children and adolescents with gender dysphoria who actually have access to useful psychotherapy to explore what is happening to them? I have no idea. Hello, thank you very much. Actually, I come from a very different part of the globe, possibly the Bangladesh. I'm not sure that a London member of the house will be very able to locate my space in the globe. Actually, we had a long journey, about 24 hours, with six psychiatrist camps, still I think many of my colleagues have the jet lag. I must say this was a wonderful experience to listen to Professor Jack, and I must say this is just meeting an author. I was actually thinking when possibly everybody has taken it into note, there's after the death of the, there's a saying, RD Lange, that the birth of anti-psychiatry, peoples were just loitering in the ground floor, they were just talking that going to psychiatry is climbing the mountains of the dead. So once again, when I listen to a long talk, I think once again, it is synonymous to some of the facts and the fallacies of the psychiatry. So this dysphoria encompasses so many branches of the human wisdom, so very difficult to make a single question, to make a single treatment strategy, that actually I have in mind. I think Professor Jack will bear me with, and one, two queries actually. We have noted in some study that ADHD people, sometimes they talk over the gender dysphoria, and about the 40% of the child, when they are at seven year old, they also talk about the gender dysphoria. I'm not sure that whether this is going to be a prologue or the ushering to the adulthood dysphoric disorder, gender dysphoria. You may have some study. And I was just thinking, you know, that we are living in a place in Bangladesh, the third world countries. We have a very good family tieship, et cetera. But when we can send this part of America, we, a study reveals that about 40% of the child, they are born out of wedlock, and one of the highest is in California. So do you have any study that the child born out of marriage, whether they are having some difficulties in the later adjustments when they go to the adulthood, regarding the sexuality, regarding the gender identity, or anything problems? Thank you very much. Thank you. I was reminded of old psychoanalytic stories that talked about what caused homosexuality was the absence of a father. So no, there are no studies that I know of. Thank you, sir. Another online question. Is there any evidence that environmental changes such as contamination, estrogens, toxins, can contribute to increasing risk of gender dysphoria? Not that I know of. Hi. Hi. I'm not a child and adolescent psychiatrist, but I do first episode psychosis, so I treat a lot of adolescents. And I suspect that I'm too much in my brain about this, because it made sense earlier. But if you have a child with gender dysphoria, and the goal is to get rid of the dysphoria, because that's obviously the part that's dangerous. And we know that a majority of children will desist when they go through puberty. I guess I wonder why do we stall puberty when you might say, well, let's just get you through, and then we'll deal with what comes out on the other side. I don't know. Why we stall? Why? Well, I don't stall anybody's puberty. Well, yes. We'll start that. Yes. Sorry. Okay. Puberty blockers. So the Dutch approach, which was developed in the 1990s, you know, so puberty blockers had been around for about more than a decade when they started doing this. And so the idea is that you have a child who's 12, and the child has gender dysphoria, has had gender dysphoria, say, since age four, and they don't know whether that dysphoria will go away or not. And so puberty blockers is a win-win situation from the perspective of not knowing what the final outcome will be. So if you delay the puberty, and the child, say, at 14, then decides, you know, that, no, I'm okay with my body, you stop the puberty blocker, and you have late-onset puberty, which is considered, you know, a normal way of having puberty just two years later than they might have had it earlier. But if the child doesn't desist and that the dysphoria persists, the child has avoided developing secondary sex characteristics that require further medical treatment. It turns out electrolysis for a beard is more expensive, perhaps, sometimes, than any surgery. I suppose maybe then I made an assumption that what changes the child's dysphoria was related to the hormone changes in puberty, but it sounds like you're saying it's more time. No, no, it's just a delaying tactic to give the child more time. I see. That was the concept that led to the development of puberty blocking. Thank you. You're welcome. We have enough time for one more question. Just me? Thanks. Hi, I'm a child psychiatrist, and I'm practicing in Mexico City. We know that the prevalence of some mental conditions or disorders are more prevalent in male or women as a depression or personality disorders. Is it that correlation in transgender people that they match with the supposed to be more prevalent conditions as a woman or as a male? I'm not aware of any literature like that, but I don't think that's the case. I think it's more complicated than that. Okay, even more complicated. Yes. We have time for one more. Go ahead. Yeah, thanks. I have somewhat of a case report of a 28-year-old female who transitioned, I think, when she was 12, approximately, started. And very unfortunately, she's developed now bilateral breast cancer, and I don't believe anybody had assessed her for cancer history in her mother's side of the family. She's very, very heavily present, her mother and her grandmother, both have breast cancer. I just thought it was something maybe to take note of if you're working with children to make sure that before a transition is executed, that a more complete history is taken on breast cancer history in the family. I know some people have had some patients I've certainly treated different people, so I just thought I'd put it out there. Okay, thank you. One more came in. This is from Dr. David Lufshitz. A wonderful talk, just to comment that eight years ago, when my daughter was at college orientation at Oberlin, the first question kids were asking each other was, and how do you gender identify? So they were taunting parents even then, or maybe not? Yeah, yeah. I had a thought, which was that one of the signs of getting old is you don't like culture change. And the culture is changing. Younger people are talking about gender in ways that are very different. Good luck finding culture change. Thank you.

Dr. Jack Drescher

psychiatrist

psychoanalyst

gender dysphoria

youth treatment

gender identity

mental health

DSM-5

ICD-11

gender-affirming care

transgender youth

ethical dilemmas