Turban and Karasic at the APA: The Full Audio

Added: 2026-05-22

[00:00:01]Welcome to a special edition of Informed Dissent for Monday, May 18th of 2026.

[00:00:09]What you are about to hear was recorded inside of a continuing medical education session at the 2026 American Psychiatric Association's annual meeting in San Francisco, which took place on Saturday, May 16th of 2026.

[00:00:28]The presenters you will hear are Dr. Jack Turban and Dr. Dan Karasic, two of the most prominent and influential voices shaping the clinical standard of care for gender dysphoria in the United States.

[00:00:44]We have received this audio and we have verified its authenticity.

[00:00:49]We are releasing it in full with no edits to content. The only alterations were made to audio quality. We have done what we could to make it as clear and audible as possible.

[00:01:03]What you hear is what was said.

[00:01:05]We want to be direct about why we are doing this.

[00:01:09]CME sessions are not private conversations.

[00:01:14]They are credentialing events. The content that is delivered in these rooms travels directly into clinical practice, into the offices where patients sit, into the decisions being made about children and adolescents, and into the testimony being offered in courtrooms and legislative hearings.

[00:01:37]The public, patients, parents, and the policy makers being asked to legislate in this space have a legitimate interest in knowing what the American Psychiatric Association is teaching its practitioners behind closed doors.

[00:01:56]Dr. Jack Turban and Dr. Karasic are not private citizens. They are the architects of a clinical framework that has shaped policy, influenced courts, and affected the lives of tens of thousands of patients.

[00:02:12]What they teach in a CME session is their professional position.

[00:02:19]It belongs in the public record.

[00:02:22]We believe in transparency.

[00:02:25]We believe patients deserve to know what is being said in their name.

[00:02:30]We believe parents deserve to know what the clinicians treating their children are being taught.

[00:02:36]And we believe that anyone with the power to make or sustain policy in this area has an obligation to hear it directly.

[00:02:46]So, we are not going to summarize it. We are not going to interpret it for you.

[00:02:51]We are going to let you hear it.

[00:02:54]What follows is the full audio from session 1193 at the 2026 American Psychiatric Association's annual meeting.

[00:03:06]A continuing medical education session titled Transgender Care Update on evidence-based and clinical practice of primary care, child and adolescent psychiatry, and adult psychiatry.

[00:03:28]>> [music] >> Um Uh I have no financial relationships sponsorship Um but I have been an expert witness in numerous cases related [clears throat] to access to care for transgender people including the ACLU in Massachusetts, and COR in the We have breaking news. The Department of Health and Human Services says gender-affirming care for youth is a risk to children's health and well-being. HHS Secretary Kennedy just introduced what the department calls actions to protect children from harmful medical interventions.

[00:04:15]The American Medical [snorts] Association, the American Academy of Pediatrics tells a lie that chemical and surgical sex transitioning is dangerous, that it would be good for children who suffer from gender dysphoria.

[00:04:29]They portray the estimated 300,000 American youth ages 13 to 17 conditioned to believe that sex can be changed. They betrayed their Hippocratic oath to do no harm.

[00:04:42]So-called gender-affirming care has inflicted lasting physical and psychological damage on vulnerable young people. This is not medicine. It is malpractice.

[00:04:54]We're done with junk science driven by ideological pursuits, not the well-being of children.

[00:05:02]Last month, the department finalized a report on gender-affirming care for youth claiming it found "medical dangers posed to children." The report alleges that gender-affirming care including puberty blockers, cross-sex hormones, and gender-affirming surgeries cause significant long-term damage. Now, the House has passed a bill that would criminalize gender-affirming medical treatments such as surgery and hormones for minors. Let's bring in University of California, San Francisco Professor Emeritus of Psychiatry, Dr. Dan uh Sooracic for more on this. Uh Dr. Sooracic, thank you for coming on. Uh the Academy of Pediatrics hasn't responded yet to this announcement, but in reaction to a May report on this topic, they said, and I'm quoting here, that the report misrepresents the current medical consensus and fails to reflect the realities of pediatric care.

[00:05:49]So, what's your reaction to the health secretary's announcement today?

[00:05:54]So, the HHS report frankly would make George Orwell blush.

[00:06:01]Uh it is a compendium of misinformation that dismisses decades of experience working with trans youth. Uh all of the research supporting those efforts and support it replaces that with um authors who are all part of organizations that are dedicated to ending care for transgender people.

[00:06:31]It's the in um in doing so, they're asking um parents to disregard their experience with their own adolescent children uh the work that they those um youth have done with therapists and with their doctors. These are people who may be engaged in care, may already be on hormones, may have already transitioned.

[00:07:01]And uh the Trump administration is putting these families in the middle of the culture war and ripping away their health care with nothing to replace it.

[00:07:13]And I think it's unconscionable and it's a great harm. The secretary says these gender transition treatments are not as safe nor effective for children and that there's an overwhelming body of evidence that these procedures hurt rather than help kids. What's your response to that?

[00:07:30]Uh that's a lie.

[00:07:31]Um so, uh there is uh enormous amount of evidence.

[00:07:37]The HHS document itself mischaracterizes and dismisses that evidence and uh substitutes it with innuendo, with references to op-eds, to references [clears throat] to the lawsuits, to references to podcasts of people opposed to transgender care.

[00:07:59]It's really a disgrace and and then you know, this was constructed clearly um as basis of fulfilling a campaign promise to end care to trans youth and and so this whole document is a rationalization for it.

[00:08:21]But it has no basis in reality and I could go on for for days with all of the all of the lies really that are there.

[00:08:33]And doctor, I'm out of time but quickly the house has now voted to criminalize gender transition treatments for minors like surgery or hormones. That still would have to pass the the Senate and so on but what would it mean to representations if that were to become law?

[00:08:48]Well, doctors would stop providing that care and would still have their careers and would be able to work taking care of cisgender youth but the trans youth and their families would be the ones hurt. There are already families who have to move from states that have banned care to states that still allow it and now every family I know has contingency plan moving abroad or going abroad to get care or finding ways to get care still in the United States and it's been tremendously stressful. The Trevor Project had a a study showing a dramatic increase in suicide attempts in the in the states that have banned gender-affirming care and I'm very worried for the well-being of trans youth who are having their care ripped away. All right, Dr. Dan Karasic, we appreciate your time today. Thank you.

[00:09:46]Thank you.

[00:09:49]So, fortunately, a federal judge did block our continuous declaration, which would take away all government funding, Medicare and Medicaid funding from providers and medical centers that that provided gender-affirming care even to one one patient. However, there continues to be a um a process that CMS has already taken public comment on to try to enact the same ban in a different administrative way.

[00:10:32]Um so, I'm just going to talk a little bit about some of the misinformation that has um been um a justification to the HHS document or put out there.

[00:10:49]Starting with um a fake tweet about something I said 3 years ago at a UCSF training um where um this was tweeted in many different forms, but basically, um they took an audio tape where one of my colleagues, Dr. Erin Jackson, was responding in from the audience to another person in the audience who had asked about severely autistic, nonverbal children, and um uh and um in any event, um Dr. Erin Jackson gave an anecdote about a non-verbal autistic child with precocious puberty who was on puberty blockers, but it didn't even, you know, require a evaluation at that point, a gender evaluation.

[00:11:45]Um, but this was put out as um in in social media and um uh repeatedly, and I ended up testifying about it in Florida in 2013.

[00:12:02]I emailed one of the people who ended up being one of the authors of the HHS report 498 document that um the government is now saying gender affirming care should be based on it.

[00:12:15]You know, said your own tweet that had an audio tape of Dianna Arenson that was attributed to me was was false.

[00:12:26]Um and yet it still appears in the HHS document along with the whole compendium compendium of stuff that's made up.

[00:12:35]Um so um this Oops.

[00:12:40]This uh place in the HHS document um has a reference uh to John Strang who's an American psychologist who did a consensus document that Dianna Arenson and I along with um other American providers uh of care to people with autism spectrum disorder who were um also gender dysphoric. Um along with the Dutch. And so it was actually a consensus between the Americans and the Dutch. And yet it's portrayed over here as if um the leading specialists in the US um are somehow divergent when they're actually citing a consensus document.

[00:13:24]And for evidence of that they use a podcast where with an audio tape this uses And so, if you go through the HHS document very similarly, point by point, it's just creating false assertions.

[00:13:49]You know, it wouldn't be such an issue except for now the government is using this both to this HHS document both as the basis to deny care to youth but also to adults.

[00:14:04]So, another place is where it says that I had a conflict of interest in um providing treatment for adolescents as such medical necessity when I had nothing to do with the adolescent chapter. My involvement with medical necessity that they cite was had to do with placement of this medical necessity statement which had been in WPATH put out in relation to [clears throat] standards of care six and standards of care seven. Standard of care seven, the surgery chapter, is transgender surgery is medically necessary. So, it was not as if I was having a conflict of interest in making it medically necessary or it's not necessary.

[00:14:56]It's based on a uh you know, on somebody advocating for it. It's just a way of um of dismissing the standards of care in WPATH statement from which they got it.

[00:15:13]Um So, another place where the HHS document um dismisses our current working knowledge of transgender care is using systematic reviews and grade scores.

[00:15:34]You see this now just in newspaper commentaries everywhere about this low certainty evidence supporting gender affirming care.

[00:15:49]But um they do this at the same time that they're endorsing treatments that have little or no evidence and um uh including psychotherapy to address gender dysphoria.

[00:16:04]Um and there's no evidence that uh you can resolve gender dysphoria with uh psychotherapy and there are no systematic reviews demonstrating that. And um the uh the way we make clinical decisions is by comparing evidence of different interventions.

[00:16:29]Um so just um to run down um uh how we practice medicine um generally. Um in um one large study of systematic reviews, only 5.6% of all medical interventions and 0% of endocrine all endocrine interventions had a high grade score.

[00:16:54]Most medical interventions have low or very low grade scores. Um in an another another systematic review of anesthesiology, critical care medicine, and emergency medicine, only 10% had high grade scores and yet no state has banned the practice of anesthesiology, critical care medicine, or emergency medicine.

[00:17:17]For complex interventions, so the complex intervention is one where there are multiple steps to enact the intervention and then multiple steps to measure the result. So, if you were just looking at puberty puberty blockers stop puberty, there's high quality evidence that puberty blockers stop puberty. But, if you're looking at does transition lead to a long-term happy life, there are many steps involved in that.

[00:17:46]Complex interventions and systematic reviews, no high grade scores for any complex intervention was found. And in terms of national guidelines for care only minority of national guidelines for care based on strong and moderate grade scores. You make these recommendations based on comparison of alternatives and there's no evidence to support the alternatives that they write.

[00:18:18]Last year at APA, there were words of presenters who did a talk on why systematic reviews people should not provide gender affirming medical care to youth and instead should provide psychotherapy.

[00:18:38]But, the authors of the systematic reviews that they used in that presentation have rejected that interpretation of their work.

[00:18:48]So, the Gordon Guyatt and the group at McMaster University on evidence-based medicine that have done the North American systematic reviews or many of them on gender affirming care for youth say they said it is profoundly misguided to cast health care based on low certainty evidence as bad care or care driven by ideology, and low certainty evidence is bad science. Many of the interventions we offer are based on low certainty evidence, and enlightened individuals often legitimately or wisely choose such interventions.

[00:19:25]Thus, forbidding delivery of gender affirming care is limiting medical management options on the basis of low certainty evidence is a clear violation of the principle of evidence-based shared decision-making, and it's unconscionable.

[00:19:40]The appropriate use of hormones is ensuring that patients receive the new care, and they're helping transgender and gender diverse patients and their clinicians and clinicians in decision-making.

[00:19:51]So, um the HHS document um uh after dismissing uh gender affirming medical care, um which in the Taylor review for um in the Taylor systematic review for the Cass review from the UK, uh moderate quality evidence that um hormones provide benefit.

[00:20:16]They dismiss that, and then um say that um uh psychotherapy is um the uh more effective intervention, um and um say that's supported by high quality evidence. But, if you actually look at HHS's own systematic review of psychotherapy uh for depression for adolescents, all of the interventions have either low quality evidence or insufficient evidence. So, even HHS's own review shows that we have lower certainty for psychotherapy for depression than hormones for gender dysphoria. But, that's even missing the point that there there's no evidence for psychotherapy for gender dysphoria.

[00:21:05]But, clearly they have a double standard, They mislead in the HHS document about it's high-quality evidence when it's not.

[00:21:13]There is moderate quality evidence for CBT for anxiety.

[00:21:18]Um they also um have um this information on trends in transgender care in Europe.

[00:21:25]Again, this did not be a large point except where it's just repeatedly mentioned such prevalence that it's been picked up in common media and and it's based on on this characterization of care in Europe. So, just give an example, there there are references to uh Sweden and Scandinavia going another way from the US, but if you actually look at this the Swedish guidelines that the HHS document actually cites, it's very similar to uh uh WPATH's standards of care adolescence chapter, which was the colleague was the um uh leader of the the psychiatrist leader of the the Dutch group.

[00:22:10]Um The difference is that it talks about starting puberty blockers at Tanner stage three. So, this is a more conservative approach, but it's more closer to uh WPATH's uh standards than to uh what HHS is uh suggesting, which is a total ban.

[00:22:33]Um and there's also in the public media a lot of references to um uh to [snorts] Finland and the Finnish study that showed that um people in Finland uh median age, I believe, 18 and a half, who um got gender-affirming medical care had um uh higher um mental health utilization than those that did not get that care, but it ignores that the same senior authors paper in another study broke down the need for psychiatric treatment by before and after hormones were started.

[00:23:16]And it showed that the even though the percent that needed psychiatric treatment stayed about the same, that the number that were in treatment for depression went down from 54% to 15%. Anxiety 48% to 15% and for suicidality and self-harm from 35% to 4%. So, it clearly showed and when when that was broken down, a great improvement when people were were started hormones. But when you zoom out and just look at um um people's need for psychiatric treatment, you don't necessarily see that effect. The answer is study that was negative before from similar studies.

[00:24:05]The judge used the new justification for So, um So, I'm going to talk a bit about our restriction of care for adults, which actually has been going on for now for several years, but um it's accelerated and in particular just uh 2 months ago, the fourth circuit um reversed its finding that um uh that gender-affirming care for um uh both for minors and adults um uh was medically necessary um and approved to be medically necessary and um uh and applied scrutiny uh to adult care. [snorts] So, the idea that you're not against trans people if you're just discriminating against their diagnosis.

[00:25:03]And so, it's Medina is is was a case about Medicaid and Planned Parenthood or state funding of Planned Parenthood.

[00:25:15]Um So, there's been an acceleration in states attempts to ban gender affirming care for adults.

[00:25:25]In Idaho, it's up to 14 years in prison if you're a doctor and you prescribe hormones to a trans adult and who has Medicaid or in a public facility. [snorts] And that's adults.

[00:25:45]And other states are restricting care for adults and um uh and meanwhile the government is restricting rights for trans people in numerous other uh kind of facets of life. For education, housing, uh disability claims, passports through the federal government and birth certificates and driver's licenses through the state, Kansas nullified trans people's driver's licenses overnight.

[00:26:28]Um The federal government's the White House's US counterterrorism strategy to 2026 uh says, "In addition to cartels and Islamist terror groups, our national counterterrorism activities will prioritize the rapid identification and neutralization of violent secular political groups groups whose ideology is anti-American, radically pro-transgender and anarchist.

[00:26:59]Um the There are government efforts to ban the discussion of gender-affirming care.

[00:27:09]Um in Florida, um there's a lawsuit using the racketeering and consumer fraud um ordinances in in the state of Florida uh with a um seeking to disband um uh WPATH, the Endocrine Society, and the American Academy of Pediatrics and um ban the distribution of uh WPATH Standards of Care 8 um and um have a civil penalty for um and for talking about any benefit that people can get from gender-affirming Um and um the Federal Trade Commission has been doing an um investigation in uh in preparation for a similar lawsuit um though their um their subpoenas um from uh uh groups involved in transgender medicine um the from from those three groups um have been uh blocked by uh federal judges.

[00:28:26]Um at uh just in the past week at NYU Langone um there was a criminal subpoena from the Department of Justice um seeking the names of all health care providers who had provided gender-affirming care in New York since 2020 uh at NYU since 2020 um and the charts of every every minor patient, every patient continued under um who received gender-affirming care.

[00:28:57]Um notably, um in addition, they have um subpoenaed um uh all communications um with uh WPATH or any of its members regarding um gender-affirming care, um including, but not limited to, communication regarding the safety and efficacy of gender-affirming care, um and um uh any reference to standards of care. A So, if I don't know if there are any NYU Langone members in the audience today, but um you may have to report uh your attendance.

[00:29:37]Um So, um also recently, um the federal prisons have been um uh forcibly de-transitioning uh trans people uh who were incarcerated.

[00:29:55]Um This was uh declaration from the expert um representing the government um in lawsuits um regarding this.

[00:30:10]This was uh someone who spoke at APA last year um uh how why we should follow systematic reviews.

[00:30:19]And what he wrote his opinion was, "Hormone therapy is unproven proven and experimental treatment for gender dysphoria that generally should not be available to those in custody.

[00:30:31]Psychotherapy is the preferred treatment approach."

[00:30:34]And then he said, um uh the affirmation model carries significant risks because humans have immense powers to deceive themselves and patients may be susceptible to conditions suggestions of affirmative treatment.

[00:30:52]And so then he says referencing psychodynamic therapy and CBT um uh that those therapies focus largely on identifying self-deception. And so he is suggesting for people with gender dysphoria that a major target of treatment is helping patients identify how they deceive themselves.

[00:31:17]So there's no systematic reviews on uh helping patients identify how they're deceiving themselves and and thus resolve their gender dysphoria. So after all of this, you know, um doing legal bans because something has low certainty evidence on systematic review, they are um trying to enforce on those they can enforce it on, in this case incarcerated people, um an intervention that has absolutely no evidence of benefit and even from one of our speakers today, um the evidence of of harm from conversion therapy. And sadly conversion therapy is the only constitutionally protected treatment for uh transgender people uh in the US today according to the court that threw Child versus Azar.

[00:32:14]And after um the fourth circuit um said that um gender-affirming care for adults is not is not constitutionally protected.

[00:32:28]So um how has this affected our uh in this case adult patients? Um minority uh stress is associated with um depression, suicidality.

[00:32:43]Trevor Project has had some studies on increased suicidality with care bands and in those who have not been able to get care as a result.

[00:32:54]My patients are experiencing my adult patients as well as adolescents increased anxiety, hopelessness, anger.

[00:33:06]Some are have been really working on things like mindfulness, changing focus, things that they're they're in their control like >> [clears throat] >> hobbies that take them away from looking at the news.

[00:33:23]So there's whether it's avoidance or active cognitive coping. People are coping in those ways. But a lot of people are doing active behavioral coping, planning for worse conditions.

[00:33:35]I've had several conditions who moved to the garage and fortunately have to have relationships with providers in other countries who can provide care.

[00:33:47]Disturbingly, McGill in Quebec just stopped providing gender-affirming care to American students attending McGill out of fear that the Trump administration can somehow punish a university in another country. And there there has um a a suggestion out of the administration that if Americans go to other countries for care, that those providers could be banned from entering the United States.

[00:34:21]And so so there is maybe some you know, reason for fear.

[00:34:28]It is something that even internationally there there is the reach of the government.

[00:34:36]Um and I have a lot of patients. So, I've had patients who in between visits, I you know, they call me and the patient's father, can I call in a prescription to a pharmacy in Canada?

[00:34:47]And um you know, I have to say, well, no.

[00:34:51]Um but I I I have patients who are, you know, disappearing to other countries and even not telling me about it until they're already there in the other country for fear of what might happen.

[00:35:03]And um I have patients who are hoarding medications, uh taking half doses, uh I think that's happening in parts of the farm and building up a stockpile either for a bunker or if uh I have patients who are planning moves to countries that don't uh carry certain proprietary expenses like medicines that they have them on.

[00:35:30]And so, I've I've had patients uh symptoms come back and it turns out it's because they're splitting a capsule of medications so that they can go to the other side.

[00:35:41]So, you know, this is a population that already has a a higher um rate of um mental health conditions. It's a vulnerable population. Um uh and yet minority stress is uh it's really I think it intensifies some of the symptoms.

[00:36:05]So, um uh So, let's see how we're doing on this.

[00:36:14]Okay. So, well, I'm I'm going to just um scroll through just uh a couple more things. Um I just want to point out um well, I've got a video that that um so, pearl, surgical regret is, is rare um, in gender affirming care. It's still important and that's something that we need to investigate and we need to be conscientious with each of our patients.

[00:36:47]Um, but, um, unfortunately, it's being used by the government to, uh, prevent, um, and then, uh, adults who have, uh, transitioned a long time ago from living their lives. Um, in the in the incarcerated setting, there there's, uh, incarcerated, uh, in the incarcerated trans women who have had vaginolasties, been on hormones for years and years and years, um, and receiving those hormones in prison and in response to a Trump administration order, their hormones were abruptly stopped and they were moved from minimum security, uh, women's work camps to higher security men's prisons where then they had to be under 24-hour observation because of suicidality that was not there before they were moved. And so, you know, just what's being, the the justification of this HHS document to do things that clearly are not therapeutic for people is something that, uh, I think needs more attention.

[00:38:00]Um, you know, the, um, the argument's being made that gender affirming care for adults is, uh, experimental and yet, um, actually, before that, Bathlin and Nuñez, um, had a systematic review from 1961 to 1991 and then, building on that, uh, Cornell University uh, um, uh did a review of studies from 1991 to 2017.

[00:38:30]And then uh Johns Hopkins commissioned by Stanford to do a systematic review. Um uh in 2021, there are decades and decades of experience to tell us that um uh that conversion therapy, psychotherapies of all sorts, do not resolve gender dysphoria, and are not a replacement.

[00:38:56]Uh and the government should not be abruptly stopping trans people's hormones and saying we can just give them psychotherapy to find out how they're deceiving themselves.

[00:39:12]And so, um I think I should stop there and um hand it over to uh to Jackie.

[00:39:26]>> [applause] >> Good morning.

[00:39:36]I'm Jack Turban. I'm a child and adolescent psychiatrist. Um and I'm happy to be at UCSF, where I direct the Gender Psychiatric Program. That's our adult program that provides clinical care to trans youth.

[00:39:49]Um and also researches the gender mental health for those kids.

[00:39:53]With a focus on questions relevant to public policy These are my disclosures.

[00:40:07]Uh and anytime we're talking about any treatments for gender dysphoria, um we're talking about use of FDA-approved medications, but they're not FDA-approved Uh and I would like to nice this talk going through stages of development. So, first I'll talk about pre-pubertal kids um and how their treatment has evolved in the past few decades or so. Then I'll talk about early adolescence and when you might think about pubertal suppression. Uh and then we'll have to talk about later adolescence when we sometimes think about gender-affirming hormones like estrogen and testosterone.

[00:40:40]I have too many slides, so I'm going to try and talk fast. If that's too fast, just let me know.

[00:40:45]Um little terminology and background.

[00:40:48]So, four important terms to know for this talk. Raise your hand if you already know what all of these are.

[00:40:55]Let's see.

[00:40:56]Um important to know your gender identity, your psychological sense of your gender.

[00:41:00]Um sex are different biological domains, right? It could be external genitalia, chromosomes, etc. Um and then those are different from gender expression, which is what you present to the world in a gendered way.

[00:41:13]So, I am wearing kind of a suit, so that would be masculine gender expression. If I were wearing a dress, that would be feminine gender expression.

[00:41:20]I guess that is the same thing as gender identity.

[00:41:24]Um so, why do we think about uh trans youth so much in psychiatry? And the reason is that there are very high rates of psychiatric morbidities. Um so, very high rates of mood disorders, usually major depressive disorder, um as common as 64% of young people, depending on the study.

[00:41:41]Anxiety disorders are also very common.

[00:41:44]I'd say we most frequently see generalized anxiety disorder and social anxiety disorder, sometimes half of kids.

[00:41:50]Uh and sadly, suicidality is where we see this huge disparity. So, as high as 30% of adults, again, depending on the study.

[00:41:58]Uh the greatest predictors of those adverse mental health outcomes are often rejection based on gender identity, rejection from parents, rejection from peers, bullying.

[00:42:09]And sadly, those rates are also very high, as high as 80%, depending on where you're looking.

[00:42:13]Um but the YRBSS data says the bullying rates are closer to about the past year.

[00:42:20]Uh so this is a graph of different studies looking at suicidality.

[00:42:24]Um so on the x-axis is the mean age of people in each study. On the y-axis is the percentage of people in that study who reported a suicide attempt before.

[00:42:33]Uh the gray line is the general population in the US.

[00:42:36]That black [snorts] line represents trans and gender diverse youth. And you can see there's a suicidality disparity pretty much across the life course. But it does seem to intensify in uh kind of adolescence and early adulthood when we see more experiences of this stigma.

[00:42:54]Uh the minority stress model uh Dr. Braddock talked about a little bit is the predominant model for understanding why we see these big mental health disparities for LGBT people broadly.

[00:43:04]Um so it was first described in lesbian women um later popularized to describe mental health disparities in gay men, cisgender gay men.

[00:43:12]And later uh Hendricks and Testa adapted it to trans people to the gender minority stress model, which is what I have here.

[00:43:20]Uh first talks about these distal stress factors that I think are pretty intuitive. I think of them as external stress factors. So things from the outside world that may worsen your mental health um that are stigma related. So if you are discriminated against, rejected, victimized, you can understand how that would drive anxiety and depression.

[00:43:37]>> [clears throat] >> Um the other less intuitive part of it is the proximal stress factors. I think of them as internal stress factors or things that live in your own mind as a result of exposure to those external factors. So things like internalized homophobia.

[00:43:51]My kids will often hear constantly that being trans is a mental illness or trans people are dangerous or trans people are sexual deviants. All right, they know these things aren't true about themselves. If you're hearing it constantly, you start to get kind of like those cognitive distortions and automatic negative thoughts related to internalized transphobia.

[00:44:12]Negative expectations is really similar to what we see in trauma-related conditions. So, you can imagine um if you grew up in Alabama, um where you were constantly bullied and physically harassed for being trans, then maybe you moved to San Francisco and lived in the Castro, where it's somewhat less likely that you'll have the same experiences. You're likely to over-index how likely it is that you're going to experience it. So, you might go into a Castro coffee that has a big trans flag and still feel that fear that something bad is going to happen.

[00:44:42]Uh and the last one is concealment. So, feeling like you need to hide who you are, going in the closet.

[00:44:47]That can drive shame, which leads to anxiety and depression.

[00:44:51]The good news is that there are some resilience factors studied that buffer against these negative distal and proximal factors. Um important ones are community connectedness. We're often trying to refer kids to community groups so they can meet other kids like them and share their experiences.

[00:45:07]Uh pride is another big one.

[00:45:09]I have a big poster in my office, should have put a picture, of just like that, out trans people in all different walks of life. So, doctors, lawyers, entertainers, etc. Um and what should be on this slide is family support, also. So, a lot of my work is working with kids and their parents to make sure they're really hearing each other so that um the parents can understand the kids' experiences.

[00:45:30]And also a lot of work to make sure the kids can try and understand the parents' concerns.

[00:45:36]Um as Dr. Krasic alluded to, what we're seeing a lot more of are these structural factors that you can map onto the minority stress framework. So, things like anti-trans laws, um executive actions, all of these things um in both public policy and law can impact different parts of the minority stress framework.

[00:45:56]We're starting to see more sophisticated econometric studies in this area um that use causal inference methods that can actually infer that certain types of laws are causing, um, either improvement or worsening of mental health at the population level. Um, this is a study in Nature Human Behavior by the Trevor Project team, uh, where they they did a composite of different types of anti-trans laws, but found that those laws increased past year suicide attempts among trans and non-binary young people, uh, by up to 72%.

[00:46:26]And that's a lot of different types of laws. So, bans on sports participation for trans girls.

[00:46:32]Um, all of the dark orange states are states that have banned trans girls from competing in women's sports. Um, the other states are states that still allow them.

[00:46:41]Uh, we've seen bans on gender-affirming medical care in about half the states.

[00:46:47]Um, it's our practice to do the Supreme Court recently [clears throat] ruled that conversion therapy bans, one of the laws that we know are protective for LGBT youth mental health, uh, are subject to strict scrutiny. I'm not going to share you the legal details, but just know, um, that the Supreme Court did not strike down Colorado's conversion therapy ban, um, but rather they sent it back to the 10th Circuit to evaluate it under something called strict scrutiny, uh, which is very hard for a law to survive. So, it's likely that it will be struck down and impact conversion therapy bans in other states. Um, but a lot of states, including California and Colorado, have introduced new laws that just target conversion therapy in a different way to try and still prevent it. We can talk about those details at the end if people are interested.

[00:47:33]Um, okay, we'll talk about pre-pubertal kids.

[00:47:36]Starting with a quiz.

[00:47:38]Um, so, what percentage of pre-pubertal transgender youth will continue to identify as transgender in adolescence?

[00:47:47]Raise your hand if you think it's 10%.

[00:47:51]Raise your hands. Raise your hand if you think it's 20%.

[00:47:58]I guess it's you guys. I used to be the answer on the boards. Um, we'll talk about why it's not the answer anymore.

[00:48:04]Uh, who thinks it's 80%?

[00:48:08]Okay, who thinks it's 95%?

[00:48:12]Okay, people. So, best guess is it's probably closer to 95%.

[00:48:17]Um, the the idea that 80% of pre-pubertal trans kids would grow up to be cisgender and gay, this 80% this statistic comes from a handful of papers, but the most famous one was this paper in 2013 from the Dutch group in J CAP.

[00:48:33]Um, and what they did was they looked at kids who were referred to gender clinics as pre-pubertal children and then followed them up later to see if they met criteria for gender identity disorder.

[00:48:43]Um, the problem here is that a lot of the kids in those studies didn't meet criteria for the gender identity disorder diagnosis. Probably around half actually didn't meet criteria.

[00:48:52]And there's a problem with that order diagnosis.

[00:48:55]In that it didn't require you to be trans. Um, and so if you were a pre-pubertal um, boy and birth assigned male and most of your friends were girls and you liked feminine play um, and dolls and dresses, then you could meet criteria for gender identity disorder.

[00:49:13]Um, even though you weren't trans.

[00:49:15]So, Kristina Olson at Princeton went back and looked at these studies and found as many as 90% of kids in those studies, when asked their um, gender identity, reported their sex. So, they were probably mostly cisgender kids with gender atypical interests.

[00:49:32]Um, it wasn't until many years later that we got this great study from Kristina Olson at Princeton uh, from the trans youth study.

[00:49:39]She followed 317 uh, pre-pubertal trans children who actually asserted a gender identity different from their sex.

[00:49:47]Followed them for 5 years.

[00:49:48]Uh, and 97.5% of them um, still identified as trans 5 years later.

[00:49:56]Historically, there have been three approaches to treating prepubertal trans youth.

[00:50:02]Um I put all three of them up here. The first is the living-in-your-own-skin model. This was popularized by Ken Zucker at the University of Toronto uh at SickKids.

[00:50:12]And this approach said that for a prepubertal kid >> [snorts] >> to do psychotherapy to try and push them to identify with their birth sex.

[00:50:19]Uh it also recommended against social transition. So, if a kid wanted to use a new name or pronouns or clothes, you would tell the parents not to allow them to do that.

[00:50:29]The logic was that they thought most of these kids were going to desist in their trans identity, so they would argue that they were both hastening the process of desistance.

[00:50:39]Um we're saying that that would generally be considered gender identity conversion efforts. Um and this is currently illegal in half the states, obviously. We'll see how that goes.

[00:50:51]On the other hand, this actually is the gender-affirmative model.

[00:50:55]Probably the most famous person to write about this was Diane Ehrensaft, who's at UCSF.

[00:50:59]She recommended that for prepubertal kids, if you tried to force them to identify with their birth sex, you were going to instill shame, cause damage between the parents and the kid, cause damage between the therapist's relationship with the kid.

[00:51:13]Um And so, don't try and force the kid to identify with their birth sex.

[00:51:20]And then if the kid wants to explore social transition, like a new name or pronouns, etc., you would let them do that while paying close attention to the community and environment to make sure the kid's not bullied and harassed.

[00:51:32]There's an intermediate model called the watchful waiting model. This was popularized uh by the Dutch.

[00:51:37]They tend to not do conversion therapy, so they don't try and force the kid to identify with their birth sex, but to wait until the onset of puberty or adolescence to pursue a social transition.

[00:51:47]Um If that was confusing, it's okay because we're really going to focus on two questions. The first one is pre-pubertal social transition, good or bad? Uh the second question is conversion therapy, good or bad?

[00:52:01]Uh let's talk about social transition first.

[00:52:04]Uh it's an area where we don't have a ton of data, but I'll tell you the data that we do have.

[00:52:09]Uh so on this graph, as you go towards the right, those are higher levels of anxiety and depression.

[00:52:15]Green is the normal range, orange is the pre-clinical range, red is the clinical range.

[00:52:21]And I put three groups of kids up here.

[00:52:23]Um so you can see that first group are kids in the US from Kristina Olson's group who were allowed to socially transition. Um and at least in the short term, they had very good mental health outcomes. Um pretty much normative rates of anxiety and depression, slightly more anxious than their uh siblings.

[00:52:39]Uh that's in contrast to two groups of kids from Toronto and Amsterdam, pre-pubertal kids who were told they could not socially transition.

[00:52:46]Their mean internalizing scores were there in the pre-clinical range.

[00:52:50]And for purposes of comparison, for totally different reasons, right? Kids are in different countries, data was collected in different years. Uh but at least what we can see is that kids who were allowed to socially transition in supportive environments can do quite well.

[00:53:04]A question we get a lot is whether or not that early social transition makes it more likely that the kid will continue to identify as trans. So there's this idea that an early social transition might lock in their trans identity.

[00:53:16]Then another argument against the social transition would be uh that those kids are going to be locked in and later need hormones and surgery that otherwise maybe they would not need.

[00:53:25]Uh so Dr. Olson looked at this also. Um this is a paper in Psychological Science.

[00:53:32]Um and what we knew before this study was that that old study that looked at the kids referred to the gender clinics, there was an association between social transition and identifying as trans in adolescence.

[00:53:44]Now, that could mean two things, right?

[00:53:46]It could mean that the social transition made them identify more strongly as trans, and so they persisted. Or, it could be that the kids who were trans to begin with were the ones who socially transitioned.

[00:53:56]Does that make sense?

[00:53:57]Um so, this study looked specifically at that question, measured degree of gender incongruence before and after the social transition, and found that it did not increase. So, the social transition didn't intensify the degree of gender incongruence, but rather, if you look at time point one, the more gender incongruence you have, that predicts if you're going to socially transition.

[00:54:16]Uh so, this seems to argue against that kind of locking-in idea.

[00:54:22]One really important thing to know about social transition is that it doesn't occur in a vacuum, right? It occurs in the child's environment.

[00:54:31]And so, we published this paper in the Journal of Adolescent Health, where we looked at social transition as a prepubertal child, as an adolescent, or waiting till adulthood to socially transition.

[00:54:41]And we found that those who transitioned early actually had a higher odds of suicidality in adulthood than those who waited till they were adults to socially transition.

[00:54:50]Um it turns out we had done a bad job with adjusting for confounders.

[00:54:55]Anyone have a guess of why we may have seen higher suicidality in those who transitioned early?

[00:55:03]Bullying. Bullying, yeah. Okay, you thought of that faster than we did. So, we went back and uh realized that we had a variable for hate crime or harassment based on gender identity. And when we included that in the model, that higher odds of suicidality went away. Then in fact, early social transition appeared protective, at least for some substance use measures.

[00:55:22]Uh so, that's social transition. The other question for prepubertal kids is conversion efforts, um or attempts to force trans people to identify with their birth sex. We published this paper in JAMA Psychiatry back in 2019.

[00:55:36]We we sample of over 27,000 trans adults. We compared [clears throat] those whose therapists Those who spoke with a therapist and the therapist did not try and change their gender to those who spoke with a therapist and the therapist tried to force them to identify with their birth sex.

[00:55:51]We adjusted for a ton of confounders and found that exposure to conversion therapy for gender was associated with a whole range of adverse mental health outcomes, including suicidality.

[00:56:04]Um I'll say at the time that nobody was advocating for this after the onset of puberty. So, the debates were really about little kids. So, we specifically looked at exposure before age 10.

[00:56:14]Uh and we found that that actually was more strongly associated with bad outcomes.

[00:56:18]Um if you look at lifetime suicide attempts, those who were exposed to conversion efforts as young children had a fourfold increased odds of attempting suicide.

[00:56:28]Uh if you think about it, it makes sense, right? That these young kids are in early developmental period where they're starting to develop a sense of self, self-esteem, and if they're getting early messages that who they are is wrong and that they are later trans adults, um that can have adverse mental health effects.

[00:56:46]Um so, conversion therapy is still legal in most US states, even before that Supreme Court ruling.

[00:56:51]The states in dark green are states that have banned the practice, um although usually only for minors and usually only for licensed professionals.

[00:56:59]Um in the rest of the states, it was legal. Obviously, after the Supreme Court case, um those green states might turn yellow.

[00:57:09]Uh this is a study we published in the American Journal of Public Health where we looked at how common it was for trans people to be exposed to conversion therapy for their transness. We found 13.5% had been exposed in their lifetime.

[00:57:21]We were surprised by where it happened.

[00:57:22]So, we kind of expected that there would be more conversion therapy in the American South, but it was mostly in these um mountain states. This is a heat map where um dark blue is lower rates of exposure, dark red is higher.

[00:57:37]Um Another thing to know is that there are disparities within those exposed to conversion therapy. Um so, ethnic and racially minoritized people are more likely to be exposed to conversion therapy than white people.

[00:57:50]Um and trans people are more likely to be exposed to conversion therapy than cis people.

[00:57:56]Uh this is unpublished and under review now, um but we did a difference in differences analysis. That's one of those causal inference methods to look at whether or not conversion therapy bans are effective in dropping suicide attempt rates.

[00:58:09]Uh and we found that they were um with a huge effect size. So, we found that conversion therapy bans led to a 6.3 percentage point drop in past year suicide attempt rates.

[00:58:21]We had to do it with um sexual minority youth because we were using YRBS data, where they hadn't collected gender identity data long enough.

[00:58:30]Okay, next is early adolescence and puberty blockers.

[00:58:33]One thing that's always missed um in the media is that kids don't just come into the doctor's office and then get puberty blockers and hormones.

[00:58:40]Um so, under current guidelines, both Endocrine Society guidelines and the WPATH guidelines, you need to undergo a comprehensive mental health assessment if you're going to access these interventions before age 18.

[00:58:52]Um so, this is a QR code uh for clinical perspectives we published in JCAT that talks a bit about what goes into those assessments. It's different depending on the unique situation of the kid.

[00:59:02]Um but things like gender history, screening for other mental health conditions, being sure about your differential diagnosis, making sure other mental health conditions are reasonably well controlled.

[00:59:12]Um but you can go into more detail there.

[00:59:17]Uh one thing to know about the WPATH guidelines is that they name a few situations in which you would well, extend the diagnostic process before considering these medical interventions.

[00:59:27]One of those is if you realized your gender identity after the onset of puberty.

[00:59:33]Both late onset gender dysphoria, if you will.

[00:59:37]Um so we were curious how common that is for trans adults.

[00:59:40]It's more common than you would think.

[00:59:42]So this is the histogram looking at the age at which people um You should have read that part. Yeah, came to realize their gender identity.

[00:59:50]60% did realize as pre-pubertal children, but 40% did not realize until after the onset of puberty. Um so if you see someone an adolescent who's coming to realize it after the onset of puberty, just know that that's not necessarily uncommon and in fact is the experience for a large number of trans adults.

[01:00:10]Another sad thing from that study is that a median 14 years elapsed between realizing that you were trans and telling another person.

[01:00:19]And so you'll often hear this idea of rapid onset gender dysphoria where from the parents' perspective it's came to find out that my child is trans all of a sudden.

[01:00:28]Um and there there's been one or two studies where they interviewed parents um about their kids' experience and the parents said, "My kid became trans all of a sudden." Um but they didn't interview the kids to ask them how long they'd been known.

[01:00:40]Um so if you actually interview trans adults, there there's a over a decade of generally elapsed between realizing and talking to someone.

[01:00:49]Um so back to the medical interventions.

[01:00:51][clears throat] So let's say uh a young person has reached Tanner 2, has gender dysphoria that's causing significant impairment.

[01:00:59]Um that could be things like not being able to shower, not being able to go to school.

[01:01:03]Um you might consider a puberty blocker.

[01:01:06]I'm going to spare you the physiology.

[01:01:09]And I'll let people want to know later, but just know these are reversible medications. It's usually a subcutaneous implant. Um marketed to last a year, usually last 2 years. They can be removed.

[01:01:19]And there are depot injections that are every 3 months.

[01:01:22]Uh the medication will pause puberty, which is helpful for kids whose gender dysphoria is causing impairment, uh so that they can have more time to decide what's next. Either stop the puberty blocker and go through their birth um adopted as puberty, or later start gender hormones, which we'll talk about. Though it's important to know that the pubertal suppression itself is reversible.

[01:01:44]Um our Dutch colleagues were the first to publish on this approach for trans kids.

[01:01:50]Answer that very pretty. You should come.

[01:01:53]Um but they published this landmark case report in 1998, where they um talked about a young trans boy came out as trans, um parents took the kid to a therapist to believe for years where the therapist tried to push the kid to identify with their birth sex. It was unsuccessful. Um and a community endocrinologist actually prescribed the puberty blocker. We'll go over this after the fancy after the protocol, but they didn't give it until the end. Um the kid later went to the Center of Expertise for gender dysphoria in Amsterdam, uh got testosterone and a hysterectomy and had a very good outcome.

[01:02:30]So since then there's been more and more interest in this approach for adolescents with gender dysphoria.

[01:02:34]Uh these are the studies we have on pubertal suppression specifically.

[01:02:38]Um to this earlier question about level of evidence, um there are two types of studies. No randomized controlled trials.

[01:02:46]Um there are longitudinal cohort studies that have looked before and after puberty blockers, and generally found either improvement in mental health after the puberty blocker, um or a non-worsening of mental health with no control group.

[01:02:58]Um either the most famous one there is the Carmichael study, um which gets cited all the time as saying puberty blockers don't work.

[01:03:06]Um few things to know about those that study is a lot of the kids got puberty blockers way too late. So they were mostly through puberty, and it probably wasn't very useful to give them hot flashes. So perhaps it's not surprising that it didn't work.

[01:03:18]Um but also there was no control group.

[01:03:21]So, those kids, their mental health appeared to stabilize, whereas generally what we see with kids who have gender dysphoria where their puberty is progressing is their mental health worsens. So, if that study had a group of kids who didn't get treatment, it would have been more interesting to look at the gap between treatment and no treatment.

[01:03:37]To that point, we have studies that are cross-sectional studies comparing those who access puberty blockers to those who desired but weren't able to access them.

[01:03:44]And in those studies, those who access the puberty blockers have better mental health than those who don't.

[01:03:49]Um with observational studies like this, you want to think about a lot of things, right?

[01:03:54]Um did they get concurrent therapy? And is it actually the therapy that made them better, not the puberty blocker?

[01:03:59]Um so, the cost of study looks at that and finds that those who got puberty blockers do better than those who got just therapy.

[01:04:06]Um others control for things like family support, etc. But you have to kind of dig in to see what the differences are.

[01:04:12]And that's almost always lost by the systematic review.

[01:04:18]Okay, that's puberty blockers.

[01:04:20]Um later in adolescence, you might think about gender-affirming hormones.

[01:04:24]So, the older Endocrine Society guidelines, they're not very old, 2009, said to wait until age 16. So, that's what most of the data were based on.

[01:04:33]Um it's also probably an artifact that that's the age of independent medical decision-making in the Netherlands, where a lot of the research is being done.

[01:04:41]Um but that's what the guidelines said for a long time. You had to wait until 16 for hormones.

[01:04:45]Over time, there was more clinical experience that young people, especially those who came out as trans early, maybe got a puberty blocker for the first time when they were 10, had the puberty blocker replaced when they were 12, now are 14 and are looking at their doctors saying, "All of my friends are going through puberty and I'm stuck in this pre-pubertal state."

[01:05:04]And the doctor's looking and seeing that they're falling behind on bone density from their puberty blocker without hormones. When you start hormones, you can up on puberty.

[01:05:13]Um so, the latest guidelines recognize that you could start earlier, as early as age 13 and a half.

[01:05:18]Um while acknowledging that there's not quite as much data for that.

[01:05:22]Though, more data's been published since that was um the decision. The WPATH guidelines removed age requirements, which has been controversial.

[01:05:31]Um I would say, at least the way I look at that, and I think a lot of providers look at it, is within the context of the Endocrine Society guidelines, that even though there's no strict cut off in WPATH, you're not going to start hormones at like age 10. So, if they're graded, it's still generally this like 14 to 16 range, or later, obviously.

[01:05:51]Uh similar uh body of evidence for gender-affirming hormones in adolescence. Um some longitudinal cohort studies looking before and after treatment, finding improvement in mental health after. Um probably the most famous one lately has been this Chen et al. study from 2023 in the New England Journal.

[01:06:10]They followed 315 adolescents um and found improvements in parent congruence, life satisfaction, depression, and anxiety.

[01:06:18]Uh to get a causal inference, they also did some [snorts] parallel trend models, and found that improvements in mental health were predicted by improvement in body congruence. So, suggesting that it is the actual physical changes from the hormones and your body aligning with your gender, that that's predicting the improvement.

[01:06:37]Um and then again, cross-sectional studies comparing those who access treatment to those who desired it and did not.

[01:06:42]Those have generally found that those who access treatment have better mental health outcomes than those who did not.

[01:06:48]Uh this is the newest study on satisfaction and regret following gender-affirming medical care during adolescence.

[01:06:54]Uh 220 kids, which is impressive.

[01:06:58]Um also, a really impressive retention rate. I would say, most academic medical centers don't do a good job at this, right? There's large kind of drop-offs, people move, or you lose contact.

[01:07:08]Kristina Olson's group is novel in that it's not based in any medical clinic. It's She's really a developmental psychologist who doesn't do any clinical care. And so, it's really just focused on keeping these kids in the study and tracking them and calling them.

[01:07:22]So, 94% retention rate.

[01:07:25]The kids were followed up mean 5 years after puberty suppression, 3.4 years after hormones.

[01:07:31]And only 4% expressed any regret. Where if you're familiar with other medical interventions, that's astoundingly low.

[01:07:38]Um but it didn't have details on what exactly the regret was about.

[01:07:44]Um and half of those who expressed some regret were continuing on with the treatment. So, suggesting that there were downsides or things that they regretted or didn't like, but the positives appears to outweigh that and that they were continuing treatment.

[01:08:00]Um some of the kind of early notes that she had on the reasons for regret were adverse effects or um developmental delay compared to peers, which is what we were talking about earlier.

[01:08:12]That you have to stay on puberty blockers for a while usually while your peers are going through puberty and that can cause social distress.

[01:08:21]Um different type of study.

[01:08:23]So, this didn't look at what percentage of kids take treatment and then stop them or regret them, but was a convenient sample recruiting people online just kind of find people all around the world um who discontinued their medical care.

[01:08:39]This author's controversial. Um she's famous for the rapid onset gender dysphoria study, which um overstated its conclusions and needed a correction later.

[01:08:49]Um but there's some reasons that I that I do find that this study I think is probably not entirely fabricated. Um and some of the answers were somewhat nuanced.

[01:08:57]Um so, again, it doesn't look at how many people are going to regret treatment or stop treatment. Also, the mean age of people starting medication was 22. So, most of them were getting treatment in the adult model and didn't have a comprehensive mental health assessment prior to starting interventions.

[01:09:13]Um but 29% said that they stopped hormones because of an external factor, so harassment, stigma, etc. Um only 30% wish that they hadn't done it.

[01:09:23]Um 34% felt it was a necessary part of their journey.

[01:09:27]50% said they were both helped and harmed. Um a third felt they were only harmed. And the second reasons for detransition included that their gender dysphoria was from trauma or another mental health condition. That it was from internalized misogyny.

[01:09:42]Internalized homophobia or social influence.

[01:09:45]I'm going to pause on this cuz these are controversial notions. Um and they probably sound familiar from kind of the ex-gay movement in the past, right? That a lot of people who went through gay conversion therapy or entered social environment that told them being gay was a mental illness, were told that these things were true about themselves and built these things up for a long period of time, right? People were told, "You're gay because you had a sexual trauma as a child."

[01:10:07]Um or gay because of peer pressure. And it wasn't until, you know, probably a decade or decades later that those people later, you know, said, "You know, I I still am gay and I think I was gaslit with these ideas more than them being true."

[01:10:21]Nonetheless, um we take these seriously.

[01:10:24]We try to incorporate them into our assessment protocols.

[01:10:27]Um to make the risk for patients lower.

[01:10:30]Yeah.

[01:10:32]This this is kind of my point. Um so so detransition can be from external factors, right? Harassment, discrimination, kind of forcing you that it's not this isn't worth it, it's too hard, I'm going to present as cisgender again.

[01:10:44]Um but also if you're constantly hearing those messages that being trans is a mental illness, that it's from trauma, you might start to internalize that and believe it whether it's true or not.

[01:10:52]Um so really complicated if you have someone stopping hormones.

[01:10:56]Um but this is a paper we published.

[01:11:00]This is a J Path one. There's one in JAMA Pediatrics also. Just about how you can try and break this down for people.

[01:11:05]So, think about external factors, think about internal factors, and also about how they're in interplay between the two.

[01:11:12]And you'll see in this this J Path paper that we try to incorporate these ideas.

[01:11:17]So, the way we'll talk to people is say, you know, there's no evidence that um trauma for instance causes you to be trans.

[01:11:29]That being said, there are some people who say that their individual experience was that they identified as trans after trauma, and then later felt that their trans identity was from that trauma, um and they actually identified as cisgender again.

[01:11:42]A lot of things could be happening with those people. We're not sure. They could have been gaslighted to those ideas. But I would hate for you to take testosterone and then encounter that idea for the first time years later and it be a really scary thought. Do you have any any thoughts on that?

[01:11:56]And we can play out um discussions around that.

[01:12:00]Same thing with internalized misogyny.

[01:12:01]Same thing with internalized homophobia.

[01:12:03]Sorry.

[01:12:05]Um that's it. I was hoping we had time for questions. I think we do.

[01:12:10]Um this is a shameless plug for my book that has a lot more detail on all of these things.

[01:12:16]Um and either of these common questions that people often have or want to talk about, I have appendix slides for some of them.

[01:12:22]Um but we can really talk about whatever would be helpful to you all.

[01:12:26]>> [applause] >> So, if people would people have questions, would you come up to the microphone?

[01:12:43]Yes, hello. Thank you so much for the wonderful talk. Daniel from Long Island University, PGY-3.

[01:12:50]Um so, I was kind of wondering if you patients uh who are coming into your clinic who are interested in interested in transitioning, uh but your university doesn't necessarily have any kind of major academic center that's going to be able to do this. Uh the nearest one's a long way and they're they may not have access to it.

[01:13:07]What would you suggest as the first steps for, you know, helping these these people on their journey? Uh if they're saying, "Hey, I'm interested in transitioning. I'm interested in getting some of this care."

[01:13:19]Start by saying where you are again. Uh Loma Linda University. So, it's a Southern California area. Got you.

[01:13:25]And um are you thinking specifically about youth or adults or both? Uh so, uh currently have a child clinic, so usually under the age of 18, mostly adolescents, but uh we do get pre-bests as well.

[01:13:40]Yeah, so, I would I we just specified because um uh there has been a lot of youth care in similarly uh for people starting from puberty blockers that have um been associated with um academic um uh centers um that uh that provide um uh more comprehensive um psychosocial interventions as well as mental health evaluations.

[01:14:14]And uh and adult care, um whereas um for older folks, um that's less common in this country.

[01:14:22]Um uh unfortunately, um many of the youth centers have been shut down and you mentioned Southern California where uh uh where most of the children's hospital programs were shut down, although maybe the Orange County and San Diego has opened up again um in response to court action and um but the um access is uh pretty tenuous in much of the country. Um Uh I saw one statistic at one point that 40% of the academic centers providing youth care had stopped and it's probably more um now and um and so youth are more and more um receiving care in the community. Um You know, actually our presenter who couldn't make it today does direct primary care where youth can get care without um any billing for Medicaid or private insurance. Um so that if that care is either banned or or pressured to end because of government interference, people can still get care. It is a shame though cuz there are some great programs um that really had an extensive um interdisciplinary um uh work that are no longer and uh we've lost the majority of them and um so people uh families are are going where they can't get care.

[01:16:02]Um yes, to make sure people have contacts so that the pressure on universities and hospital systems and providers is very intense from the Trump administration. Um so there's the proposed proposed CMS rule that will take all of Medicaid and Medicare from any university or hospital that receives Medicaid and Medicare funding.

[01:16:22]So no hospital can really survive that, right? And so if that goes into effect, I think a lot of these types of most of the academic medical center clinics will close um because people realize that that's happening. We are starting to see more community clinics pop up that just don't take any public insurance. They just take commercial insurance. Um So Yeah, think of it as kind of how it was in the United Kingdom but there weren't very many practices that were kind of getting back to that.

[01:16:48]You will sometimes find a one-off provider just like a private practice um pediatric endocrinologist or adolescent medicine doctor who who will feel comfortable doing it outside of the medical center but you you have to network to find them.

[01:17:01]And um I I I'll just add that um things are still really in flux. Um so, judges have stopped um uh enforcement of RFK Jr.'s um pronouncement that was at the start of this session.

[01:17:21]Um where uh where all funding um will be taken away.

[01:17:27]Uh so, I I testified in a case of on Children's Hospital um where um uh where they abruptly stopped care for all of the youth um in response to the RFK Jr. threat.

[01:17:41]And the response of their lawyers it it was is it better that we stop providing care to trans or we stop providing care to trans kids and we can't give chemotherapy to trans kids.

[01:17:59]And my thought is that that's not a question we should have to answer in this country in 2023.

[01:18:07]Um but it's still really in flux and given us rules to practice the law that no public or another attempt to shut down um we all care um except maybe for that primary care, maybe even private insurance care. Um for you that we will you and and adult or aging um at a minimum and um and in some states uh pediatric services as well as is already happening.

[01:18:37]So, but people are finding ways to ways to get care and there are contingencies.

[01:18:45]I know in San Francisco as well as elsewhere for people to receive care in blue states with direct primary care where there's no insurance money involved and so they can still get care but that leaves out people who lack the resources for that and so it's not an adequate substitute.

[01:19:06]Next question.

[01:19:07]So, prior forum, these speakers suggested that if you treat kids before [clears throat] puberty, you run the risk that they'll never develop the capacity for sexual excitement, sexual sensitivity. Can you address that? Yeah, so there there was a Dutch study where they compared trans women who as youth had received puberty blockers versus those who had transitioned later and and compared their sexual functioning to cisgender adult females.

[01:19:45]So, they were looking at them all once they were adults but looking back and those who had received puberty blockers actually had slightly better sexual functioning than those who had transitioned later and in all of those groups it was similar to sexual functioning in cisgender women. So, it this assertion is is simply inaccurate.

[01:20:15]>> [clears throat] >> There's another Dutch study by Ungerleider et al. 2018 Pediatrics where they looked at sexual functioning before and after these various interventions and found improvement after.

[01:20:27]That being said, sexual functioning is really complicated. So, we I find patients who have had puberty blockers, hormones, vaginoplasty and I find sexual function. And I have to talk to you more about what I do.

[01:20:40]But I don't know if there is a lot harder.

[01:20:44]And I find something in the what is now adults, um, sex therapy can be really helpful because there's so many factors involved, right? There's how comfortable are they in their physical body from their gender dysphoria. A lot of these kids have had trauma. A lot of them are really afraid of how they're going to react when they come out that they're trans.

[01:21:02]Um, if your psychiatrist and the patient's on psychiatric medications, and they have those, how sex will function. So it's just important to keep a broad differential.

[01:21:11]Thank you.

[01:21:12]Next question.

[01:21:14]Hi. Um, so I'm a psychiatrist in Park City, Utah. Um, and about 50% of my patients are transgender adults.

[01:21:22]And I My question is more about, um, like sort of how to integrate effective psychotherapy and then to follow up with this population. Um, because personally like I I myself feeling like helpless and hopeless like the person you were referring to earlier on. And you know, leaning on sort of just supportive principles, but like CBT sort of feels like it's penalizing because it's like yes, there is real danger here. Um, and um, yeah, and just kind of curious like your thoughts there.

[01:21:58]Yeah, I I mean, those were my thoughts when I had the slide of the government's proposal that you take a trans woman who's had vaginoplasty and then a woman's prison and you cut off her hormones and put her in a men's prison that then CBT is going to actually be a substitute for her having lived her previous life. Um, but I do think that there are aspects of cognitive behavioral aspects that are helpful that that it is necessary for in this environment of extreme stress where people really don't know what's going to happen tomorrow for people to be able to get up in the morning and go to work and have their relationships and live their normal lives and and so I think that um that all the ways that people do that through better coping skills through mindfulness through psychotherapy if they need it through anti-depressants if they need it and all those things are important and we as psychiatrists do really have a vital role and and instilling hope is challenging in this environment and yet we we also need to do that as part of the our work and while while not being Pollyannaish and and that is a difficult balance to strike I think that if you know you look at historical comparisons of people and places of of [sighs] of increasing threat maybe the most effective thing is helping people relocate somewhere safer but it's not a possibility for for many of our patients and so helping them get through the stresses and the uncertainty you know is is critical.

[01:24:10]Uh Jack Drescher has also this great paper on incorporating minority stress principles in other evidence-based practices.

[01:24:17]So it's called a model for adapting evidence-based interventions to be LGBTQ affirmative.

[01:24:23]Um But what what part of psychoeducation is all often put up that chart describing minority stress and how that internal cognitive factors work. And just being able to recognize when that's happening for people is helpful and then you can do cognitive restructuring around it.

[01:24:37]So, if you have people who are often thinking um no one's ever going to love me because I'm trans, I'm mentally ill because I'm trans, Candace Owens said that being transgender is like being transracial.

[01:24:46]These are all real examples. Um I I will kind of like try I will elicit those and then sit down and do cognitive restructuring around like what happens or what happens again.

[01:24:55]Um and try and have little mantras so that um they don't challenge those in the moment.

[01:25:01]So, um but if those get internalized thought processes are really bothering people, I think they're more malleable.

[01:25:13]I have a question.

[01:25:15]Yeah, I'm a psychiatrist who used to use to About 10 years ago, I was approached by a plastic surgeon who wanted to start a transition clinic.

[01:25:23]Um working with endocrinology, OBGYN, neurology. It was a great program going.

[01:25:29]Then about February 2015, it magically disappeared from the website and no mention of it existing at our uh university ever again.

[01:25:37]Um and it's it seems that in Houston, they've systematically started to break down everything regarding uh transgender care and medicine. And I'm not sure if you're familiar with the verdict yesterday that came out in Texas.

[01:25:50]Um Texas Children's Hospital is now required by law to provide detransitioning services.

[01:25:57]Um and they have to pay for the next 5 years as part of the settlement.

[01:26:02]And they also had to fire the five doctors that were providing the transgender care.

[01:26:07]Um So, apparently the doctors they should staff this new detransition clinic? Yeah, and that's what I was going to ask is how just thoughts. I mean, now we're going to have to have this mandatory detransition clinic run by I have no idea who wants to volunteer for that job. Yeah, I mean, I'm I'm fascinated. I almost want to volunteer for that job because [laughter] it would be curious Free. Where else in this country do you get free care except the detransition clinic is going to be entirely free care. Well, I mean, auto maybe for all care in this country.

[01:26:37]Well, and it's kind of kid to me detransition. Like every single kid in Texas they took away their insurance.

[01:26:43]So, they are all being forced lately detransition. So, Yeah. in a way I I think they think it's um you know, people who can realize they were cisgender, but there are a lot of people who are forcefully detransitioned. I don't know if they'll feel great enough to go to this clinic that is political. I I wonder if besides firing the physicians whether they dropped the charges because they they dropped the charges on all of those.

[01:27:04]That was part of the settlement why Texas Children's settled is that they dropped all the charges against the physicians and stuff.

[01:27:11]That's good cuz I I was going to be an expert in one of those cases. Um and so, um and you know, maybe that's for the best and those doctors can move out of Texas and take care of people elsewhere.

[01:27:24]But, um it I agree with you. Who better to work on detransition than people who do have experience with this whether it's mental health providers or endocrinologists.

[01:27:39]Um who who you know, how many pediatric endocrinologists are left in Texas? You know, at this point.

[01:27:46]Um you know, so many who moved out of uh states um like uh reproductive health people moving out of uh affected states. And um uh yeah, it's it's very it'll be interesting to see how many patients they have, how many providers, what kind of care they give, the systematic reviews they're they're to use to, to, you know, um Anyway, it's another curiosity of this, of this era. Texas also has detransition law, a firm that only does detransitions. There's a team of lawyers, although at least one of them now works, I think, in the Department of Justice.

[01:28:37]Um but this whole infrastructure for detransitioners, which it's great that they can get all the, whether it's medical or legal services or whatever they need, but it does seem very artificially, you know, constructed for a small number of people.

[01:28:59]Thank you.

[01:29:02]Yes. My name is Sally Oregon and I'm a P3. I just wanted to thank you for this presentation. I really loved it and I had kind of a two-piece question. First, I was wondering if there's any way to get access to the slides Yeah, um should we just have people contact us if they You can contact us and we'll be happy I'm so happy to send the slides and the graphics as well.

[01:29:32]I don't know if the ABA has any um Oh, you can You can find me on the app.

[01:29:41]Yeah, we we upload them to the website, maybe.

[01:29:45]Yeah, that's right.

[01:29:46]I'm not I'm not sure, but you can feel free to, I think both of us are easy to find with Google and if anyone's interested, you can feel free to, to contact us for slides.

[01:30:01]>> [clears throat] >> And then my second question was, you mentioned transition and detransition and then feelings of regret and then re-regret.

[01:30:31]>> I was sorry. So, your first point is and probably one that there are a bunch of different studies that operationalize detransition differently. Some of them are just having started hormones or actually regretting treatment.

[01:30:44]Um The studies that have been better conducted like the Person Olson study look at 5 years and so people are still relatively young.

[01:31:04]I don't think there's a great statistic to say Am I My experience, um certainly without it for an extended period because there's so much focus on you, but in terms of adults that there have been um adults who detransitioned either because of circumstance um That was the session 1193 from the American Psychiatric Association's annual meeting in San Francisco.

[01:31:37]Tomorrow, we will release session two.

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[01:32:56]>> [music]