Youth gender identity and transitioning

[0:00:27]

RICK WEISS: Hello, everyone. Welcome to SciLine’s media briefing on youth gender identity and transitioning. I am Rick Weiss, SciLine’s director. And first, for those of you who are not familiar with us, SciLine is a philanthropically funded, editorially independent free service for journalists and scientists based at the nonprofit American Association for the Advancement of Science. Our mission is straightforward—it’s to make it easier for reporters like you to get more scientifically validated evidence into your news stories. And that means not just stories about science, but any story that can be strengthened with some science. And I’m still waiting to hear if anyone has found a story out there that cannot be made better with at least some science. Among other things, we offer a free matching service that helps connect you to scientists who are both deeply knowledgeable in their field and are excellent communicators. We do that on deadline for you. Just go to sciline.org, click on I Need An Expert, and we’ll get back to you within a few minutes to let you know we are on the case. And while you’re there, check out our other helpful reporting resources.

Last thing about SciLine, especially relevant to today’s briefing, we are all about science and are explicitly neutral on matters of policy or politics, which may raise the question of why we’re focusing today’s briefing on a topic that’s proven to be nothing if not intensely political and policy-oriented. And the answer to that is that science has an important contribution to make to this, and really just about to every contentious policy area out there. Science cannot answer all the questions that are raised by today’s changing sensibilities about gender, but it can help us understand the basis for many of these changes and inform many of the decisions that policymakers today face. So, we know that you, as journalists, will be writing stories on this topic because of the politics, but we hope that in the process, you will enrich your stories with scientifically derived evidence that we’re going to share with you today.

OK, a couple of quick logistical details before we start. We have three panelists who will make short presentations of about five or six minutes each before we open things up for Q&A. To enter a question during or after these presentations, simply hover over the bottom of your Zoom window, select Q&A and enter your name, news outlet and your question. If you want to pose your question to a specific panelist, be sure to note that. A full video of this briefing will be up on our website, likely by the end of today, and a time-stamped transcript within a couple of days. If you’d like a raw copy of that recording more immediately today, please just submit a request with your name and email in the Q&A box, and we can send you a link to the video by the end of the day. You can also use the Q&A box to alert SciLine staff to any technical difficulties.

OK, I’m not going to give full introductions to our speakers. Their bios are on the SciLine website. I just want to tell you that first we will hear from Dr. Jenifer McGuire, who is associate professor at the University of Minnesota. And she’s going to speak about what science has revealed about how gender identity develops, including what aspects of a child’s environment—such as family, school, community support or not—might influence formation of gender identity. Next, we’ll hear from Dr. Alex Keuroghlian, who is associate professor of psychiatry at Harvard Medical School and director of the Division of Education and Training at the Fenway Institute, who will focus on mental health issues relevant to transgender youth, including what the best research has concluded about the mental health outcomes among youth who undergo social transitioning and related medical care, and how the timing of these decisions matters for mental health outcomes, and what we’re learning about the impacts of certain policies that interfere with these best practices. And third, we’ll hear from Dr. Madeline Deutsch, professor of family and community medicine at UC San Francisco, who will focus on physical health issues relevant to genderfluid or transgender youth, including some of the basics you ought to understand about puberty-blocking drugs and how these hormonal treatments affect growth and development and some of the particular health care needs of transgender individuals. OK, that’s a lot, but we have a lot to go through today. It’s going to be a very interesting briefing, and let’s just get started with you, Dr. McGuire.

[0:05:05]

JENIFER MCGUIRE: Thank you, Rick. Hi, I’m Jenifer McGuire. I use she and her pronouns. I’m a professor and extension specialist at the University of Minnesota in the Department of Family Social Science. First, I’ll give you a little bit of background about gender identity development. The word cisgender means that your identity aligns with your body. I’m cisgender. I’m female. I was born female, assigned female and I live in a female body and take female roles. Transgender means that there’s some discordance between your identity and the body that you were born with. There—this can include nonbinary identities and even a desire to change gender but not necessarily an action to change gender. It’s best to think about transgender as an umbrella term. There are trans, nonbinary, genderfluid, agender, et cetera—and all of those are within an umbrella considered transgender. Sexual orientation is different than gender, although they do have intersections. So, sexual orientation has to do with how you—who you’re attracted to. So, I identify as queer, meaning that I am in relationship to other women predominantly. Not everyone who is transgender has a sexual orientation that is not straight. Some do, and sometimes sexual orientation can change over time with gender changes.

There’s a few things to be aware of when you’re thinking about gender development and transgender youth. First of all, there’s an element of identity versus expression. So, your identity is the deeply held belief that you have about exactly who you are and how you want to call yourself. Expression includes things like how you do your hair and your makeup or not and your jewelry or clothing and the way that you interact with the world. One thing that we have found is that when an identity is taken, it tends to be holding for a long time. So, a recent article found that among children who socially transitioned, about 93% stayed with that same identity. Some had some shifts with other identities, but most who take an identity in childhood will stay with that transitioned identity.

The timing of development of gender identity is similar for transgender kids as well as cisgender kids. So, there’s a few milestones that happen in both populations. For instance, around age 3, 4 or 5, kids start to become aware of gender as a construct that the world is organized around, and they begin to place themselves in a variety of categories of gender. They think of themselves as boy or girl or maybe neither boy nor girl or both boy and girl. And sometimes kids are able to articulate that at the early age, and that’s where you see preschool and kindergarten transitions happening. Other times, kids aren’t able to articulate it for a variety of reasons, either because their family doesn’t push the need to articulate or because their family makes it clear that it’s not OK to articulate. And so, for those kids, sometimes they don’t articulate it till adolescence or adulthood or even late adulthood.

Things to think about have to do with the fluidity and intensity of expression. So, how much is someone presenting their gender identity, and how important does it seem to be to them, and how often does that hold true? It doesn’t mean that someone is or isn’t trans, but it’s something to think about in terms of how to best support young people. Finally, you want to think about the family and structural support that trans kids have, which will be an upcoming slide. Supportive families are associated with far better mental health. And this is a field that is developing, the study of families for trans kids, but we do find that kids who are tracked through clinical settings or because they’ve socially transitioned with parent support are doing much better in their mental health than kids in more population-based studies where the parental support is less clear or it may not be existent. We found in one recent study of young adults that those who reported having an ambiguous family support to their gender during adolescence, which was over half of our sample, their mental health and well-being was similar to those who had a family who reputed—repudiated their gender identity, and so that strain on mental health was just as significant for families who were ambiguous as for families who were rejecting. Family rejection is a precursor to other kinds of risks, like homelessness and suicide risk. School and social contexts are critically important to improve outcomes. So, trans kids are about 3.7 times more likely than cisgender youth to experience bullying, and they’re about 3.3 times more likely to miss school because they don’t feel safe at a school environment.

There’s a lot of conversation about sports for trans kids, and in general, in a recent study of Minnesota kids, we found that 73% of the trans kids had zero days of sports in the last seven days versus 45% of cisgender kids, that overall sports participation, physical activity and diet behaviors are not as healthy among trans kids as among cisgender kids. School climate can be a reason to avoid social contexts. So, sometimes trans youth report not going to the bathroom all day or not wanting to be in places where they can’t use their chosen name. We’ve seen increases in anti-trans legislation over the last five years. Last year was the biggest year ever. This is all tracked at humanrights.com. The anti-transgender legislation can enhance the environmental negativity that trans young people feel, and they hear the commentary, and they know that it applies to them. When there are periods of anti-transgender legislation being discussed and covered in media, there’s an increase in hate crime reports as well. And here’s some references and resources for you that you can click to link that cover the topic. And thank you very much. I will now pass the presentation on to Dr. Keuroghlian.

[0:11:08]

RICK WEISS: Thanks, Jenifer, for that great introduction. And these slides will be available, folks, soon after the briefing. Dr. Keuroghlian, over to you.

[0:11:19]

ALEX KEUROGHLIAN: Thank you, Rick, and thank you, Doctor, for that great initial presentation. I’m going to continue where the first presentation left off, and I’m going to share some findings from U.S. Transgender Survey. This was a survey performed in 2015 cross-sectionally with transgender and gender-diverse participants from all 50 U.S. states where almost 28,000 people who participated. The study found that 10% of respondents reported family members abused them because they were transgender. Eight percent were kicked out of the house because they were transgender. (Inaudible) experienced serious mistreatment in school, verbal harassment, physical attacks, sexual assault. Seventeen percent experienced such severe mistreatment in school that they had to leave before graduating. The survey also found that transgender people were much more likely to live in poverty compared to the general U.S. population, had a (inaudible) rate, had much lower home ownership than the general population and a much higher likelihood of homelessness, both in the past year and across their lifetime. Additionally, survey findings indicated that many transgender people reported at least one negative experience with a health care provider, like being verbally harassed or refused treatment because of their gender identity or expression. Many reported not seeking needed urgent or preventative health care in the past due to fear of gender-related mistreatment, and many didn’t go to a health care provider when they needed to simply (inaudible) couldn’t afford it in the context of pervasive familial, educational, employment and housing discrimination. Looking at suicide-related data from the U.S. Transgender Survey, 48% of respondents (inaudible) in the previous year. Twenty-four percent made a plan to kill themselves in the previous year. Seven percent attempted suicide in the past year, and 40% of respondents reported attempting suicide at at least one point in their lifetime. Forty percent lifetime suicide prevalence is higher than for any other studied population in the United States. Of those 40%, 34% had their first attempt by age 13, and 92% had their first suicide attempt by age 25.

What is gender affirmation? It’s the process of changing from living and being perceived based on how gender—based on how society sees us, related to assumptions regarding our sex assigned at birth, to living and being perceived the way we see and understand ourselves. There are different components to a gender affirmation process. There’s psychological affirmation, which involves exploring, discovering, accepting one’s gender identity; social affirmation, which can include changing your name, your pronouns, the way you dress, your hairstyle. There’s what some call legal affirmation, or changing the gender markers on your official government-issued documentation. There’s gender-affirming medical care, which we’ll hear about more from the next speaker, from Dr. Deutsch. That can include pubertal suppressants, gonadotropin-releasing hormone analogs used in early puberty to press pause on endogenous puberty. And subsequently, the opportunity to induce puberty that aligns with the person’s gender identity with, say, estradiol or testosterone. Then there’s gender-affirming surgery, which includes a range of surgeries to align a person’s body more congruently with their gender identity and desired expression.

We did a study with the U.S. Trans Survey that we published in the American Journal of Public Health in 2019, and this was looking at the prevalence, nationally, of efforts to change a person’s gender identity from transgender or gender diverse to cisgender, which is, in casual parlance, referred (inaudible) conversion therapy. We don’t use the term therapy because that implies it’s a legitimate clinical practice, which, as we’ll see, it’s not. It’s, in fact, quite harmful according to the research. And we found that 14%, approximately, of respondents to this survey across the country reported experiencing gender identity conversion efforts in their lifetime, and that’s approximately 188,000 transgender and gender diverse people in the U.S. We then published a study in JAMA Psychiatry in 2020, again with the U.S. Transgender Survey data, looking at the relationship of these gender identity conversion efforts to suicide attempts. So, we found that people who are exposed to gender identity conversion efforts had more than twice the odds of attempting suicide in their lifetime, and those exposed to gender identity conversion efforts before age 10 had more than four times the odds of attempting suicide in their lifetime.

Another study we did based on the U.S. Transgender Survey was looking at timing of social gender affirmation for transgender and gender diverse youth. And we looked at youth who first experienced gender—social gender affirmation before age 10, people who first experienced social gender affirmation as teenagers and then people who first experienced social gender affirmation as adults. And we found that people who are socially affirmed as children before age 10 or as teenagers had just as good mental health in adulthood as people who are not socially affirmed until adulthood. In fact, people who (inaudible) age 10 had lower odds of a cannabis use disorder in adulthood than people who were not socially affirmed until adulthood. And that’s important because there’s this school of thought, at least historically, that’s referred to as watchful waiting, this idea that children (inaudible) what their gender identity is, so we shouldn’t let them be socially affirmed. And once they turn 18, they can make their own decisions. And we found that there’s no reason to do that. Mental health outcomes are just as good or potentially even better when people are affirmed before adulthood. We did find that people socially affirmed as teenagers had higher odds of worse mental health in adulthood if they were exposed to school-based, emotional, physical or sexual harassment. So, the point isn’t to not let teenagers be socially affirmed. It’s that we need to work with schools and communities to build safe learning environments for these teenagers to thrive in their gender identity and expression.

We did another study out of the U.S. Transgender Survey that we published in the Journal of Pediatrics in 2020, and this was looking at the relationship of pubertal suppression to suicidal ideation. We found that accessing pubertal suppression, compared to desiring and not accessing pubertal suppression, was associated with decreased odds of suicidal ideation. The study, published earlier in 2022 in the journal PLOS ONE, again using the U.S. Transgender Survey, looked at the relationship of access to gender-affirming hormone therapy and mental health in adulthood, and we found that accessing gender-affirming hormone therapy from age 13 onward as a teenager is associated with better mental health outcomes in adulthood, including decreased suicidal ideation, compared to desiring but not accessing gender-affirming hormone therapy. It also—again, with the U.S. Transgender Survey—this had looked at factors associated with what’s referred to as detransition, or no longer identifying as transgender or gender diverse or no longer pursuing gender-affirming care at some point. And we found that in the vast majority of cases, people don’t experience a detransition due to fluctuation or doubt in their gender identity. It’s due to external factors, like being incarcerated, family pressure or community pressure, joining the military, moving, no longer having access to gender-affirming medical care providers. And everyone in this study, by definition, went on to identify as transgender and gender diverse again subsequently because they participated in the study. So, we concluded that if you as a clinician are working with a patient—somebody who’s experiencing a detransition, know that it’s very likely due to external factors, and that there’s a good chance they’re going to pursue gender-affirming medical care again in the future.

Finally, there’s a big move to try to remove the requirement to give a person a psychiatric diagnosis of gender dysphoria before they can access medically necessary gender-affirming medical or surgical care. Currently, in the Diagnostic and Statistical Manual of Mental Disorders, there is a gender dysphoria diagnosis. Many in the community and many experts who are also involved in research believe that this is unnecessarily and harmfully stigmatizing and pathologizing, and therefore there are efforts to remove this and find other ways to bill and code for gender-affirming medical care.

What are some guiding principles for a gender-affirming approach for mental health conditions? We can normalize the adverse impact of gender minority stress, of stigma and discrimination, against transgender and gender diverse youth. We can facilitate emotional awareness, regulation, self-acceptance, empower assertive communication, restructure certain—what we call minority stress beliefs, like believing it’s never going to get better—nobody can ever be able to love me—validating unique strengths of transgender and gender diverse people, fostering supportive relationships and community, and in our practices, affirming healthy and rewarding expressions of gender. We’ve developed a number of guidelines that we published in the peer-reviewed literature on a gender-affirming approach to mental health care, including recently publishing psychopharmacologic guidelines for transgender and gender-diverse people, how to affirm gender identity in the setting of serious mental illness, how to distinguish and address gender minority stress experiences and borderline personality symptoms, which are two different things and often get conflated, and guidelines for screening, counseling and shared decision-making around alcohol use with transgender and gender diverse people.

Finally, in the fall of 2021, we published a study in the American Journal of Public Health showing a relationship between municipal gender identity nondiscrimination laws, protections, in 506 municipalities in the United States across 49 states and completeness of gender identity data collection of health centers in those municipalities. It’s from this study that having strong gender identity nondiscrimination laws locally is associated with more visibility of gender identities and systematic collection of gender identity data within care that we believe is important for providing high-quality care. Thank you for your time.

[0:21:41]

RICK WEISS: Great, Dr. Keuroghlian, and thank you for a very data-rich presentation there. And I’m going to go over to Dr. Maddie Deutsch. I’m going to ask our panelists to hold off on the Q&A box. We want to handle these things mostly verbally so that everybody can hear when we get to the questions. Thank you. Dr. Deutsch.

[0:22:00]

MADELINE DEUTSCH: Great. Thank you very much. Let me just begin my show here. OK, great. Great. Sorry. So, I appreciate the opportunity to be here, and I’m glad that folks are interested in this topic. What I’d like to do to start is sort of a priori show you what the evidentiary basis for what I’m going to speak to you about is, and these are—there are three key position statements that exist out there. The Endocrine Society guidelines were published in 2017. The American Academy of Pediatrics put out guidelines in 2018, and the WPATH Standards of Care 8 have been approved by the WPATH Board, of which I’m a member, and are going to publishing; should be available within a couple of days. So, the content that I’m going to talk to you about includes the updates that are included in Standards of Care 8. Many other professional societies have published position statements in support of this medical care, including the AMA and the APA, but I did want to make it clear that the evidentiary base for what I’m going to speak about comes from these guidelines, as well as research and studies that are reviewed within these guidelines. So, if you’re looking to kind of fact-check or look at the basis for what I’m going to talk about, you can find it in these documents. These hyperlinks will be in the PDF legacy document that will be posted.

So, just some general kind of a priori considerations when approaching the medical care of trans and gender-diverse kids. As was described by my colleagues and on the basis of what they described to you, these medical interventions are defined as medically necessary by all of those professional bodies and guidelines that I just shared with you and indicated for the management of what we’re really moving towards calling gender incongruence, which is the terminology used in ICD-11 and is aligned with Dr. Keuroghlian’s comment about depathologizing this state of existence. Care should be provided by qualified clinicians who are operating as part of a multidisciplinary team, so this is structured and ordered approach to care, and then parental or guardian consent as well as assent of the child or the adolescent is required. So, there is a detailed informed consent process that also includes the assent of the child before moving forward with any of these treatments. For pre-pubertal children, there is no medical care involved in the management of kids who are not yet in puberty. There’s no hormones, there’s no surgery. There’s no anything with regards to medical care. Generally, the interventions are both the provision of what we refer to as social emotional support, so this is anything from family counseling to help parents or guardians or siblings, relatives, community members, other stakeholders, members of a church group, understand what’s going on, help integrate identity, assist with identity exploration, defining goals. And then there is an entity referred to as a social transition, so that would be, for example, child starts using the chosen name and pronoun. The child begins living in their identified role. The child begins wearing clothing and expressing themselves outwardly in a way that is aligned with their internal sense of gender identity. So, this could be all the time. This could be at school, but not when we see Grandma. This could be only on weekends. There’s a lot of different ways that that can be defined, and it really is case by case given all of these factors taken into consideration.

How do we determine when somebody is in puberty? So, this is just a thing in medicine. It’s not just unique to determining pubertal staging for trans kids. In general, the approach to staging puberty is using something called the Tanner stages. And so, these are a range of measures of genital, breast and body hair development stages, configurations, and there are stages one through five are described. Tanner stage two is a milestone that has been identified universally as the stage to reach to qualify for accessing these gender-affirming medical interventions, and so this refers to either the presence of breast buds in people who have ovaries or the testicular volume has reached four milliliters in people who have testes. Upon reaching Tanner stage two, there are a couple of different ways that you can go. Each of these decisions are case by case by the multidisciplinary team in collaboration with the parent guardians involved, as well as assenting patient. You can either use these puberty-delaying medications, which are typically a family of medicines that are referred to as GnRH analogs, gonadotropin-releasing hormone analogs, and there are sometimes other medicines are used depending on certain specific indications or what’s available, insurance pays for, etc. But these medicines, what they do is they put the brakes on puberty. They put you in a holding pattern. You’re an airplane circling the runway, waiting for your position. These can be used for a couple of years without any concern, and there’s catch-up. Puberty blockers can be used as an opportunity to further explore gender identity, to prepare for integration into school or the community, to deal with different family issues. Also, if the child is very young, they—it might be felt by the team that the child should wait a couple years before starting hormone therapy. Like, if the child is a 10-year-old person with ovaries, that would be too young to start taking testosterone, so you might go on puberty-blocking medicine for a couple of years. And then the decision would be made by the team and all of the stakeholders to begin gender-affirming hormone therapy. It’s begun when appropriate on a case-by-case basis, and then generally, you continue the puberty-blocking medications once the hormone therapy has begun.

So, the mechanism of these GnRH analogs, it shuts down signals from the pituitary gland in your brain to your gonads that tells them to make sex hormones. So, the gonads, your testes or your ovaries, stop making estrogen or testosterone sex hormone, and it generally results in a regression back to—one stage of Tanner staging, so people who are Tanner two will go back to Tanner one. And then we have extensive experience using these medications in kids who have a history of precocious or early puberty, so there’s an excellent safety record in non-trans kids. The primary concern in using these medications is the impact on bone density and development. In general, it is felt—and there’s some data to suggest this—that once hormones are started, that density does catch up. So, the approach to using sex hormones in kids with ovaries, generally you use testosterone. Some other agents in the contraception family may be used to help stop menses if administering testosterone alone doesn’t do that. In children with testes, it’s usually estradiol, which is in the estrogen family, and then also in combination with a testosterone-blocking medication, which is usually either continuing the GnRH analog or using spironolactone.

Some of the considerations for sex hormones, it’s—they’re only begun after careful consideration of the indications. These are not flippant decisions. These are and should be multidisciplinary decision-making, including stakeholders with consent and assent in the context of people with appropriate expertise to do these assessments and give these treatments. Dosing is generally ramped up over two years to approximate typical pubertal plot process. There are some kids who present while they’re already in puberty, Tanner three, four or five and then—and just composed puberty, and then they kind of jump in wherever—you meet them kind of where they are. But for kids who are starting pre-pubertal, starting at Tanner two, generally, you dose—ramp up the dose over a couple of years. There’s frequent laboratory monitoring. There’s ongoing assessment and reassessment for co-occurring medical conditions that would require special attention, like anything from acne to cholesterol conditions. The pubertal growth spurt will occur if begun—if it begins before bone development completes. So, there’s these things called growth plates at the end of the bones, which is from which the bone length grows. And that’s how people get their height. If you start hormone therapy before the pubertal growth spurt has completed and those bones have locked into their final length, then the child will attain the ultimate height of their identified gender. So, people with testes will grow to a typical female height. Whereas people with ovaries who are taking testosterone would grow to a typical male height, which can be very gender-affirming for these kids. Some reproductive health considerations—trans kids who’ve gone through natural puberty, egg retrieval is often possible. Sperm retrieval is also often possible with temporary cessation of hormones. Ideally, we would have coverage for and access to freezing of eggs and sperm before hormones begin. For kids who have not gone through their natural puberty—so these are the kids you snare at 10 or two—there is some early data suggesting that egg retrieval may be possible in some cases. The testes do not mature, and thus sperm production does not begin. And so, these kids may have some fertility considerations in the future. But that has to be weighed in—taken into consideration with the strong benefits of giving this treatment.

So, in summary, pubertal delay and gender-affirming hormone therapy are medically necessary, as recognized by numerous professional societies and guidelines. Treatment should occur after an assessment for gender incongruence and in the context of a multi-disciplinary team of experts. A parent and guardian consent and patient assent are required. Bone density generally recovers with initiation of hormone therapy. Storing sperm or eggs prior to hormones in youth who have undergone natal puberty is ideal. Gamete production in youth, which—so gametes are eggs or sperm—who do not undergo natal puberty likely will face loss of fertility, though some new evidence is emerging. But again, the risks of these treatments should be weighed carefully in consideration with the known benefits of treatment. Thank you.

[0:32:19]

RICK WEISS: Thanks, Dr. Deutsch, for that really nicely detailed look at the medical side. So, I think we’ve had an amazing set of presentations here that set the stage. We have a number of questions coming in now from reporters. And I’m going to start with the first one here, which is from Meg Wingerter from the Denver Post, who says, I’ve seen estimates of how many teens identify as trans ranging from 2% to 5%. Is the answer very sensitive to the population you sample or how you ask the question? Why is there some variation there? And what do you think is the best number?

[0:32:57]

JENIFER MCGUIRE: I’m happy to take that one. I’ve done a fair amount of interviewing and surveying youth about their gender identity. It does vary depending on how you ask the question. So, if you ask a question that says, you know—are you anywhere under the transgender umbrella?—more people will give an affirmative response. If you ask a question that says—what was your assigned sex at birth?—and then a second question that asks how you identify now and then cross tabulate it, you’re going to get a smaller number. And so, how you ask the question varies quite a bit in terms of how people answer it.

[0:33:32]

RICK WEISS: And any others, especially on what—you know, if reporters want to use a number today, what do we think? Is there a range that ought to be used to keep that as accurate as possible?

[0:33:45]

MADELINE DEUTSCH: Yeah. So, the Williams Institute at UCLA has an estimate that’s primarily an adult-based estimate. And it’s in the range of 0.6 to 1.2%. I actually have a study that I did that I would be happy to share the screen with right here. Give me one minute to pull it up. And so, this is a—I have a slide here. So, this was a review of the literature that I did. This is now—it’s not from 2012. That must be a typo. This is from 2016. And so, this is already several years ago. But I looked at several population-based studies that had been published up to that time. This was a detailed review of the literature. And you can see the populations. And this is the number per 100,000. So, you would put—there’d be three decimal places here. So, a stratified sample of 1,000 Boston high school students—this is going back to 2009. Adult random dialing in Massachusetts in 2007, 0.45%. The Boston was 1.6%. Then there was a question within a cohort of the Nurses’ Health Study. That was 0.3%. And then a nationally representative of New Zealand high school students who were asked a yes-no question regarding transgender status is 1.2%, so, a pretty diverse group of studies geographically, age wise.

And then what I want to point out is that some of the data there—you know, the data there are, like, between seven and 12, 13 years ago that it was collected. A lot of this has—there are secular trends in society where people are beginning to understand what this term means and didn’t even know what that means. So, they asked kids in New Zealand in 2014, are you transgender, yes or no? There may be a lot of kids who are on a gender spectrum but don’t identify as transgender, but maybe identify as gender fluid or nonbinary or have some other gender expression that is not cis gender who might have said yes if the question had been more inclusive. So, there’s not something in the water that’s making there be more transgender people. It’s that there’s more language now to describe identities. People are learning, like, yeah, I was assigned female at birth and I don’t identify as male, but I’ve recently learned that there are all these other ways that I can identify, and I’ve never felt like female. I just also am not male. So, there’s—a lot of it is, like, if you don’t have a language to describe it, you can’t describe it. So, some of this increasing percentage that we’re seeing of people recently is more because it’s just, like, suddenly, we have the ability to actually talk about it.

[0:36:21]

RICK WEISS: Very interesting.

[0:36:22]

JENIFER MCGUIRE: I’ll add to that. In the 2016 Minnesota School Survey, which surveyed 9th and 11th graders across the state, the percentage—it was one of those open-ended questions. It said, do you identify within the transgender umbrella, and the percent was 2.7%.

[0:36:39]

RICK WEISS: OK. Another question here from Kavin Senapathy, a freelance reporter based in Wisconsin: My understanding is that the sex binary—i.e. girl, biological female, XX, and boy, biological male, XY—is extremely simplistic to the point of erasure in that these constructs are as much social and scientific constructs as the gender binary is. This biological essentialism seems to be part of the root of transphobia and misogyny. Can you speak to how the educational curriculum and social influences perpetuate biological essentialism that harms trans people?

[0:37:24]

ALEX KEUROGHLIAN: I’m happy to start with this. Yeah, no, I’m happy to start. I agree with this comment, by and large. And it’s true that in addition to gender not being a binary reality in human experience—and gender diversity has existed throughout history among humans from the beginning of time, and there have been different civilizations and points in history when more or less room has been made for the naturally occurring gender diversity among humans. In addition, there is also an artificial binary conceptualization of physical sex characteristics that doesn’t reflect the physical reality of human bodies. And there are people who are intersex, who don’t have physical characteristics that fit traditional notions of female and male bodies. And sex anatomy—as a result of that, physical sex characteristics really exist on a continuum, and we’re now in a moment where I think there’s a lot of advocacy happening for that to be recognized within medicine, as well.

And to the point about education, at our medical school in Boston, at Harvard Medical School, for example, we have an initiative to improve our medical education across all four years to more accurately integrate into all the courses—preclinical courses, clerkships, and then advanced courses—more accurate, nuanced understanding of the diversity that exists in terms of gender, in terms of sexual orientation and in terms of physical sex characteristics.

[0:39:11]

RICK WEISS: Others want to comment on that?

[0:39:12]

MADELINE DEUTSCH: Yeah, yeah. So, I definitely agree with what Dr. Keuroghlian said. I think I would want to add—to try and strip this question down a little bit. And, you know, I’m trying to think about how do you both ask this question and then answer it in a way that people who don’t have kind of a background in social sciences and don’t really understand what this is all about, is? And I think that—I almost have, like, a kind of—how—you know, how much does it matter? And I think that, you know, the reality is that it’s not really skin off of anyone’s back to allow somebody else to transition and live as they will. You know, my next-door neighbor may choose to dye their hair. They may choose to quit their job as a lawyer and become a—you know, a house painter. People make decisions that don’t really affect me, and it’s not—you know, so it really isn’t any skin off of my back. And so, the neighborly community thing to do is to say, hey, I like your new hair, or congratulations on taking that mid-life career change risk. It sounds like you’re going to be much happier doing that work.

The reasons that are put out there that we shouldn’t allow this to happen is—the two things that tend to get floated are, one, the kind of, like, boogeyman in the bathroom thing. Like, someone is going to come—you know, is going to come in and commit a sex crime. That—there’s just no—that just doesn’t happen. There’s absolutely zero data to back that up. Like, there’s—it’s just—it’s not that there’s no data. The data does not back that up. And then the other one is one of contagion among kids that, well, if we’re letting kids do this that there’s some contagion spreading or that there’s a trans industrial complex that is profiting off of this. No one’s making any money off of this. I took a pay cut to go into this field from what I was doing—the medicine I was practicing beforehand. And so—and, you know, nobody wants kids to become trans who aren’t. And so—because trans people know how awful it is to live in a gender that you don’t identify, so we certainly wouldn’t want somebody who’s happy in their gender to change it.

So, I think when you kind of step aside from those two reasons, there’s really—it doesn’t cost society anything to do this. I mean, you know, it costs—hormones cost a few hundred bucks or whatever, but it doesn’t cost society anything to do this. So, I think that it’s—I agree with everything that’s been said. I like the question that was asked and the way it was phrased.

I like Dr. Keuroghlian’s answer. I also think that, like, those are interesting parlor questions to discuss, but at the end of the day, I don’t know how important it is to dive into those foundational questions when trying to figure out some of these bigger questions of, like, do we—should we be banning this kind of care?

And the last thing I’ll say about, like, just essentialism, when we talk about essentialism, what we’re talking about and these kind of structural essentialisms—you know, I take my kid to the doctor, and she’s having a urinary complaint and she’s—my kid was assigned female at birth. She identifies as female. She’s cis—but the doctor says, well, you know, the thing about girls is that they have shorter urethras. And so, it would be so much better if the doctor could just say, like, your anatomy, you have a shorter urethra. That doesn’t imprint upon my daughter’s brain that only girls can have short urethras, and that boys can also have uteruses. So, that’s an example of how, like, these kind of structural things get baked in. Thank you.

[0:42:37]

RICK WEISS: You know, your answers here remind me that often, I ask a question at the beginning of these briefings that I actually want to throw in now because I think it’ll be helpful to reporters as they try to cover this topic. And that is, just from your own personal experience, what you’ve seen in the media, what are reporters doing well? How are they covering this beat in a way that you think is positive, and/or are there some critiques or some advice you would like to give to reporters about things you see in the media that you think are not being done so skillfully and that could use some attention? And why don’t I just go through the three of you quickly and see how you address that question directly to the media and how they could do better? And why don’t I start with you, Jenifer?

[0:43:21]

JENIFER MCGUIRE: So, I’ll say what I think reporters are doing very well is humanizing the phenomenon for the public, by finding case examples and families who share their story and kids who are willing to share their story and doctors who share their stories and therapists. And so, I think that’s been really powerful and successful. One thing I would caution reporters is to be careful about reporting about tropes, right? So, the boogeyman in the bathroom is a common trope, and I think sometimes people can view that as fact or because so many people have said it that it’s true, but paying attention to what tropes there are and trying to avoid them.

[0:44:01]

RICK WEISS: Thanks. Alex?

[0:44:03]

ALEX KEUROGHLIAN: Yeah, I think what the media has done well is, in many cases, to ring the alarm on these legislative and governmental efforts to pass these bans on gender-affirming medical care for youth that are not at all based on scientific evidence or the mainstream of medical practice, and where that has been stated loudly and clearly and is being exposed in terms of what’s happening state by state, that has been commendable. And to Dr. McGuire’s point, when that has been coupled with personal narratives that illustrate the human harm and toll of those efforts on trans and gender-diverse youth, their families and providers trying to deliver this medically necessary care.

Where I think the media could do a better job is in presenting a false equivalence that there are two sides within the medical mainstream to—as to whether gender-affirming medical care for youth should be accessible or not, and I think that the reality is we know there is not a debate within the medical mainstream. I think the really critical piece to include in all these stories is what Dr. Deutsch presented at the beginning of her presentation, that every major medical professional organization in the country has endorsed gender-affirming care for youth as medically necessary care—The American Academy of Pediatrics, American Medical Association, the American Psychiatric Association, American Psychological Association, the Endocrine Society, the Pediatric Endocrine Society. That really resonates with people because that is a summative consequence of the robust scientific and clinical evidence to support provision of gender-affirming medical care for youth.

[0:45:50]

RICK WEISS: Great. And Maddie?

[0:45:53]

MADELINE DEUTSCH: Yeah. So, I think in general, over the many years I’ve been doing this, I have generally enjoyed working with the press and have found my general engagement with the press and the media and journalists to be objective, and the journalists are interested in really getting to the root of what is going on. I think that where there’s some concern that has arisen is in—probably in the last year to year and a half, especially as this issue has now come to the forefront and has stopped really being a kind of scientific/human interest story and has become a politicized issue, is I have unfortunately had a number of interactions with major outlets, major articles that have been published or stories released where, you know, in my view, the journalist was coming to the story either having some predisposed beliefs and they were not being objective, or they were looking for a story. They were looking for a story that was going to generate clicks, and that to me was concerning.

I’ve had a couple of instances—you know, I’m a, you know, medicine physician. My bread and butter is, you know, breast cancer screening and cervical cancer in trans men. And I have been asked to come to interviews to talk about, you know, one thing, and then I get there and it really starts—they want to kind of dive into some of these more politicized issues. And one of the things within that is I’ve seen there’s this kind of, like, sentiment in society in general that we have to give everybody equal time. And, you know, you have 95% of experts saying, yeah, we’re doing this the right way, you know, and then there’s going to be a couple of people who are going to be saying, well, I disagree with that. And then, you know, to me, that doesn’t seem objective to give equal time. It seems you should give a weighted amount of time and consideration based on the consensus.

And so, you know—and then the last thing within that is, in a couple of major stories, I have attempted to provide a great deal of written documentation that refutes what the angle of the story that the reporter is presenting. And that information has been rejected. So, written proof of—I can’t get into details. But then the final article that’s published ignores that information and goes ahead and continues with the storyline and components of the story or paraphrasing that the reporter felt should be reported. And that, to me, is very unobjective and concerning.

[0:48:31]

RICK WEISS: Great. I think that’s all very helpful. I have a couple of questions here from Christie Taylor from “Science Friday.” And, reporters, by the way, if you do have questions, remember that’s the Q&A icon at the bottom to use. Christie asks, do you have advice for covering these stories without traumatizing or inviting harm to families and children that share their stories with us, or trans people as a whole? Christie is also curious whether much of the expertise on trans kids and care is coming from researchers who are themselves transgender. Two questions there, a little bit different.

[0:49:11]

MADELINE DEUTSCH: Yeah. I mean, I can answer briefly. I answered this in the chat before I knew we weren’t supposed to do that. But, you know, there may be—you know, I don’t know that there’s any more reason to suspect that a trans person doing this research would be biased than you would suspect that a cis person doing this research would be biased, or that a woman doing research on women’s health would be more biased than a man doing research, a woman who’s been pregnant doing research on family planning and abortion, a woman who’s had a—you know? So, there’s so many opportunities for bias.

You know, there was—there were allegations of bias when one of the California supreme court justices ruling on the marriage equality Prop 8 issue in California was gay himself. And can he be objective? And it’s like, well, could a heterosexual judge be objective? So, I think that we have to take an a priori assumption that people doing science are objective scientists. And nobody wants kids to have bad outcomes, cis or trans. There’s no trans industrial complex. It doesn’t exist. Drug companies don’t make any money off of this. Most of us doing this work are making less than we would do in other fields. We’re doing it because we think it’s the right thing to do. And like I said before, trans people know more than anything what it’s like to live not in your identified gender. So, we definitely don’t want somebody who’s not trans to be, you know, ushered or pushed forward into the wrong identity.

[0:50:37]

JENIFER MCGUIRE: The only thing I’ll add to that, which I also put in the chat before I knew I shouldn’t, was that as—coming from a contextually based research environment, I think it increases the ecological validity when you do have members of a community participate in the research about that community. And so, a general philosophy of nothing about us without us is a good way to think about research. And because trans people have historically been eliminated from opportunities to be the generators of research on themselves over the last 50, 60 years, it has been taking time. And so, there are a lot of universities training up trans Ph.D. students right now who are joining the field and contributing to the research in really important and ecologically valid ways that allows for insight that, you know, those of us who are allies don’t always come to as easily. So, that’s a piece of it. There’s objectivity, and then there’s ecological support. So, I support including trans people in research about trans people. I think it’s important.

[0:51:39]

ALEX KEUROGHLIAN: I think, in terms of these stories, two things. One, it’s important to have the perspective of, certainly, trans and gender-diverse scientists and experts and also people who are not professionals in the field with lived experience. That can be very powerful. And it’s been unfortunate in some major stories published this year, in 2022, that that has not been front and center, or the article will clearly primarily be giving, you know, airtime to people who are not of the communities impacted by a lot of the decisions being made and the unfortunate politicization that’s occurred. The other thing is to run what you’re going to say that has been shared with you as a journalist from a trans or gender-diverse young person or their family by them so that they know what is being said based on your interaction with them and can have the confidence that it is—their perspective is being accurately and fully represented. And that’s—I mean, I’m a psychiatrist. I practice trauma-informed care in a trauma-informed health center here in Boston. And that kind of transparency, autonomy, choice and voice is critical. And if you’re not doing that in every way, then you’re potentially contributing to the retraumatization of communities that have already experienced a great deal.

[0:53:04]

RICK WEISS: Yeah. That’s a very interesting point to be made. You know, the sort of tradition in journalism is, of course, that you never show your story to your sources before the story runs. And that’s—makes a lot of sense, I think, for some political stories, for some gotcha stories, for investigative journalism. I think there’s an interesting case to be made for stories where people’s, you know, personal lives are more at stake and especially stories where kids are involved to maybe go that extra step and make sure that what you are expressing is not going to be damaging—inadvertently damaging—to the people who have helped you create that story.

Question—we’re just about at the end of the hour. I want to get a little more in. Question here from Amy Mathews Amos, a freelance reporter in New Mexico. The presenters discussed children identifying before puberty, which appears to be the most common situation. Is that right? Is it the most common situation? And is it common for trans people to begin identifying as trans in mid-teens but identify as cis before that?

[0:54:06]

JENIFER MCGUIRE: I don’t think it’s the most common to identify in early childhood. I think it’s becoming more and more common, and it’s the point at which many people start to question their gender. It has a lot to do with the context you’re in and whether or not you know you’ll be supported. Environments where pediatricians and teachers and other community members are supportive and give parents feedback and support about how to support their kids allow kids to come to this earlier. Other people simply will have some fluidity or change in their life course and after puberty starts or sometime in their mid-teens will become more aware of who they are and how they want to identify. All of those pathways are valid. There’s a large contingency of the population who identified after living as a cisgender person for a very long time and then having children, raising them, and then once their kids leave home, then identify. So, there’s a lot of variability.

[0:55:05]

RICK WEISS: I want to try to squeeze in one quick question here because it’s so interesting, and I think it comes up a lot, before we wrap our hour. It’s a question from Karen Bouffard, a health reporter from Detroit News. I think there’s a concern by some parts of the public that a child who receives gender affirming care might somehow change their mind later in life and not be able to go back to the gender they were assigned at birth. How do you address that? I think, Alex, you did talk about some data on that. Do you want to take a shot of that?

[0:55:34]

ALEX KEUROGHLIAN: Yeah. I’ll just quickly—I saw Dr. Deutsch unmute herself, so I want to hear from her, too. But it’s extremely rare for people to regret pursuing gender affirmation, gender-affirming medical care. It’s a myth that’s something that’s really been pushed to confuse the public for political gain. The data don’t support that. It is extremely rare for people to—who identify as transgender or gender diverse—to subsequently identify as cisgender. And even in the incredibly rare situations where that happens, it’s very rare for people to regret accessing gender-affirming medical care. That’s pretty much all I have to say about—the other thing is that gender—part of the problem is people think about gender in this very nondynamic way. Gender is something that is dynamic, is going to, you know, evolve throughout a person’s life, and that’s a healthy, natural part of human existence. So, we, to a great extent, have to move beyond thinking about it that way. I’d love to hear Dr. Deutsch’s…

[0:56:33]

MADELINE DEUTSCH: Yeah. I mean, I think the first thing I would say is that Dr. Keuroghlian published one of the premier papers in this area, and it found what anecdotally myself and many people doing this work know, which is that the overwhelming majority of the small percentage of people who do, quote-unquote, “detransition”—the overwhelming majority of those people are detransitioning not because of a change in their identity. They’re detransitioning because of external forces. They are not being accepted. They are experiencing discrimination, and they just can’t—it’s just safer for them, and they’re miserable about it. The trope of—you know, this is kind of this, like, whataboutism trope of, like, well, what about, you know, if a kid’s—the thing is, we just don’t see that. And again, this is an equal time issue where in this day and age, with social media and TikTok and everything, there are people, there are some vocal, very small minority who have now been seized upon by nonscientific elements in this area as a kind of voice and as the argument in the whataboutism argument of, like, well, what about these people? But when you actually look at the data, including Dr. Keuroghlian’s fantastic study, it shows you that the overwhelming majority of people who detransition—which is a minority of people overall—the overwhelming majority are doing it because the society is not accepting them for who they are. So, this kind of, I just made a mistake, and it just wasn’t right for me—I mean, I’ve treated 5,000 patients in 16 years. I’ve probably seen, like, four people who came to me and told me that was part of their story—three, four?

[0:58:05]

RICK WEISS: That’s very helpful to hear. OK. We’re about out of time. I usually, at the end here—I’m going to give you each about 15 or 20 seconds to just say a take-home message. If there’s one thing you want reporters to walk away with today, what would it be? Jenifer, I’ll start with you.

[0:58:23]

JENIFER MCGUIRE: I would say the context and social support that we provide for kids around their gender identity is critical to their well-being.

[0:58:31]

RICK WEISS: Great. Alex?

[0:58:35]

ALEX KEUROGHLIAN: Lead with the voices of trans youth and their families, who are really impacted by all the science and all the policy that’s at play here. Don’t let other people ultimately speak for them and have the final say.

[0:58:49]

RICK WEISS: And Maddie?

[0:58:51]

MADELINE DEUTSCH: Please look at the science and talk to the scientific experts. Thank you.

[0:58:57]

RICK WEISS: Well, that’s a great segue to my closing because that’s exactly what we tried to do today. So, I hope this has been helpful to reporters. I think this has been a fascinating and very informative briefing.

For the reporters on the line, as you leave today, I want to encourage you strongly to take that 30 seconds to answer a three-question survey you will find as you log out. It’s very helpful to us as we try to develop these briefings in ways that are most useful to you.

For all of you, of course, also, we encourage you to check out the SciLine website, sciline.org, and follow us on Twitter at @RealSciLine.

I want to really thank in a big way our guests today who are willing to step forward and talk to the media—always a risky affair, no matter what the topic is. It’s a situation where you put the facts out there, and you never know what’s going to happen with them. And I really appreciate all of you, especially in today’s environment, being willing to have this conversation. And thanks to all who have attended. We’ll see you at the next SciLine media briefing.