Treating Trans Youth with Dr Johanna Olson-Kennedy

Today, I’d really love to welcome Dr. Olson-Kennedy. I’m going to let her introduce herself, and let her tell us what she does and some of the greatest work that she does. Jo, if I could hand over to you?

Absolutely. My name is Johanna Olson-Kennedy. I’m the medical director for The Centre for Trans Youth Health and Development in Los Angeles, at Children’s Hospital Los Angeles. I’ve been doing gender work with gender non-conforming children, trans, adolescent, and young adults for the past twelve years, almost exclusively. We have a large clinic of about just over 1300 young people between the ages of 3 and 25. We see about 5 to 7 new trans or gender-questioning, gender journey young people every week. It’s very exciting and robust. We have the largest youth clinic in the United States, and it’s such a great privilege to work with these young people because they teach me new things every day.

And my very first, most obvious question is going to be, over the last twelve years, what changes have you seen? And which are most stark to you?

I think like so many things in gender work, there is this cognitive dissonance where a lot has changed but not enough has changed. And so, one thing that is sort of fundamental or important is that there has been more visibility of trans youth. This is really important because when we think about they way that young people who are trans or gender-diverse are developing, there is not a lot, and has not been a lot of, stories or pathways that they can look at and say, “Oh, this is what it means to be trans” or “This is how it is for people who don’t have a gender that matches their assigned sex at birth.” And it gives them a sense that this is a trajectory that humans have been on since the beginning of humans. It’s one trajectory of development, but I don’t think it was ever presented that way, which is what people really lost in the past. I think this is a really important piece that transgender narrative is so much broader than it has been in the past. It’s been very narrow in the media, and therefore in people’s own minds. The voice of transgender youth is so much stronger now because there is much more availability for that voice.

That’s something that we see all the time over here. What has brought on that massive increase in the number of trans people and trans children coming forward to get help? Why today? Why is everyone talking about transgender? Why has that been today on everyone’s agenda?

You mean it’s not the water? I say this often when I speak, that I don’t know why it’s been so difficult for people to understand that transgender adults started as transgender children and youth. There is this pervasive or prevailing thought process, certainly in the lay community, but also in the professional community, that somehow at some point people become transgender. But that’s not really the accurate telling. I think what is actually happening is that there are different timetables for people to put their gender puzzles together. And I think as the narrative of trans youth becomes more accessible, people are going to start understanding it earlier. I think about the fact that there are 1300 patients in our program, but the population of youth of 18 and under in Los Angeles is 2.6 million. Even if you estimate one percent, which has been one of the more common prevalence numbers, that still means that there are still 26 thousand potentially trans youth in our city. This idea that everybody is trans or everybody at my kid’s school is trans is actually not real. I just think, as we say in this work, it’s super hard to see a unicorn and not talk about it. Because these stories are extraordinary, and the young people who are coming forward and talking about their truths in their authenticity of self, it is very notable. Because unfortunately in our society we don’t have a strong commitment to authenticity anymore, especially in our country, and so these young people in their moments of truth and bravery and courage and their struggle and torment are very notable. I think that’s why people talk about it. But the reason more people are coming out earlier is because there is room for it. There is room for vulnerability and there is less shame. Some day there will be celebration of trans identity, but we’re not quite there yet. I think that we will be.

I think you’re right. We aren’t there yet. We’ve got a long way to go. But even over the last few years, we’ve really seen things improve and change. Of course, the internet has helped, and people are scared that perhaps the internet has taught our children wrong and has given bad influence. I really remember one of the children in my clinic. She was saying that she knew something wasn’t right, that she just didn’t know what it was, but that something didn’t fit. In her family and herself, it didn’t fit. And she just couldn’t work it out, and then she was under the covers with her mobile phone, and looking on YouTube, and she came across a video of a trans person and she was like, “That’s it! That is me.” She was so excited. It was two in the morning and she went racing into her parent’s bedroom, and I can just imagine it, put the lights on, and said, “Mum! I know it. This is what is me. I am transgender.” I’ll never forget her excitement as she told me that story. We’ve got so much education from a lot of different sources now, haven’t we, for people?

People’s failure to recognise that something isn’t going to resonate with someone if it doesn’t resonate with them, right? We used to say this about condoms: you can’t make condoms available because it will make people have sex. We know that that’s not true. There’s been lots and lots of research that says that’s not true. And I’m always fascinated by parents who have more than one child, they have maybe a trans kid, and another kid who is cis gender, not trans. And I ask them if their trans child is watching a different internet that their other kid? Is that what it happening in your house? Their kid is only watching things about cis gender people. I think it’s important to let people know that all young people are pretty much exposed to the internet, right? The story you just told about that one young person is a common story of people having access to language, to put words to their experience. Just because you have words for your experience doesn’t mean your experience wasn’t there. It just means there weren’t words or language for you. I think about how brilliant the internet it. That with a few clicks, you can connect a community. Connection is so important for people of all ages, right? Finding your tribe and finding your community is really important for people. And because we know that early treatment is so much more effective for people, it’s great that people can connect to community. That’s really important.

You use of the word community is lovely. When I first started this work, quite intensely, people used to talk about the transgender community. In medicine, it’s not like we call something the diabetic community, or the heart failure community, do you know what I mean? I was interested in why the transgender people have been given this group community feel. I realized that people who are having difficulties, they stick together and support each other and learn from each other. And the community network that we have here, and I’m sure you have one where you are, is so strong and so supportive. It’s really intense. Certainly the difficulties that I have had over the last couple of years with my regulators, that transgender community has patted me on the back, and they’ve said, “Helen, you’ve one such a great job for us. Please don’t stop, we’re behind you all the way.” It’s been really amazing, that community feel.

Marianne, I don’t know if you had something you wanted to say about that, or if you had anything rolling off your tongue while we’ve been talking.

There’s lots to say. The first thing that I am picking up on, and I’m going back to my own experience being born in the sixties. There were no role models, there was nowhere to go for information. I think the first time I found what I would call in those days my identity, wasn’t about finding my community. I was finding my identity, where did I fit? It was in the Collins dictionary. And I don’t know what possessed me to open the page, and I found transvestite. Even though it didn’t fit perfectly with what my experience was as an 11 or a 12 year-old, it was life changing just to see that there was a word for what I was feeling.  I think now the internet just means that these children aren’t sheepishly walking into a library. At two o’clock in the morning, they can type something into their mobile phone and connect with others, which just wasn’t available back in my day. So for me to see the surge in numbers seems the most natural thing given where we are in 2018.

Absolutely. Jo, I am interested in the non-specialist services available to transgender children and adults in the USA. Obviously yours is a specialised clinic. If a child and a family went to their primary care doctor, what kind of level of knowledge or expertise could they expect there?

When people are coming to their pediatrician or family doctor or whoever they are encountering for their routine pediatric care, it’s going to largely depend on where in the country that is, not dissimilar to other countries. The irony about our program here is that it didn’t start out as a gender clinic. We are an entire adolescent medicine division, so we see young people for every medical reason that could exist. We do a lot of other services as well, but we’ve grown into a very large gender clinic. I think there’s going to be some places in this country where people have had exposure and education. They’ve attended conferences. There are certainly more medical schools that are trying to include education around hormone care, around gender dysphoria, puberty blockers, but it’s still very rare. Most of the time what people’s knowledge would be is, “Maybe your kid is trans or maybe not. Let me give you a referral to someone who knows more about that.” I think the primary thing that happens is a referral to a specialty clinic. And that’s great. I would rather have that than what often happens which is you can’t do anything about this till you are 18, so you may as well just learn to love who you are – which does still happen a lot. I think it’s also important o acknowledge that there are large swaths of the country where there is no trans youth care at all in states upon states upon states. I remember I was doing an educational lecture for school nurses in Idaho, and they said, “Oh, this is so great. Where can we refer people to?” and I said, well, Oregon. That’s a completely different state. And so there are many places in the country where there is no care and that’s really challenging. I think people underestimate. And thinking about what Marianne said about not having language or anyone to talk to about this or not even knowing what is going on, just feeling that something is different, and that’s certainly still true for young people. But I also think about gender dysphoria being a lonely place. There is a certain amount of loneliness that’s gong to happen even for trans people in a room filled with people. That experience and that identity is very uncommon. Even though more people are talking about being trans, it’s still the reality for a lot of trans people that they’re going to occupy spaces where they are the only trans person. Thinking about gender dysphoria as a lonely space, it helps us understand the importance of early care. My husband is trans, and he said to me once as I was talking about gender dysphoria in a more theoretical perspective about it being traumatic, this ongoing series of micro and macro aggressions that people are tolerating and constantly acclimating to that level of trauma and maybe it’s not that you’ve been stabbed in the chest and you’re bleeding everywhere and are going to die, but it’s an onslaught of macro aggressions – and he said this, and this is what he tends to do, which is put a sort of real and emotional experience to what I am talking about theoretically, and he said later on that day when we were doing an educational lecture, “What people don’t understand is the time that you’re walking around not in your true and authentic self, you are wounded. And the longer that time goes on, the longer you are wounded.” And if ever there is an endorsement for early access to care, that was it, right? We are talking about should we let people walk around wounded because of our own uncertainty? Which really is what people are saying. It’s remarkable to work in a field that has been entirely created around easing the discomfort of everyone around the patient, and little to no effort, energy, and kindness and compassion directed to the needs of the patient. And so we spend a disproportionate amount of time, or one may argue all the time making parents, teachers, legislators, officials, maybe religious figures comfortable. And no time helping the person who is there for care to be comfortable. And if you think about all the guidelines, that’s really what they’re about.

Sometimes, and certainly in the UK, I reference the fact that I feel the system is geared up to protect cis people from making a mistake rather than actually caring for the trans people, if that makes sense.

A hundred percent, absolutely. And the thing is, though, what’s undergirding that, and I really think it is important to acknowledge, is that I always say what is there in that concern? What is there at the end of that sentence, because what does it mean to make a mistake? What does that mean? So we’re gong to accidentally make someone trans who says? First of all, there isn’t cis gender fragility, right? That sort of implies that there is fragility to cis gender gender. That’s the first thing. And then the worse piece under that is that the worst possible outcome is that someone is trans, which actually, isn’t the worst possible outcome. But if you think about that, that is what undergirds all of this. It is what drives people to create huge and unmanageable and often inaccessible assessment periods. It never takes into account autonomy of humans, that let’s talk about what it would mean if we just let people move forward and we affirm and believe what they were telling us, right? At the end of the day, who is responsible for that? The person that made that decision. And so I think that there are so many problems with the way that the system is created now. It started from the underlying idea that people who have a gender difference than their assigned sex at birth are mentally ill. And we can’t shed that. We seem to not be able to shed it except in a few places. If we could get rid of that idea of asserting that your gender is different than your assigned sex at birth, we have to make sure you are not crazy. But that’s still where we are anchored. As a community of professional providers, we still remain anchored there, because if we didn’t remain anchored there, we wouldn’t assert these statements like are you sure? What if this is the wrong thing? What if this was a mistake? Without even defining in our conscience what people even mean when they say this is a mistake. Like of course there are going to be people for whom hormones aren’t the right thing for them. There’s not going to be a lot, but we also have to acknowledge for people, they’re going to stop. Because what happens is that we build up a lot of mental energy and we spend a lot of bandwidth moving and getting up to a place where we’re going to affirm someone with these interventions that have irreversible effects. Isn’t that the whole conversation around youth; we have to figure out if this is the right thing, we’ve got to work up to this, and then it’s like it’s this giant switch or shooting a bullet that you’re never going to be able to come back from. But anybody who has undergone hormone therapy to go through a second puberty knows that it’s not how it works. It’s slow. And it’s agonizing for most people. Most people aren’t going to continue to put in a needle in their body every week or take a pill every day just to sort of say “I told you so”, right? I’m a physician and we can’t get people to finish ten days of antibiotics. Why do we believe that people are going to do that? It doesn’t make any sense.

I think going on from that, it creates terror for parents, when suddenly their 17 or 18 year-old says I just want to see what it would be like without these hormones, I want to break from them. I just want to explore what would it be like to be in the middle, more non-binary, or even just explore my feminine side again. And parents are terrified that they’ve made a mistake, that it’s hard to do something and have that hormone. Actually, surely our identity or sexuality or anything about us is an ever-changing thing throughout our lives. And if someone wants to just have the luxury of just employing it and with swapping hormones again, what is wrong with that? But parents seem terrified with that. They think that means that everything has gone completely and awfully wrong. And then the child is terrified that if they do do that, then they are allowed to go back onto the opposite hormone to the one their body produces naturally. I’m just a big believer in let these people explore their identities throughout the whole of their life, and, as a doctor, help them to do that in a way that I can help them.

I think it’s important that we recognise and probably start talking about that us as cis gender people tend to look at gender as a landing spot. We tend to see it as what’s it going to be? Because we can’t conceptualize gender differently. that’s not our experience. For trans folks, gender is a journey. It’s going to move back and forth. There are going to be twists and turns in the road. And maybe people get tired of taking pills every day, or putting a needle in their body every week or every two weeks. Maybe people are exhausted by that. Maybe people are thinking through is there a way to do my gender without all these annoying things? All of that is great. All of that is fine. I think that we get so mired again in is this right or wrong. When I think about a 17 or 18 year-old, that as a parent, you’re going to let that young person drive, right? We know that people need to get places. We know that that’s important. It’s important for autonomy. It’s important for people’s lives. I am wondering. I am not comparing physical or phenotypical gender transitioning to a car accident, but I am wondering if people when their kids get in a fender bender, why did I ever let you drive, I should have never let you drive for your whole life. We make these decisions or help and facilitate our young people with their truths all the time. Of course there is a possibility of consequences. Of course there is.

We’re not going to get through this life without taking risks, are we? I sometimes think the risk taken with trans children is that actually, we’re going to set them up for a lifetime of other mental health issues if we don’t help early on. And yet, we might prove to be something that they did when they were younger that they may live to regret, in their twenties or thirties. But if they are still in school, if they have got better education, if their earning potential has gone up. They’re going to be in a better place to then deal with the mistakes they made when they were younger.

Absolutely. I think about this all the time. I think about what does it mean or what are we creating when we do not affirm people’s truths? Because we know that because we have that data. People say this to me all the time. I was just talking to Peter Donne about this and I said, “You know what, what does UK do about children and social transition?” for kids who have not yet even started puberty, and because in the United States it is much more common now. It’s pretty common that if your kid at five or sic years old is saying I am a girl or I’m a boy or I’m not sure, that we are totally supportive of people who are wearing different clothes, or who are wearing their hair different, or going by a different name. and recognizing that all of those things, if they are helping somebody thrive are positive things. And here is what people say: If you socialize with someone in the wrong gender they are not going to know what their real gender is. I think about this all the time. We have a comparable group of people that were socialized in the young gender. Everyone who transitioned in adulthood. Nobody seems worried about that. Oh my gosh, we let all those trans adults socialize in the wrong gender. Nobody’s ever worried about that. what people are worried about is the potential that we make a cis gender kid trans.

I think in the UK, the children that are lucky enough to have parents who are willing to explore with them, and a school environment that allows them to change and the extended family – grandmas and aunties and uncles – who are also willing to let that child explore what it’s like to be he instead of she or to have long hair instead of short, and the clothes, too, what have you. Those children are very lucky that they’ve got that potential to be able to explore it. And then go through their early years nearly unscathed. So they go through playing football, whatever children want to do at that age. The difficulty that I am seeing with those children is that all of a sudden, puberty starts. And puberty can start quite quickly and quite suddenly and quite unexpectedly. All of a sudden, that child didn’t probably appreciate what their teen years might bring if some intervention wasn’t given. And all of a sudden, they start this road of puberty that they can’t stop. And in this country, maybe they go to their GP or their family doctor, who may or may not agree with it, may or may not know anything about it, may or may not refer onto specialist services. And if that child again is lucky enough to have a GP who will refer on to specialist services, there’s about an 18 month waiting list for children to be seen at the moment at the specialist services. And then quite a long six- to twelve-month assessment process to start puberty blockers. So we have ended up by being so socially transitioning, which I am fully in favor of, than we are having a really happy go lucky youngster who suddenly starts puberty and then there is nothing that that child or family can do about it. And then all of a sudden we hear those stories of self harm and non-socialization and dropping out of school and dropping out of the family and not joining them at Christmas and those awful stories that break your heart whether you are a mother or a doctor or a counsellor. They break your heart. And we hear them all the time. People talk about social media, and we’ve got the social media that the youngsters use, and we’ve got the social media that the parents use, and you can see their stories of their child going through puberty but it’s really killing them after having had such a happy and successful social transition. And it is heartbreaking.

That’s really tragic that we have this intervention available to not have that happen, but through the auspices of the system and the waiting and then the assessment, you’re actually not stopping their puberty. And that’s a real shame because that intervention is such a profound intervention. When I think about the landscape from science and the medical perspective, doctors are probably one of the single biggest game changers but they are not effective at all if people don’t have access to them early in puberty.

In the USA, would a family doctor who has done reading or education or whatever, would they be allowed or would they feel competent or confident to give a puberty blocker? Or is it the kind of thing that will only be given by a specialist?

I think that most pediatricians would probably not be comfortable doing it, but I have to say also that if someone was in early precocious puberty, they would probably also not feel comfortable doing it. So they would send that young person to an endocrinologist for blockers. It’s not something that they couldn’t do. This is certainly – I’ve worked and shepherded people through this, and because it’s not that hard, I think it’s easy to learn. It’s really overcoming people’s discomfort and helping people get educated. This is not something that would be out of the scope of a general practitioner, a pediatrician, but I think that there is not a lot of people who are comfortable doing that. I think there are increasing numbers of people who are, which is exciting.

I’m going to ask a very obvious question that is asked a lot in the UK, and that’s about age. So what child is too young to have a blocker, and what child is too young is to start a puberty that requires a medical induction of puberty – so you know, giving the hormones of the opposite gender that they were assigned at birth? You must be asked this question a lot: what age for blockers and what age for hormones?

I think that we can understand and look to the idea when people have precocious puberty. Not necessarily trans kids, but people who go into puberty at four or five years old. Those kids get blockers. So there really isn’t a young age. There is no reason to put a blocker into somebody who hasn’t started puberty. That doesn’t make any sense. Because there is nothing to block, I think it is utterly absurd to put an age on any of this work, but I can tell you for sure blockers, because the pint of blockers is to stop the progression of puberty. So that being said, it’s actually very rare that we get people in – so we have 1300 young people in the program, and they graduate out at 25, so we’ve obviously seen many more people than that, but I think of those 1300 people, we probably have less than 10% who access care before puberty. So who are kind of in the pipeline, who know that when our kid hits puberty, they’re going to get a blocker, so if people get in that early, you want to start them in early puberty. It’s more complicated for people assigned male at birth. I think there is additional conversations that have to happen, because the distress for those kids are usually later pubertal findings, right? I’m just going to divide in the trans masculine and trans feminine, just for the ease of conversation, recognizing that that binary is not everybody’s story. For trans boys, the thing that is so horrible for them is chest development. Obviously, that is the first sign of puberty. So it’s really important that when chest development starts, people have access to blockers. But it doesn’t mean that people who are coming in past that point don’t benefit from blockers. They definitely can. For trans girls, it’s interesting. Because testicular enlargement being the first sign of puberty is not necessarily where people describe a lot of distress. The things that are visible or that are getting them this gender, like their voice dropping, like the development of their facial hair, those are the things that really bother them. But because people with testicles start puberty later, they are already behind their peers and usually what you hear is everyone has breasts and I don’t. when I think about the physical features that cause people distress and dysphoria, it’s the presence and or absence of different body parts. For example, I never really hear trans boys saying I hate my vagina or I hate my vulva. That’s not usually what you hear. You will hear trans boys sometimes say when am I going to get my penis, am I going to grow a penis? They don’t have anything to hate when they are born. Nor do they have anything that is mis-gendering them unlike trans girls who are born with genitals that mis-gender them. And so the distress profiles look different in childhood. If somebody accesses care early enough, then when they start puberty, they’re appropriate for blockers. Whether that is 8 or 12. Or anywhere in between. I am not a big chronological age person; I think there is a lot of issues around that. that being said, I think that – and this is also important – because one 13 year-old is not another 13 year-old. I’ve started people on gender affirming hormones as young as 12. Not a lot, but on a few instances. And here’s why not a lot. There are two issues. One is pure concordance. There is this importance of being with your peers and your developmental process. But the other thing is if you’re going to take hormones your whole life, do you really want to start that early? You may want to give yourself some time. Each individual person is different, right? There is good reason, there are a lot of things to put into that algorithm. And the central thing to put into that algorithm is the young person, where are they? Are they experiencing a huge amount of distress and dysphoria? Are they like this is okay I can stand a blocker for another year or another two years and I’ll be fine and just e a little bit of a late bloomer. So much of it depends on the individual. I would say that the reality of our clinic, and this is not different for a lot of places around the country, is that most people are accessing care around 15. There are significant concerns that I have about putting 15-year-old trans masculine young people on just blockers. It’s induction of menopause, which is really problematic.  And so while we have these endocrine guidelines, some of the things are really great about them because they acknowledge that trans youth need care because there wasn’t anything that really said that other than the 2009 version of the guidelines. And so that was really helpful, but it was really problematic that they put blockers until they were 16 in there. That means potentially that they are going to make a recommendation to block at puberty. People are going to be just on blockers for even 7 years at times, which could potentially be problematic. It’s going to put you behind your peers in development, at times. The other piece of that that is challenging is that people are coming in at 13 or 14 or 15 who are already well into or done with pubertal development and now they’re going to be put into medical menopause. There’s not really an acknowledgement of that. I think that is important, and it is something that as a provider, you learn. When you do this, and then you suddenly have a lot of people saying “I am getting hot flashes” or “I have short term memory problems” or “I have insomnia” or “I’m depressed” or “I have an exacerbation of my mental problems” because blockers are puberty purgatory. All they are doing you is suspending you in some place. When you think about the things that we know as developmental physicians, we understand, especially people in my work and adolescent medicine, we understand the importance of development. We know that if somebody has precocious puberty and they go into puberty at six or seven years old, and they go on a blocker, we take that blocker away at twelve. Why do we take it away at twelve? Because that’s the time around when people are going through puberty. And so everybody is allowed to go through puberty at around twelve, unless they are trans, then they have to wait until sixteen. See how that doesn’t make sense?

In the UK, the NHS system is that when you are referred to the clinic, as I said, we have a long waiting list. And then a long assessment process. And then every single child, it doesn’t matter what age they are, they have to go on a blocker for a year before they are allowed to be considered for hormones. And there is a lot of parents who find that very difficult. One family said to me once that there were no other kinds of medicine where you were forced to have one single type of treatment even if you don’t want it. It’s true, isn’t it? It seems like the rules are different for trans people.

Yes, anything that has to do with gender has different lines of scrutiny attached to it. And what is interesting is that it kind of makes the assumption that – so this would always just amaze me or it’s been a question mark; there is some sort of thought process or belief when I see or hear about clinics that have those kinds of rules. Like you have to be on blockers for x amount of time. Or you have to do this and that. I think to myself, what is it that either people believe or they feel has been proven about gender consolidation during that waiting period? Because what I know to be true, and I started figuring it out after I had sat with probably fifty young people and listen to them go through their process with me, is that like adults, people who come out in adolescence have already gone through a process of coming in. And what’s amazing about that process is that it entails those things that we were talking about: going online, finding your community, getting language to talk about it. It also includes a lot of those things that parents go through when their kids tell them, like grief and anger and disbelief and a whole bunch of other things. There are very few people that experience any kind of positive emotion beyond relief. To say, “Yay! I’m trans!” doesn’t happen very often. So people roll through all of their own stages to what it means to discover that you have a minority identity in all of that means. And then they come out to their parents or their doctor or their therapist, and they are often met with “Are you sure?” or “Have you thought about that?” Then they think that they have probably thought about it too much that they might be diagnosed with OCD. Or with autism, because they had a fixation on gender. I think that there is some real value in asking are we making people go on blockers for a year because their parents need to come in? Or are we making them go on blockers because we think there is something inherent in that time period that people are gong to know that they are really trans? Because we don’t actually apply this to cis gender people. The model that we apply is that we assume that you knew that you were a boy or girl when you were three. And you knew you were a boy or a girl when you were three because we live in a cis normative environment that is constructed in such a manner that if you were swimming downstream. But when you are trans, you are swimming upstream. Some people make their way upstream and figure out their gender puzzle at three, and some people figure it out at thirteen, and some people figure it out at twenty-three, and some people figure it out at fifty.

You were saying something about that you sat in a room with fifty young people and I think wouldn’t it help the world so much if we could show them real-life transgender children. So many people have an opinion on what these children should and shouldn’t be allowed to do when I am sure that they have never met one in real life. Which brings me on to another question which I am sure you are asked a lot because certainly we are, and it’s about how can you possibly prescribe the treatments that you are prescribing, or give the medicine or advice that you’re giving when there is no research to back it up? What do you say to people who say that to you?

First of all, I now have the privilege of sitting with probably a thousand young people over time between the ages of 3 and 25. And then as folks get older and I remain in contact with people, it’s safe to say that at this point now, I have probably taken care of more trans kids than most humans doing this work. I think that there is the data in the world of clinical experience that we have, right? It’s watching the success stories of young people grow into themselves, sitting with them while they are on this journey, and sitting with their families if they are lucky enough to have them. So there is that body if clinical evidence that is very strong. It is probably most compelling and honest, because you can put 75 kids and do a study and look at what happens with them, but it’s all bounded. And that’s very important, by the way. That’s also why I am a researcher. There is only a handful of studies that look at trans youth. The challenge of being a provider for people when they get to 25, no longer being that provider, is that longitudinally, and this is something that I thought about a low – people say what is the follow up of thee young people? I mean, at 25, they graduate and go somewhere else for care. So getting this kind of longitudinal data is difficult because trans youth care is really like a lot of it has only been happening now for about ten years in this country. So you can imagine that there are not hoards of people that we can get longitudinal data from.  The other thing that is frustrating is that people really don’t see trans folks as credible, as the sort of experts in their own lives. And so we create a lot of hubbub about what about those few people who said this isn’t the right thing for them? However people language around that; it’s a mistake, it was the wrong thing or whatever, or they took a different turn in their gender journey and made some decisions to stop hormones. But many people then go and start up again. So what do you do? Do you go to people on their death bed and ask them where did your gender land? Do you go to them on their death bed and say what do you think about those hormones? Right now I have longitudinal data from a hundred young people that I enrolled in a study about 8 years ago. And it’s really cool. Some of the young people – two of the young people started hormones at twelve. And then some people were all the way up to 24. The youngest was twelve, the oldest was 24. And really asking those folks who were the youngest, what does your life look like right now? What are you doing with your life? That data is really important.

I also think that, Marianne, you hear this a lot, but if there were hoards and hoards of people who thought they were trans when they were young, and they didn’t end up being trans when they were older, we would hear their voices more now. But in fact, what we do hear is lots of trans older people who are trans saying that they knew from a very early age and that they wish that they had the gender affirming care that is available to young people, or becoming available to young people now. They wish that they had had a chance, even a small chance, at that when they were young.

Basically, all the people I have spoken to – historically, I’ve been active among trans people for 25 years – even though you speak to some who will say that this was a sudden realization, when you talk about the past they will realize that there were signifiers that were pointing in this direction and they just didn’t join the dots, if that makes sense?

Can I ask you to say your opinion on the question of what happens if someone changes their mind? Because this is something that drives fear into the hearts of doctors and therapists and nurses in this field. What if that young, innocent child was to change their minds, and you’ve given them hormones that make their body change in he wrong way? Can you give us your take on that?

This is a complicated question. Obviously, it’s very different if we’re talking about someone who is very young versus someone who is older, but I will say this: that I would have a hard time imagining a person going back and saying to their parents why would you have affirmed me? What were you thinking? I think that it many instances, the decisions to move forward with hormones, understanding that they actually take quite a while to start creating change sin physical bodies, we need to really look at as a harm reduction model. I think we need to say that we know for sure when people progress into the wrong endogenous puberty, they are at significant risk for negative health outcomes. we know this to be truly. We have a lot of data that says that and we need to start saying are we willing to risk that because there have been a few people who have taken not the right decision for them? Or who will make a different decision later? What does that actually mean? Does that mean that someone has additional breast tissue that they would not want at a later point? But they could get that breast tissue removed if they absolutely need to. But that’s very rare that that happens. Conversely, could that be somebody has maybe a deeper voice or some facial hair that they wouldn’t otherwise want? I think going further with that question is really important. If people make a different decision, I think the confusion is that we are holding to a space where we’re saying people are deciding about their gender. That is not what people are deciding. People are deciding what to do with it if it doesn’t match their assigned sex at birth. Trans folks come to have a better and more nuanced understanding of their gender every single day that goes by. That hormones, blockers, gender affirmation gives them additional data. What doesn’t give people additional data is continually saying that they don’t know what they are talking about. They don’t understand it, they don’t know who they are, they have no idea what this is going to mean in the future. All that does for young people is give them something to bump up against. Affirmation gives them real data to understand if that’s going to be the best thing for them.

Jo, is there anything that you wanted to bring up that would be useful to anyone listening to this?

Oh my goodness, I could talk about gender for hours and hours, but it’s really exciting that there are people who are working on this, and really working from a place of compassion and understanding that trans adults started as trans children, and that the care and this work is so important. I think that living with uncertainty is okay. I think we need to drop out pursuit of certainty and work on our pursuit of compassion. I think that we would provide a much better medical environment for young people.

Well, Jo, it has been an absolute privilege to have you talk to us today. I feel very privileged working in this field. I face difficulties from people who haven’t understood what I have learnt from transgender children and adults. They haven’t understood that, and they fear what might be ahead. What I heard from my patients has been amazing, and I actually feel very privilege to be working in this field. And in a field that is changing so rapidly in that affirming approach and the other thing that I feel incredibly privileged is something that I don’t feel doctors get a chance to do very often in their career, and that is save a life. And the people who don’t understand will often say that those suicide statistics are just made up, that they’re wrong, unbelievable, and can’t possibly be true, but when you work in this field you see that they are true. Young people, young children, young adults are harming themselves and killing themselves because they cannot cope with that feeling of the wrong puberty and what it’s going to do with them. And so to be privileged to work in this field is immense, privileged to have talked to you and hear your wonderful words, and also the privilege of potentially saving a child’s life. You know, doctors don’t get to do that very often.

I completely agree. There is no other field that completely – I feel like this piece of medicine is such a beautiful amazing combination of social justice, human rights, and science, but it’s also the ongoing day-to-day, incredible gift of sitting in a room with a human being who will sacrifice everything to be who they are. And what kind of world would we live in if everybody was available for that journey? It would be remarkable. If there was ever a hope for humanity, it’s sitting with trans young people, and listening to the level of thought and level of insight and unbelievable observations that they have about the mistakes that society makes about gender. It’s really a privilege.