Dr. Johanna Olson-Kennedy on the “Gender Barometry” of Children
May 4, 2016
There’s a big difference between the practice of bloodletting, phrenology, eugenics, lobotomy and gender barometry. The latter is the current recipient of five million dollars in government NIH funding.
Dr. Johanna Olson-Kennedy is a self-described physician-activist whose medical practice is devoted to promoting treatments that permanently retard the reproductive systems of children who are distressed by social sex roles. These treatments stunt the growth of adolescent’s sexual organs and cause sterility. They cause lifetime drug dependence, disability and perpetual medical monitoring among formerly healthy individuals. Most of the subjects are homosexual. By so doing Dr. Olson-Kennedy purports to enhance the ability of children who can’t conform to restrictive sex-roles to pass cosmetically as members of the opposite sex on a superficial social basis. Such treatment is intended to individualize and pathologize the distress caused by social sex-roles and abort any potential social unrest or organized revolt against cultural norms.
Dr. Olson-Kennedy operates the largest pediatric eugenics sex-role clinic in the world, under the supervision of Dr. Marvin Belzer at the Children’s Hospital of Los Angeles.
In her own words: Dr. Olson-Kennedy’s theories of Gender Barometry, Brain Gender, Height Normality, Neural Grooving and Teen Malaise as excerpted from the ‘Straight Talk MD’ [http://straighttalkmd.com/transgender-transition-extended-episode/] podcast: Enjoy!
[Note: interviewer questions have been condensed and paraphrased and appear bolded and in brackets like this sentence.]
[Interviewer: Philosophical question- did you choose your destiny or did your destiny choose you?]
I think a little of both. I think we’re choosing our destiny today. So, I think I had the incredible fortune to land in a fellowship program where this work was already being done by my mentor and the division head Dr. Marvin Belzer. And when I arrived there to do my fellowship in Los Angeles I was struck by the multitude of programs that were in the division, and certainly caring for trans youth was one of those programs.
[how long has Dr. Marvin Belzer been doing this work?]
He started doing trans youth care in around 1993-94, really in the context of our HIV youth program, so we had some young people who were receiving care for HIV but who also were interested in care around their physical gender transition, so they needed hormones, hormone care monitoring, and Dr, Belzer just jumped right in at a time when youth care was really very scarce. And so this is kind of where this care lived for a while and then it started breaking out beyond that, taking care of young people who were not also needing care around HIV but who just were, who needed hormones or needed monitoring for their hormones, and then the age of access started getting younger and younger. I came on as a faculty member in 2006 and at that time it corresponded with when the Dutch had really published a protocol about using hormone blockers in early puberty in order to keep young people with gender dysphoria from going through a puberty that didn’t really match how they felt. And as a pediatrician I felt like -what an amazing thing. What an amazing thing to pick up a pen and a prescription pad and really give someone this opportunity that they wouldn’t have otherwise had in history. And that gift, being able to provide that gift to people is, it’s a remarkable thing to be able to do as a healer. And I said that’s, I think that’s what I want to do. I wanna do this blocker practice model of care and also do hormone care for older adolescents. And what’s remarkable is if you start doing this work I don’t think you stop. It’s really incredible. And it gives me this opportunity every day to have the fortune of helping people live authentically. And there’s really not a lot of people that can say that. That in the context of their work and every day they get to contribute to a human rights issue on a macro level, and also on a micro level be able to really impact somebody’s quality of life.
[the difference between biological sex and gender identity?]
I think that we have to be mindful of even saying “biological sex”. I think that it’s- the language has evolved very rapidly even over the last couple of years, where more, I think we have said in the past “biological sex” to mean something that it doesn’t necessarily mean. So I think “natal sex” or “assigned sex at birth” are probably more accurate reflections of what we mean when we talk about what happens with a baby who’s born who has certain appearing genitals, and the assumption that is then made that makes a marker, a sex marker of male or female on their birth certificate. Gender identity is really our own internal sense of maleness, femaleness, both, something else entirely [laughs] , neither. And that’s really a subjective experience as we know it right now. I do think though as we see increasing numbers of studies coming out about brain neuro-anatomy we’re really going to understand that gender identity most likely lives in the brain, the structures of the brain and the way that the connections are made in the brain. And so it then sheds light on the inadequacy of saying “biological male or female” because that assumes we separate our brain from the rest of our body. Or our brain from our genitals or reproductive tract, which is not really a complete way to talk about bodies.
You know, “transgender” it certainly could mean different things to different people but I think we’ve broadly come to understand it as a word that really captures folks who have a gender identity or gender expression that is maybe stereotypically different from their assigned sex at birth. So somebody who has a gender identity that’s different from their assigned sex at birth, and I wanna be really clear because a lot of times we talk about this is if, first, that male and female are opposite. And that all trans people have, like if they’re identified female at birth or assigned female at birth that then they identify as male- or if you’re assigned male at birth you identify as female- but that is not the case for all of trans folks. And so I think it’s really important to be specific about that trans folks identify as a gender that’s different from their assigned sex at birth. It may not be quote unquote “opposite”.
[what is gender variance or gender nonconformity?]
I really love the word gender “nonconformity” and it’s probably because personally I put very little value on conforming. [laughs]. And so I think it puts the onus of the difference on the society around the individual. So conformity around assigned gender, assigned sex at birth, really has to do with the way that gender is experienced, performed, and expressed, and so for people who have an experienced gender identity or an expression of gender, or a performance of gender that might be not stereotypically associated with their assigned sex at birth – they can be broadly categorized as gender nonconforming.
Yeah, transsexual is an interesting word, and it has a long history. But it has in the past, a lot of times the language and the lexicon of gender has arisen out of the medical community or the academic community and really was developed to distinguish people who underwent physical either hormone or surgical models of care in order to change their physical body to more closely match their gender of identity. But it’s not exclusive to- not everybody who does that resonates with that term, and so some people do and some people don’t.
[the term transvestite -is it used anymore?]
Not really. I’m sure somewhere it is but it’s not commonly considered a word that we would, that really has a lot of meaning to people. I think, one of the best historical documents that we can read around the classification or lexicon of gender in the world of academia comes from Harry Benjamin’s book ‘The Transsexual Phenomenon’ that he wrote in 1966 and he talks about this. He talks about different categories of people with these different names, you know, “transsexual” and “transvestite” and it’s very interesting to read that document because the “true Harry Benjamin transsexual” which is how sort of how people were referred to back then are differentiated from folks who just wanted to wear clothing that may not have been stereotypically expected for their assigned sex at birth. And so there was sort of this classification done by non-trans people about ‘Oh this is what means you’re really transsexual versus a crossdressing’. [sic]
[biology of transgender- is there a hormonal factor or cause in utero?]
I mean I think the superficial answer is no, there’s not one single thing that has been identified in the world of science but it’s, but we can learn and understand about gender behavior from some of the populations that we know that are in the DSD community or intersex community. I think what’s likely is that there’s a complex interplay of hormones and hormone receptors that are all experienced in a huge spectrum, in a huge array in utero. And that likely is what’s impacting gender identity development prenatally. I mean, I really do… – in the past historically you know, folks of trans experience were always thought to have had childhood trauma or inadequate parenting or some other non-chemical, non-hormonal or non-physiologic experience to explain their trans experience and I think we’ve largely gotten away from that, I’m hoping at least in the world of science. I think that’s probably still a very predominant sort of lay community perspective but I do think we don’t, we don’t, -we’re just starting to get an understanding of even what’s happening in the hormone milieu of prenatal environments.
[biology of transgender, is there a genetic factor?]
Um, there have been..what I can tell you is that there have been twin concordance studies that look at, like, identical twins versus fraternal or sororal twins and certainly there is a higher concordance among identical twins, which speaks to the idea that there may be genetic factors that play a role. Which isn’t surprising because if, you know, if genetics are gonna have a role in the hormones and hormone receptor milieu that’s happening for people as they undergo brain development.
[neurological differences in transgender individuals?]
I think that’s what we have very, very preliminary data that started out asking the question ‘are there sexually dimorphic regions of the brain’ or ‘do the brains of men and women..’
[meaning of “dimorphic”?]
Yeah, so: ‘Are there parts of the brain that look different in men and women?’ And that’s definitively been shown in studies, brain studies that have been done. And then the next logical question in the world of trans science is well what do those places in the brain look like in trans folks? And this is certainly not my area of expertise but the earliest data has shown that…um, it points to that… really that trans folks may have hybrid, hybridized brains, so those sexually dimorphic regions may be partially masculinized, partially feminized. I think we have a lot more to learn about this and I certainly wouldn’t wanna definitively say ‘yes we know that these specific regions’, but it’s not surprising that some of those regions that are hybridized share ..uh, share.. sort of spaces where we think there might also be differences for people around sexuality. It stands to reason that those brain spaces maybe [laughs] may share compartments. I guess that’s the best way to say it.
[can you use MRI scans to confirm diagnosis?]
Yeah I think we always have to be very aware when, in the world of science, when we cross over to try and identify etiologies. I think we also don’t understand why people are “cisgender” or not transgender. [laughs] And we actually have a lot more people to study to understand that question. And I think it also is that slippery slope of -if you, if you do find some things that are- if lets say, we do figure out where gender identity lives in humans, for anyone, regardless if they’re a person of trans experience or not. I think we have to ask ourselves: do we really want some kind of litmus test and if that does exist, then if you have an MRI and your brain doesn’t look like that does that sort of nullify or make your experience less authentic? And that’s really a difficult place to be in. I think that right now it’s safe to say that gender identity is a subjective experience. We’re all the keepers of our own gender and it’s not really appropriate to either undergo medical testing or even have an outside mental health professional verify your gender identity. We don’t really ask people who are not transgender to undergo that same kind of process.
[can a five year old really know they’re transgender?]
I don’t know that a five year old knows that they’re transgender but a five year old can certainly know their gender. I think what happens is that one of the downsides of seeing only media about younger children or a preponderance of those stories is there’s an expectation that trans people would have known their gender at five and had been articulating it and talking about it and.. and so, that’s actually not the majority of cases. This is really an interesting phenomenon that’s happening because we have more permissive environments and we have parents that have a very different kind of relationship with their children then they have had in the past. (Not those same parents but parents of older generations). And so I –we- have information and knowledge about gender constancy that comes from data not related to trans experience at all but that asks the question ‘when do children come to know their gender?’ and it’s quite early. I think what happens for-
Early childhood. Three to five years old.
[but some kids don’t identify as trans until older?]
I think that kids of trans experience in the three to five year old age range are just doing what they like. And so a lot of their being able to “know” anything has to do with what’s around them. So kids three and four and five year olds don’t say “I’m transgender so I like toys that aren’t typically associated with my assigned sex at birth”. They don’t have that kind of nuanced, what I call, what I’ve been starting to call a “Gender Barometer” or a way to understand gender and all of the implications of gender that we come to understand as we get older. Little kids just do what they love: ‘I like this’ or ‘I like that’. And for a child who has people around them that say “That’s great! You can play with whatever things you want! You can wear whatever clothes you want. Whatever makes you feel comfortable.” That child’s gonna have a very different experience around understanding their gender than a child who hears “You can’t play with that because you’re a boy”. “That’s a girl’s toy”. Or, “That’s a dress and boys don’t wear dresses.” Or, – and that’s usually the direction by the way that I’m talking about- it’s very rare that someone says to their assigned female daughter “You can’t wear pants, that’s for boys”, you know, “You can’t play softball or baseball or football or basketball because you’re a girl”. That- we don’t generally hear that, we hear it in the other direction. And so as kids start to get older and they start to get more clear cultural messages about the adequacy or appropriateness of what they love, their reaction is going to strongly, most likely, determine what happens around their gender identity and their expression of it, if they are of trans experience.
[what should parents do if their kids want to play with toys or wear clothing not stereotypical for their sex?]
I think that parents can make the choice to allow their child or support their child in doing what they love within the space of their own house relatively safely and easily. If a parent has a lot of what I sort of call a “Psychic Earthquake” about this then that might be more difficult. I think there’s still a proclivity and certainly even in cases where parents are supportive -the earliest responses with a child that you think is your son, wanting to play with dolls or wanting to wear dresses, the earliest proclivities are to redirect. I think that this happens commonly. People really don’t know how to handle or can’t really wrap their head around or deal with the judgment around letting their son wear a dress. I think that’s really difficult for a lot of people. But I do think that they also recognize the distress that their child is in around sort of getting these messages of that’s not okay. Who you are is not okay. That’s really damaging for any human to hear repeatedly in covert and overt forms.
So parents can certainly support. Parents should seek resources for themselves. They should try to find mental health providers that they can work with so that they have space to talk about everything that’s happening for them. Because it’s really not fair to ask your five or six year old child to hold that space for you as a parent or caregiver, adult parent or caregiver. [sic]
The, more decisions come [sic] when a child is really interested in doing these, in doing, um, maybe gender nonconforming behaviors and expressions outside of the home. I think that safety is a really paramount concern. But I also think that safety shouldn’t be used as a reason not to support a child. But, um, there are logistical things that need to be thought about. What’s gonna happen in a setting for a child who is in school? What’s gonna happen in that school for that child? What’s gonna happen around, you know, extended family? What’s gonna happen in communities of faith? You know, church, temple, other places of worship? And thinking about those things and talking about those things are really important. How are parents going to explain to parents of other kids? About why their maybe perceived son is wearing a dress? These are all things that are logistical issues around supporting a child in doing gender nonconforming expressions or behaviors or even statements about their gender. [sic]
[what is gender dysphoria?]
Gender Dysphoria does have diagnostic criteria that are outlined in the Diagnostic and Statistical Manual of Mental Illness. But I do think that gender dysphoria is described as the distress that arises for some about the incongruence between their assigned sex at birth and their experience of gender. And the, you know, gender dysphoria can show up at any time. And it can show up for people who are 18 months or two years old. And it can show up for people who are twelve. And it can show up for people who are forty [laughs].
So I think the people who have the great fortune to be doing this work come to understand how gender dysphoria looks different in different age groups and developmental places. For little kids, there may be kids who are gender dysphoric but are not understanding that their distress is related to gender. Many, many people that I’ve seen that present for care in adolescent or young adulthood say ‘I knew that something was different or wrong”. A lot of time it’s languaged as “wrong”. ‘But I didn’t know what it was. I couldn’t connect it to gender until I was a little bit older’.
And this is probably a great place to interject that, you know, for assigned males and assigned females at birth the experiences are different. That’s really important. Because if you’re assigned female at birth and you like to do sports and music and wear pants and boy’s clothing and maybe even boy’s swim trunks and a rash guard and there’s just not the same level of of red flag alert that happens for families or even caretakers and providers, pediatricians and family medicine doctors or other people that care for children, that there is when you’re assigned son wants to wear a dress as we were speaking about before. So that gender dysphoria looks different in those groups. For a kid who really wants to.. you know for an assigned boy who really wants to wear a dress there’s gonna be a different conversation that happens. So that young person may get very different messaging very early on.
[less social tolerance for boys?]
Absolutely, I mean we still live in a very patriarchal misogynist society and it’s very androcentric and the idea that, I mean if you are in a society that sort of believes covertly and overtly sends the message that femaleness is less than maleness it stands to reason that there will be little tolerance for feminine behavior among assigned boys. There’s a huge latitude for gender expression and clothing and things for girls and even the that way we talk about it, I mean we have a word that is not disparaging: “tomboy” that we use for assigned girls that are maybe doing more what we expect to be masculine things (feels weird even to say that, but umm) we have a word that’s not ostracizing and disparaging and the words that we use to describe assigned boys who wanna do quote unquote “girl’s things” are very disparaging. It’s considered an insult if you -when you insult a boy and you use female or feminine terms it’s insulting. But when you use male words to describe girls it’s considered a compliment.
[what are hormone blockers?]
So in 2006 we were so lucky to have the work from the Netherlands get published. This idea that you could suspend or block somebody’s endogenous puberty process. I think that puberty is a time that’s- as an adolescent medicine specialist- is the scariest for me with youth of trans experience because it really, it’s not just being in a body that you don’t necessarily resonate [sic] it’s the solidification of an adult version of that body. So in childhood it’s very easy to escape that reality because in many, many ways prepubertal boys and girls bodies look the same. And so I think that puberty and the development of secondary sex characteristics of the reminder of sort of childbearing potential and things like that is really traumatic for a lot of people. I’m a cisgender woman so I can’t put words into people’s mouths but certainly that has been described to me over and over and over again. That puberty is the time when, almost always, young people who were previously happy well adjusted kids kind of socially isolate, they go into their rooms, never to be seen again by the family. And this is really of great concern to parents. You know “I had a really happy child and then around the age of maybe ten or eleven my child disappeared and all they do is go online. All they do is sit in their room and don’t want to participate in family activities. They started struggling in school. And this is also an emergence of depression and anxiety, self-harm, and suicidal thoughts. Puberty blockers have opened up the landscape for really important piece of work for trans youth [sic]. This idea that you could avoid the development of certain secondary sex characteristics can be really helpful for people. So if you are an assigned girl at birth, not having to go through chest development can be really helpful. Not having to ever start a menstrual cycle. Not having some of the body developments that happen for, that happen for folks with ovaries. If, for folks with testicles not having your voice drop, not getting an adam’s apple, not starting the growth of facial and male pattern body hairs [sic]. It can be, can be really helpful in keeping some of that anxiety and distress down that happens for youth in the puberty process.
[Why not directly start cross sex hormones if the gender is established at the onset of puberty]
That’s a great question. There are reasons from a medical perspective and there are reasons from psychosocial perspective and there are reasons from existing data that we have from the Netherlands. So the medications that we’re using to do blocking are medications that we’ve used for thirty-five, forty years to stop puberty process in kids with central precocious puberty, or puberty that starts at four and five years old. We really don’t want kids going through puberty at that time. It’s a bad, that’s a (laughs) we don’t want a five year old to start their puberty process, there’s implications on not just their psychosocial self but on bone and growth. So the medications have really good safety profile they’re also reversible. So that means that if lets say a trans kid at eleven, you know, over time, the next year or two years says that “Hey this isn’t… I’m okay with going through my endogenous puberty”. And maybe that’s because they feel more gender fluid, or maybe that’s because they settle into their assigned sex at birth. It’s incredibly rare. There’s really only one child that has been reported in the literature that went on the blockers and did not go on to cross-sex hormones, or gender-affirming hormones. And that kid had come into the blocker process with a non-binary gender identity. So that was not a young person that was definitively saying “I identify as male or female”. This was a young person who said “I’m not entirely sure what that’s gonna look like.” So I think there are some kids who, starting cross sex hormones might be perfectly appropriate and bypassing blockers might be perfectly appropriate for those kids, but certainly giving young people this grey area where they can really get more cognitive development, get more social development, and frankly more linear growth (laughs). This is another thing-
[do blockers prevent continued growth/stature?]
No it does not. I mean, linear growth is really based on other factors, growth hormone and other things but the-
[so puberty blocking doesn’t block growth hormones?]
It does not. That’s the nice thing about puberty blockers, or gonadotropin-releasing hormone analogues is they’re very specific for the process of the release of sex, sex steroids. So sex steroids do play a role in the growth spurt of adolescence but they certainly don’t inhibit linear growth [sic]. So this is one of the, let’s think about a trans-masculine person, so assigned female at birth, this is a person with ovaries that might start their chest development at the age of nine. Well it doesn’t make peer concordance sense to start a nine year old on testosterone. Because they’re not, their friends who are probably cisgender boys are not starting their puberty. It also is the case that if you use enough testosterone to induce secondary sex characteristics that are masculine you also have to use enough to suppress the development of the feminizing sex characteristics. So in order to suppress the menstrual cycle you might have to move a little quicker. And for a nine year old that doesn’t make sense ‘cause -who wants to rock a mustache at eleven? I mean that’s kinda weird, so (laughs).
[kinda wished I had one at that age(laughs)]
So I do think there are a lot of things that go into the decision making equation and what we don’t have, and we can certainly extrapolate from other populations, we don’t really know the best way to say, maximize growth, height, linear height potential, in transmasculine young people. Height is something that is maybe over valued, but it’s still valued for men in this country and certainly elsewhere and you know, height for women is not valued. Enough height: you wanna be tall enough, but not too tall, right? So there’s a whole lot of societal expectations around people’s heights. Height… and we need, we don’t really have any data on that at all in trans youth. So I think blockers can be really useful in that way. That we can have people continue to grow. One of the concerns that we have is if people are started on estrogen their growth plates are gonna close. So that can be, that’s what we want to happen for most people going through an endogenous puberty regulated by estrogen or ovaries but that’s not necessarily we want [sic], something we want to do in a person with testicles who’s very short at the beginning of their pubertal process.
[what age do you start cross sex hormones?]
I think it’s a real mistake for people to think about chronologic age. Just because the developmental process for each human is so different. There are kids that I think are perfectly appropriate for gender affirming hormones or cross sex hormones at thirteen, and some that for various and sorted reasons it’s at sixteen, it just really depends, this care really requires an individualized approach. And it’s one of the things that makes the care both amazing, enjoyable and lovely but also difficult is that these kinds of understanding of about where a person is at and understanding their level of anxiety and understanding where they are with their peers and their level of whether that’s important to them or not. Some kids want to take their time on starting hormones and some kids really don’t and all of that goes into the decision making. Their medical health is important. Their height is important. So there are so many things that have to be thought about in this decision, and I think one of the biggest unfortunate things that’s happened in this care is that there have been chronological ages that have been talked about in our care guidelines that are both validating of trans youth but also are very inhibiting of trans youth being able to do anything outside of those clinical care guidelines.
[social transition -what is the age for that?]
So I have about 101 kids that I put onto a protocol of the 600 that are in our practice, but a hundred of them that are new to hormones and I asked them “when was the first time that you really knew your gender was different from your assigned sex at birth?” Where you knew that. Not where you were doing gender, when you were doing gender non-conforming behavior, things like that, but when did you actually connect that you had a gender that was different than your assigned sex at birth. And the average age was eight. So, on average eight. And the next question was “When did you disclose this information to your parents?” And it was seventeen. And so, we’re talking about nine years, ten years where people really sit on what I consider to be a huge piece of information about their core self. And think about all the things that happened to them in that time and what goes into their neuralgrooving [sic] process and their internalization of negative messages. So I do think while it’s amazing that we’re getting more and more young people it’s really still the case that people are coming into the clinic at seventeen to twenty-five seeking care, they’ve already been through an endogenous puberty process. And so those kids, those young people, they’re not really kids but those young people and young adults when thinking back to their childhood, had we seen them at five years old, it might have been a really different story for them but because they’re now coming in post-pubertally they may have this order, this checklist of transition be very, very different.
For children who are talking about their authentic gender at a very young age most of them are going to be socially transitioned even before they start blockers. Now. That’s pretty common now. For kids who are entering into care later they may or may not want to do elements of social transition or complete social transition prior to using hormones because if you’ve already been through a quote “male puberty” you know, the development of an adam’s apple and their voice has dropped and the have a skeletal stature that’s distinctly masculine, genital changes and facial structure, there may be very, very good reasons that somebody doesn’t feel comfortable presenting as a more feminine version of themselves until they have been on hormones for some time. And that makes really a lot of sense because of what we were talking about earlier. The societal reaction to what appears to be men in female attire, make-up, or hairstyles is really difficult to navigate especially for a teenager.
So I think there have been occasions where people have said ‘I don’t understand why my teenager doesn’t wanna go out and buy dresses and wear make-up and all of this stuff”. And, first of all that’s not going to be important for every transfeminine person, but alon, maybe they have very good reasons for making those choices. And that’s again, part of that having conversations with people and seeing what works for them.
[challenges of social transition in high school or elementary school?]
I think, and again there’s some strategizing that happens for families around this. So does it make sense to do the social transition in the summer or does it make sense to do it prior to starting a new section of school, like elementary school or junior high or middle school or high school or college. You know -is there strategy in changing schools or going to a different district. And I’ve seen families do this in all of the above ways. (laughs) So I’ve seen families whose- the youth actually say “I’m leaving for spring break and I’m coming back with a different name” and what do we need to do in order to prepare that young person for that change? And again, like so much of this depends on where you are in the country. It’s gonna be very different if you do that in, you know, a very liberal sort of arts, small private school in Hollywood versus you know you’re in Arkansas in a public school where there’s very little experience of this within that school district. It’s just gonna matter. That’s very important. It’s important for the safety of the child. It’s important for even being able to productively function in a school environment. If a school environment is hostile for a young person then it’s going to be really hard to do what they need to do in school which is learn and make friends and academically achieve. So people do this in lots of different ways. The challenges that people face often come from the school setting, come from administration, they come from teachers, school psychologists, people that don’t have a lot of experience and are- definitely have their own opinions and ideas about whether or not, you know, youth can actually be transgender. I mean, it makes complete sense that transgender adults started as trans kids but a lot of people don’t really believe that. There are people who simply state “I don’t believe that this is a thing”. Which I always say is akin to not believing in cheese. It’s very strange, because gender really isn’t a belief system.
So I think it’s impossible to have a conversation with, I’ve never had a conversation about trans youth that doesn’t include a conversation about bathrooms and other sex segregated spaces because these seem to be the spaces where everyone around the young person gets very worked up, very knotted up. And it’s interesting because the person who really has the most anxiety about this is the young person. And so there’s a couple of things that we very rarely do hear public outcry about a trans masculine or trans boy who wants to use the boys restroom. You always hear the outcry from parents of cisgender girls who don’t want a trans girl in the bathroom with their kids. Which is very strange to me because something that’s universally true of women’s bathrooms is stalls. Private, privacy. And in the other direction in a much more public style restroom for trans boys it seems like it would be much more alarming, it comes from our constant societal view that transwomen are sexual predators. And even when they’re seven and eight years old there’s a feeling that somehow that lives and wellbeing of cisgender girls in that bathroom are in danger. The person who has the most to fear is actually the trans kid. And very, very few people are thinking about advocating for those youth.
[How long does hormonal transition take and how does it permanently affect fertility in kids?]
So hormones are basically inducing a puberty. So the puberty process does take time. It certainly doesn’t happen in weeks, unfortunately for the kids because they really, the young people would like it to go faster than it does. There are things about cross sex hormones that are permanent and some things that are, many things that are not. And it’s different, again for folks taking estrogen or feminizing hormones and folks taking masculinizing hormones. I think that what we know to be true in science and medicine is that testosterone is an incredibly powerful medication. It works quickly although it does take time for some of the more subtle changes. But- and this is also very different in kids who’ve been on puberty blockers versus kids who’ve already gone through one puberty. So for kids, you know it’s very- when somebody’s already gone through one puberty part of the job of hormones is, you’re almost thinking about layering one puberty on top of another because you actually can’t reverse the changes of an endogenous puberty, except through surgical means. So hormones are really additive. They can’t take away anything. Which is really hard because if you’ve already gone through a puberty with testicles your voice has dropped. Your voice isn’t gonna change when you take estrogen. Because you can’t ungrow your vocal chords, you have to retrain your voice or get vocal chord surgery. The same thing is true really of facial hair and body hair. Once you stimulate those particular glands in your body even if you completely eradicate all of your testosterone (which is not a good idea) but even if you did that those follicles would not stop. You’d still continue to grow that hair at a slower rate. So you can, um, so in, when you’re dealing with a person who’s already been through one puberty you’re really doing anything that you can to be additive with hormones. And so it’s a different, it’s sort of a different process. And a lot of times other ancillary things have to happen like lazer or surgery, electrolosis. Those are things that people have to consider if they want specific changes.
So it really, we tell people that it’s a two to five year process, a lot happens with masculinization in the first year, so people their voices will drop, they will get facial and body hair, they willl have fat redistribution and ability to to get muscle, especially in the upper body, and there will even be some, some facial restructuring because of soft tissue changes. For trans feminine folks breast development certainly starts in the first year, softening of the skin and again that body fat redistribution. But it’s a slower process and it takes longer and many times it’s inadequate.
People want to have surgery, chest surgery. So it’s definitely variable from person to person. It definitely matters if someone’s been on blockers, if they haven’t been on blockers, and I think talking about that is really important for providers who are going to be writing prescriptions for hormones and then monitoring, is talking about: what are things that are realistic? What are things that are not realistic? There are just some fundamental differences in sort of, nipple areolar complex placement, between xy and xx individuals, and those are all worth a conversation I think, for sure.
[mental health outcomes of pre-pubertal social and medical transitioners versus post pubertal transitioners?]
I think that for a long time, I mean the Dutch showed us this earlier, that young people who start transition earlier, because we have more hormone receptors in our bodies when we are younger, they definitely can expect more changes than somebody who started later for sure. And there’s been a clear link to people feeling better and having a better quality of life who’ve been able to achieve more of what they’ve wanted physically. I do think that this cohort of kids who are socially transitioned in childhood is really coming up, and we’re gonna learn more and more about them every year. But this idea of socially transitioning in early childhood is so very new that I don’t know that we could even make commentary about outcomes, but what I can tell you is that compared to… so there has been some very…
[objective outcome data? Scholastics or school performance?]
So there have been studies in the past looking at kids with gender dysphoria and showing clear levels of anxiety and levels of symptomatology that is in the clinical range. What’s exciting is that there’s some new data that’s going to be coming out in the next month or two that looked at anxiety and depression among kids who are socially transitioned and supported in childhood and it’s very favorable data, I’m really excited about it coming out. [Mental Health of Transgender Children Who Are Supported in Their Identities
Kristina R. Olson, PhD, Lily Durwood, BA, Madeleine DeMeules, BA, Katie A. McLaughlin, PhD
http://pediatrics.aappublications.org/content/pediatrics/early/2016/02/24/peds.2015-3223.full.pdf . The study defines “living as their natal sex” as conformity with unwanted sex-role stereotypes and the study has no control group of children whose stereotypic sex-role noncompliance is supported without claiming to be the other sex -GM]
And that being said, I don’t think that we, that I, would not like to promote the idea that social transition is the panacea, and that it’s gonna eradicate gender dysphoria, because it’s not. Gender dysphoria is the distress that arises from the incongruence, and the incongruence is never gone. You can’t go back and unassign your gender at birth, your sex at birth. You can’t do that. And so, gender dysphoria shows up in a lot of ways. And we have to be mindful of that because what happens often is parents say “Well, we let you go on hormones, and we let you socially transition, then why are you still depressed?” or “why are you still anxious?” or “Why are you still self-harming?” And, as cisgender people, we can’t understand what it means to have gender dysphoria because we don’t have it, and so we have to be mindful as clinicians to look for it, and see how it waxes and wanes over time. And I think that we underestimate- so someone could be completely socially transitioned in childhood, they could go onto feminizing hormones at an early age, and they’re gonna navigate high school when sexuality is sort of at a premium, with genitals that may or may not be what they resonate with, or what feels right for them. And so that’s gonna be a big place of gender dysphoria for people, is, at the end of the day you have different challenges when you are non-disclosed, you’re completely perceived as your authentic self, but you are really restricted from entering into intimate spaces. Both with friends but also with potential partners, and that plays a big role in people’s lives. Especially teenagers.
[daily home school work challenges for these youth?]
I think that I could probably summarize it in a way that I heard from somebody else, from, about “gender noise”. The constant, ongoing bombardment of preoccupation and bandwidth about gender. The spaces, the covert and overt messages, about how to “do girl” right, how to “do boy” right. How to “do man” right. How to “do woman” right. It’s different things for different ages. When conformity is at a premium in the middle school years, feeling different for any reason is horrible. And so for a young person that either has not socially transitioned yet, I always say this: Before you disclose your authentic gender your secret is: you’re trans. And after you socially transition and you’re presenting as your authentic self, your secret is: you’re trans. And so there’s that ongoing…for younger kids, and for a lot of people, “secret” equals shame. And living with shame on a daily basis is hard. It’s a big task and it shows up in a lot of ways. For older kids I think there are things like “Who am I gonna partner with? How am I gonna tell people this truth about myself?” and “How am I going to talk about it?” and “Who do I have tell and when do I have to tell them?” And there’s a common perception that people have, and it comes from parents a lot as well, but, you know, “Oh, if I don’t disclose this information I’m lying to people”. And it’s like yeah, actually not. I mean this is private information. You should have the right to disclose it or not, depending on your situation and what feels right for you. And there is a constant and ongoing thing that I hear, which is that, you know, “Cisgender people feel entitled to know things about trans people that they have no right to know.” And empowering young people to say: “Google it”. You wanna know more about it? Google it. You know I don’t actually, I’m not obligated to tell you my life story. I’m not obligated to tell you about my body. I’m not obligated to tell you about my genitals. Or any of those things. And that’s a really important piece for both families and young people to have in order to be armed to move forward and feel better. At the end of the day, until we start celebrating trans identities we really can’t expect young people to integrate trans identity into their core self with great happiness. I think we need to start helping young people and helping the society be aware that this idea that there are only two genders is ridiculous. And that gender equals genitals? That’s just not real. And because young people who are disclosed and are incredibly brave and being advocates at very tender ages: they’re leading a gender revolution. And it’s exciting. And it frees us all. Whether we’re trans or whether we’re cisgender.
[has increased public visibility of transgender been helpful or hurtful?]
I think both. The answer is both. I think that as trans visibility becomes greater there are a couple things that we’ve seen happen. Which is: more violence against transgender women, of color, specifically. I think that we can-
[what do you attribute that to?]
Um, well I could do a whole show just about that. It’s… I think that, you know, there is violence against trans women of color that comes from within their own families, I think there is violence that comes from partners, intimate partner violence when people are disclosed, and I think there’s simply just stranger “I’m going to see someone who’s trans and it gets me so worked up that I just feel entitled to kill somebody, hurt somebody”. And I think those are probably all driven from different things. I think that at the end of the day people, when they don’t understand something, they’re ignorant about it, it makes them uncomfortable. Difference makes people uncomfortable and people deal with discomfort in different ways. And some people deal with it with violence. And there’s sort of an entitlement around that. Like, “I’m entitled to actually be violent towards something I don’t understand or someone I don’t understand”. And so I think that we have to be aware that trans visibility isn’t always a great wonderful celebratory thing, although the flip side of that is how many young people have accessed care because of the feeling that families have of sameness. If this can happen to the Khardashian family, to the Jenner family, then it seems more real. And it seems like “I can understand it more and maybe this is something that I really need to address in my own family”. What I’m really hoping is our amazing trans women of color, Janet Mock and Laverne Cox and others who have been amazing about sharing their stories, that that trickles into communities of color. Because something that is not happening is younger trans youth of color coming in to get blocked. We haven’t seen that. That’s pretty rare. In my clinic it’s… you know, some other clinics have more diversity in the young people that they’re seeing, but in the heart of Los Angeles, where we have a very diverse community, we really should be seeing more young people, more trans youth of color coming in for the opportunity to get puberty blockers, and I hope that we see that. It’s certainly not something that we’ve seen so far.
[is there any science on who would be a good candidate for sexual reassignment surgery and who would not?]
I think a couple things. The first thing is that we need to move away from even our language on that because the implication is that, you know, your sex will be reassigned after you have genitals that look different than your current ones. I really think gender- “genital reconstruction”, or “gender confirmation”, I mean, again, you don’t need certain genitals to have a gender. But I do think that, you know, genital surgery is something that is important for some people and not as important for other people. And I think that for a long time when genital surgery was not accessible to a lot of people because of finances it was something that a lot of people put off the table for themselves. But as it’s become now more increasingly covered by insurance I think we’re gonna- we have seen- skyrocketing numbers of people who are accessing genital surgery. There have been, you know, the research to date that’s looked at regret, I mean the numbers of people who regret genital surgery, are incredibly low, 0.5 to 1.0%. Those studies have really –
[better than hernia repairs]
Absolutely. [they both laugh]. That’s better than a lot of surgical interventions. And I think that even among the people that have, sort of, regretted that decision, it has to do not with that they have gender instability but that they were doing this whole physical or phenotypic gender transition in adulthood and they had an entire life in one gender role that they then lost. And that would be cause for regret I think for anyone, who lost everything in their life because they were pursuing their authentic self.
So I do think that surgery is really important for some people and not for others. I think chest surgery for transmasculine or transmen can be very important early in the process. But I do think that specifically genital dysphoria for trans women is a profound experience and I think sometimes that gender dysphoria is not even significantly impacted until genital surgery. We put… uh….a lot of… we really put a lot of meaning into genitals. Specifically, sort of, penises. And I think that for trans women who want to partner with cisgender men this is a major barrier for them. This is what young people tell me a lot, which is, you know “I just can’t even go into that, those spaces, because I’m scared for my health and my life and I don’t know how to talk about this”. There’s very few people who are really open in saying “Well that’s okay if you, you know, I really love you and it doesn’t matter what genitals you have”. That’s just, very difficult for people. Until things really change dramatically.
[Tell us about your research]
Over the last five years I’ve really been trying to investigate what the impact of early treatment is on youth who are getting blockers and youth who are starting hormones. Recently was, well over the summer, awarded a large NIH grant. I have three amazing PI colleagues at Chicago, Boston and San Francisco, UC San Francisco who are going to undertake this on a large scale. We’re really looking at young people from various parts of the country that are undergoing either hormone blocking or cross sex hormones and really trying to say definitively: Is this safe? Is this good for people’s mental health and wellbeing? And really our clinical experience, what we know to be true anecdotally, we need to put onto paper for the United States experience.
[specific parameters of health monitoring in your research?]
So certainly things that are just basic anthropometric measures like height and weight and BMI. Blood pressure, heart rate, things like that. But then we’re also looking at the impact of hormones on liver enzymes, and hormones on hormone levels, and lipids. Things like that where we know from other populations [*see class action lawsuits: testosterone mills-GM] they may be impacted from the use of hormones.
[Dr. Olson-Kennedy refers to  the measuring of liver damage caused by processing high doses of foreign synthetic cross sex hormones, and  measuring the suppression rate of endogenous (innate) hormone production/reception caused by flooding the endocrine system with high doses of foreign synthetic cross sex hormones, and  the increase in cholesterol level elevations caused by synthetic testosterone– GM].
For blockers our real physiologic interest is really about height and bone health [low mineral bone density-GM]. We know that when people go onto blockers they only accrue bone density at a pre-pubertal rate. Which makes sense because they’re not in puberty, that’s what we would expect them to do, but we want to make sure people are not dipping into osteopenic or osteoporotic levels of bone density. That’s a really important piece of information to have. And then, the mental health outcomes are largely what the focus of the study is on, so it’s really about: What are some of the symptoms that young people are having prior to starting treatment and how are they being impacted. What’s happening to some of those, even diagnosis, that young people are coming in with, over time as they’re undergoing hormone therapy. And then also looking at what the experience of parenting a gender nonconforming young person is. And that’s a piece that we haven’t heard enough about.
[what would you recommend society could do to help transgender people?]
I mean, we could make a better society for everyone if we weren’t so committed to, “if you have this assignment or these genitals at birth you have to behave and look like this”. I think we could really change the experience of all humans. I don’t think it’s good for anyone to be boxed in to any specific type of thing. You know, I don’t know what gender utopia looks like. I don’t know if that means no one’s identifiable as any gender or even what it’s gonna mean to be identified as male or female or neither or both in the future. But what I do know is that a lot of the societal constructs that exist today are harmful. And that if we really looked at them and said, you know, our human experience can evolve beyond this. And we can do better. I think that we would be better off. And I think that if we did less sex segregating, especially early on, it would be better. If we didn’t line up boys and line up girls and start sending those messages very early on. It’s really the covert messaging that happens that is harmful to all humans but especially, you know, kids of trans experience. That we’re taught really early on how to “do girl” and how to “do boy” and that if we’re not doing that correctly that something’s wrong with us.
[There don’t seem to be many centers like yours]
I think for trans youth especially you know not nearly as many as there need to be, certainly more and more people are digging into this work and getting excited about it. And that’s, that’s really good. I do think the danger is that people go into the work wanting to do the work but not really having all the resources that they need. I mean even in my clinic, the biggest clinic in the country we are completely resource poor. When I came into the program in 2006 we had 38 trans youth in the program, we have 600 now and the same staff and structure. And we are, you know, we are in danger of having to close our doors to new patients. So I think that having resources in place, and hospitals and academic institutions getting behind this work is really important. Really saying, “this is an important thing to incorporate”. I think what’s really new is that it’s gonna live in the world of pediatrics and adolescent medicine. That is very new for trans care, which has previously lived in the world of adult care. So pediatricians and academic institutions educating people about this is really important. Trans care getting taught in curriculums even in medical school, would be really important. And people just bringing on, at least even for consultation, people who’ve done the work or are experienced in it is really helpful. It’s unique in the sense that, you know, staff, front point people, and front office staff really are going to play in role in the experience that young people have. So cultural competency is really important. You know, if you were going to take on the care of individuals with diabetes you would not have to train your front office staff to use correct pronouns and names. That’s a whole added layer of care that needs to be considered. Because it can be really off-putting right from the outset. It can make a person feel very unwelcome if the first thing they’re met with is being called their birth name if that’s not the name they go by or being called “Mr. so and so” or “Miss so and so” if that’s not right for them. And so that’s an important piece. And really, until we do make some major paradigm shifts in our culture, making sure that young people are aware that there are safe spaces. And that has to be done through posters and signals, and things that people do to make their offices safe spaces.
It’s important for people to know that trans experience has been around since the beginning of human experience. This is not a new thing. There are not more trans people than there ever have been and it’s not because of something we’re putting in our food [laughs].
No. [laughs] It’s not BPA. And so just acknowledging that there is an amazing and rich history that trans folks have. Knowing that history and understanding that, can help people recognize that the trans experience is not something to be scared of. It doesn’t mean people are mentally ill. It’s just an alternative trajectory from a cisgender experience.