In The Den with Mama Dragons
You're navigating parenting an LGBTQ+ child without a manual and knowing what to do and what to say isn't always easy. Each week we’ll visit with other parents of queer kids, talk with members of the LGBTQ+ community, learn from experts, and together explore ways to better parent our LGBTQ+ children. Join with us as we walk and talk with you through this journey of raising healthy, happy, and productive LGBTQ+ humans.
In The Den with Mama Dragons
The Science of Gender with Dr. Jack Turban
Many of our children are more expansive with regard to gender than we would have ever considered in our generation. As parents of LGBTQ+ children, we are invested in having the tools we need to best support them and help them as they navigate the complexity of their gender identity. In this week’s episode of In the Den, Jen talks with psychiatrist Dr. Jack Turban about a range of topics that impact our transgender and gender diverse children.
Special Guest: Jack Turban
Dr. Jack Turban, MD, MHS is a Harvard, Yale, and Stanford-trained child and adolescent psychiatrist and founding director of the Gender Psychiatry Program at the University of California, San Francisco (UCSF). He is an internationally recognized researcher and clinician whose expertise and research on the mental health of transgender youth have been cited in legislative debates and major federal court cases regarding the civil rights of transgender people in the United States.
His research focuses on the mental health of transgender and gender diverse youth, particularly as these topics relate to public policy.. His research has been cited in major court cases regarding the civil rights of transgender people in the U.S., in state legislative debates around the country, and in the United Nations’ independent expert report on conversion therapy.
In addition to his research, he is a frequent op-ed contributor with work featured in The New York Times, The Washington Post, CNN, The Los Angeles Times, Scientific American, and STAT. His new bookFree to Be: Understanding Kids & Gender Identity is now available.
Links from the Show:
- Purchase Jack’s book Free to Be here: https://www.amazon.com/Free-Be-Understanding-Gender-Identity/dp/1668017040
- Jack’s op-eds: https://www.jackturban.com/op-eds
- Jack’s interviews: https://www.jackturban.com/interviews
- On trans women in sports: https://www.scientificamerican.com/article/trans-girls-belong-on-girls-sports-teams/
- Pediatric Gender Identity: Gender-affirming Care for Transgender and Gender Diverse Youth: https://www.amazon.com/Pediatric-Gender-Identity-Gender-affirming-Transgender/dp/3030389081
In the Den is made possible by generous donors like you. Help us continue to deliver quality content by becoming a donor today at www.mamadragons.org.
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JEN: Hello and welcome to In The Den with Mama Dragons. I’m your host, Jen. This podcast was created to walk and talk with you through this journey of raising happy, healthy, and productive LGBTQ humans. Thanks for listening. We’re glad you’re here.
Many of our children are more expansive with regard to their gender than we would have ever considered in our generation. And we gather together because we are invested in having the tools that we need to best support them and help them as they navigate the complexity of their gender identity. And I’m hopeful that some of our listeners might not have children in this category but they’re also interested in learning how to help society navigate and care for this next generation.
Our expert today has such wide-reaching knowledge in this subject, there is zero chance I’m going to be able to ask all the questions that I have. But we are going to try to tackle gender and mental health, sports, medical care, transition, legislation, childhood, and bathrooms all in an hour. I’m so excited about our guest today
Jack Turban MD MHS is a child psychiatrist and director of the Gender Psychiatry Program at the University of California, San Francisco. He is also a frequent op-ed contributor, with work featured in The New York Times, The Washington Post, CNN, The Los Angeles Times, Scientific American, and Vox. He is also a regular commentator on mental health, particularly on issues related to gender and sexuality. And none of that really touches the magnitude of his experience. He is also the author of a book called Free to Be. This is an authoritative deep dive into the science, medicine, and politics of gender identity. Head to the show notes for a link to purchase his book and get a better understanding of the topics that we touch on today. Also, we’re going to link to his op-ed pieces because they were pretty phenomenal. I feel super lucky to be in conversation with him today. So, welcome Dr. Turban, to In the Den.
DR. TURBAN: Hi, thanks for having me.
JEN: Before we dive into all the topics that I want to cover, can we do a little teeny bit of vocabulary right to start?
DR. TURBAN: Sure.
JEN: So when people are talking about gender identity, I mentioned it a few times in the intro, what do they mean?
DR. TURBAN: So gender identity is probably one of the most complex topics in my book. And it refers to our psychological sense of ourselves in terms of masculinity and femininity. As you can imagine, there’s a lot of people who have probably seen, with their kids, this can manifest in a million different ways, right? Because it involves how you relate to gender roles and expectations. There also is some science to suggest that there seems to be this feeling of feeling masculine or feminine that’s hard to put into words. I sometimes call this a transcendent sense of your gender. But you just feel male or female. And then for some young people, there’s also this relationship with their physical bodies where their different sex characteristics of their bodies just don’t feel in line with who they are. So we talk about it a lot more in depth, but it’s just this really complicated way in which we think about ourselves and our masculinity, femininity, or combination of both sometimes.
JEN: Okay. And for the purpose of our conversation today, when you talk about sex, what are you talking about?
DR. TURBAN: So when I say ‘sex’ I’m usually referring to what’s on someone’s birth certificate. And the vast majority of the time that’s based on what a doctor or other health care professional sees when a baby is born based on their external genitals. I always give the caveat that, because I work in the space, for the vast majority of people, their genitals are going to align with their chromosomes. They’re going to align with their hormone profile, their organs, etcetera. But, because I work specifically in this space of taking care of transgender youth and also some youth where not all those characteristics align, there are different medical conditions where, say your anatomy might not predict your chromosomes as well. That sex could be defined a million different ways. But when I say “sex,” I’m just referring to what’s on your birth certificate with this acknowledgement that for some people, that’s an oversimplification.
JEN: Okay. Perfect. Can you talk about the concept – I just think these things are going to come up over and over so I’m trying to be clear from the start – can you talk about gender dysphoria and if that’s the same thing as being transgender.
DR. TURBAN: It’s a little bit different. So gender dysphoria is a diagnosis that psychiatrists give. And it’s defined in this book that psychiatrists use called the DSM that outlines how we define all our different mental health conditions. So, gender dysphoria is when you have a gender identity different from your sex for at least six months and that that difference between your gender identity and your sex is really distressing to you, or creating dysphoria. And that dysphoria needs to be so severe that it’s causing some sort of functional impairment in your life. So, inability to go to school, inability to shower, inability to make friends, and do the things you need to do. Being transgender just means you have a gender identity different from your sex assigned at birth. But, as you can imagine, there might be people who are transgender who aren’t so distressed about their physical bodies and may not have that functional impairment. So they’re definitely related, but technically two different definitions.
JEN: Okay. Perfect. I think the language that we use is really important and I’m hoping you’ll address that. How does the way we talk about these things with our children or in society hold influence on how society views them?
DR. TURBAN: It’s tricky because there are so many different terms and people use them differently. And then it’s just so easy to get confused, first of all. And then it also sadly makes it easy to spread misinformation. So, over the past, I’d say maybe five to ten years, we went from a space where not a lot of people were talking about trans kids. There were both trans adults and trans kids around and they were being cared for and usually even in small rural communities, when a kid would come out as trans, you really knew that kid. So the whole community would rally around them and learn and figure out how to support them. But things changed, right? So now people who don’t interact with trans people at all are talking about this in the political realm and really taking advantage of how a lot of the terminology is confusing to scare people, right? You’re hearing gender ideology. I actually don’t know what that means to this day. That one’s just a political term. You’re hearing people say that kids are being mutilated and sterilized, all these really scary things. People will inflate being transgender with having gender dysphoria and getting medical interventions, right? Just all of these kinds of nuances that are really important and the language where if you don’t understand them, it’s really easy to mislead people and scare people.
JEN: All right. Before I get into the nitty gritty of all the topics, I want to hit something that I hear over and over and over again. Statistics do seem to indicate that the number of people identifying as trans or non-binary or gender expansive, these numbers are growing. Do we know why?
DR. TURBAN: The numbers are growing, but I think it’s important to know that the numbers are still very small. So even with the latest CDC estimate, which said maybe around 1.9% of kids identify as trans, it’s still a very small number. So it’s increasing, but you’ll hear this exponential increase or this huge social contagion or like it’s this huge number of kids. It’s still a relatively small number of kids. And there are a few different things, I think, going on. It’s hard to know exactly the degree to which different ones are playing roles in terms of the numbers and statistics. But I can tell you one thing that’s definitely happening is people are talking about gender more so there’s a little bit less stigma. So kids who are transgender, they’re seeing transgender people on TV or they’re hearing about on the news and they’re thinking, “Maybe this is something I can talk about, I can tell people about. It doesn’t have to be a secret my whole life.” I take care of a lot of trans kids. I also take care of a lot of trans adults in one of my other clinics. And a lot of those trans adults were horrified to tell anyone they were trans until they were sometimes 30, 40, 50. So young people aren’t feeling like they need to hide it as much. And that’s definitely why we’re seeing more people openly being trans. There’s another thing happening, though, where younger generations are thinking about gender in a much more complex, nuanced way than my generation did and older generations did. So in the past, people, when they came out as transgender, it was probably mostly people we say trans in a binary way. Like, my sex is male but I identify as female, and I have gender dysphoria and I want medical interventions. Like this intense difference between your gender identity and your sex. But some young people are thinking about gender in this more nuanced way and saying, “You know, I don’t totally relate to what’s expected by society in terms of femininity. I don’t relate to a lot of that. So to express that, I’m going to say I’m nonbinary because I don’t feel totally male, I don’t feel totally female and I reject these social categories or gender norms. And they might still consider themselves under this transgender umbrella. But that’s really, really different from that other type of kid, right? That kid’s not going to want medical interventions. That kid’s not going to get puberty blockers, not going to get hormones. Whereas, that other type of kid might really benefit from that. So that’s been another thing people have been using, I think, to scare people is implying that that 2% of kids who are trans, all those kids are going to be rushed into medical interventions and hormones when in reality, it’s a very small fraction of those kids who are the types of kids who actually get those medical interventions.
JEN: Fantastic. I actually want to talk next about medical interventions and just kind of break it down a little bit. So if we think of the big term that’s used is “Gender-Affirming Medical Care.” So if we’re talking about that big umbrella term, what does that mean?
DR. TURBAN: So gender-affirming medical care means any medical intervention. And I can walk you through. It’s really important to know that different interventions are considered at different stages of development, so kind of how far a kid is.
JEN: So can I interrupt for one second to be clear. Like, if I get estrogen for menopause and testosterone because my testosterone is low even though I’m a cisgender woman, in the medical world, do they still consider that gender-affirming care? Or is that term uniquely used for trans kids?
DR. TURBAN: So I would say most people use it for trans kids. But you’ll see it is sometimes used that way in the medical literature.
JEN: Okay.
DR. TURBAN: So, there was a paper recently that was looking at gender-affirming surgeries with that phrase they included both people who were trans men who were having removal of chest tissue to feel more comfortable in their bodies. But they also included cisgender men who have breast tissue from all sorts of different medical conditions who are having similar surgeries. And they called that gender-affirming care also.
JEN: Okay.
DR. TURBAN: So some people will use it to mean broadly any medical or surgical intervention that makes you feel more in line with your gender, which can happen for cis people as well as trans people. But I’d say 95% of the time or more we’re talking about trans kids.
JEN: Okay. So one of the most common misconceptions I hear about this care for kids is that children, particularly tomboys – everybody suddenly trying to protect the tomboys – are being rushed into transition. What are the actual recommendations for these interventions that happen? Are there people who are being rushed?
DR. TURBAN: No. So if anything, I hear complaints from my patients that we’re really slowing down the process and making it hard for them to access these medical interventions. Because under the current guidelines, there are two main ones you’ll hear about, The Endocrine Society guidelines and the Standards of Care from this organization called WPATH. They’re pretty similar to each other. Both of them say that you need to have a comprehensive mental health evaluation before you can access any medical intervention as a minor. So you would have to come see a psychiatrist like me or a psychologist and really talk about things in detail. You go through your history of gender and how you’ve thought about yourself. We screen for if you have any other mental health conditions. There are certain situations where that diagnostic process gets extended. So for kids who have autism, for instance, where it takes a little bit more time to explain things to them because they have more rigid thinking, or for a young person who came to think they were trans more recently – like let’s say in the past six months as opposed to five years ago – that might slow things down also. But it’s really a very slow, methodical process that’s very conservative. And, if anything, becoming more conservative given the political atmosphere of really understanding this young person holistically and are medical interventions right for them or not? Also, are there nonmedical interventions that they need? Do they have other mental health conditions that we need to support? But you need to have that holistic mental health assessment under current guidelines before you can access any medical intervention.
JEN: And you are doing the mental health side of things. Do you want to just touch on the physical sorts of things that are recommended for these kids?
DR. TURBAN: Yes. So, for prepubertal kids, no medical interventions. The guidelines are very clear about that. Those young people might do something like try a new name or a new hair cut or new pronouns to explore, and the role of the mental health team is to make sure they’re not bullied, make sure their self-esteem is intact, make sure they can explore those things in a safe, nondirective way. The earliest medical intervention you might consider is a puberty blocker. And that can be considered around the early stages of puberty. We call it Tanner II puberty, so just when puberty is starting. The thing that’s nice about these medications is they put puberty on pause so the young person or teen/adolescent doesn’t have all this anxiety and distress about puberty progressing. Which, you can imagine, if you’re a trans kid is horrifying because it can’t be undone, right? If you are a trans girl – which for all intents and purposes think of yourself as a cisgender girl – who is told “You’re going to go through testosterone puberty. Your voice is going to deepen. You’re going to get facial hair. You’re going to start to look more and more male.” You’re a young girl, that’s scary and none of those things can be undone. So it’s a really nice option for trans kids. They can just put that on hold, take your time, work with a therapist more to decide what next steps are. In the rare instance that a young person says, “You know what, I’m actually not trans. I want to go through…” – or sometimes they’re nonbinary or whatever. It can be more complex – and they decide they want to go through their birth puberty, you can stop the medicine and they’ll go through the puberty they were going to go through otherwise. So it’s kind of this nice pause button on puberty progressing.
Later in adolescence you might consider estrogen or testosterone. So these are irreversible medications that do cause physical changes that can’t all be undone. Some of them might change a little bit like body fat redistribution could be reversible. But, voice deepening, for instance, is nearly impossible to reverse. And so that's a much bigger decision. You need to have another one of these comprehensive mental health evaluations before starting that. Traditionally that’s considered something you could do around age 16. But the latest guidelines do acknowledge that there can be circumstances where you would want to start earlier in the teen years, so sometimes around 14 or so. But, again, it would be when the clinical scenario makes sense, right? So if you have a kid who has really complicated mental health concerns and the kid’s not so sure about their gender identity being stable. And the parents aren’t so sure and they feel like there’s a possibility they might change their mind, that’s probably not a kid you’re going to start estrogen or testosterone on the earlier side. But, if you have a kid who’s been very clear that she’s a trans girl since she’s five, she got her puberty blocker when she was ten. Puberty blockers last, if you do the implants that can be removed, they still only last one or two years. So maybe she’s on her second puberty blocker and she’s now 14 looking at you saying, “Ddo you really think I’m going to start thinking that I’m a boy? Why are you making me wait when all of my peers are going through puberty and I’m stuck in this prepubertal state?” that that’s a situation where you could consider starting hormones a little earlier.
JEN: Okay. And then what about surgery?
DR. TURBAN: So genital surgery is generally reserved for adults, so 18 and up. You will sometimes hear rare circumstances – and again, this would be a case that would have to be very, very clear that it makes sense – where you’ll have somebody maybe have their vaginoplasty when they’re 17 before they go off to college so that they can have their healing before they start school, so they don’t have to take time off school because it’s a pretty big surgery. It’s not a small decision. The recovery time can be substantial and really disruptive if you try and do it freshman year of college. Phalloplasty, so surgical construction of a penis, a much less common procedure than a vaginoplasty. I’ve never heard of that being done for someone under 18. More commonly you might here, mostly trans boys, have chest surgery as minors. But, again, that is a much bigger decision than puberty blockers or hormones because it’s a surgery and surgeries have risks. So occasionally there might be a young person who has really severe gender dysphoria, say they’re so distressed by their chest that they can’t shower or they’re binding their chest and having chest pain, or it’s just becoming very clear that it’s not sustainable to not have the surgery. You might sometimes have that surgery before 18.
JEN: So a lot of our listeners, including myself, live in states where it’s no longer legal to access any of this care for their children. So, for those who are unable to access care, medical care or who are not really interested in accessing medical care, what are some other options that exist for treating gender dysphoria?
DR. TURBAN: This is a new circumstance. So we’ve not been faced with this until relatively recently. Even as a lot of states were passing these bans, they were being challenged in the courts as unconstitutional and most courts were ruling, yes, in fact, it is unconstitutional to ban this type of medical care for this one condition. But, as you’ve seen, things have changed and some of the appeals courts have overturned those decisions and we’re seeing that states are starting to not have this treatment available. Sadly, there aren’t other evidence-based treatments for that physical gender dysphoria. If you are distressed that your body doesn’t align with your gender identity, I don’t have a talk therapy to fix that. We tried it within psychiatry, not me, but my predecessors, to do all these different therapies to try to get young people who are trans to identify as cisgender again. But they never worked and we published a study in 2019 – it’s relatively recently so this is somewhat new information – finding that exposure to that therapy to try and push kids to be cisgender is linked to bad outcomes including suicide attempts if they continue to be trans later in life and there’s no evidence that they can be successful in making the kid cisgender. If there are other mental health things going on, like if you also have major depressive disorder or generalized anxiety disorder, we have evidence-based treatments for that and psychiatric medications for that where you can try and kind of help with everything else. But, sadly, for some of these kids, at the end of the day, the problem is that physical incongruence and there's not a lot that you can do. There are other things that predict good mental health outcomes for trans kids, like having a supportive parent. So reminding your kid that you love them and accept them and being a mama bear to make sure there’s no bullying at school and comes down hard on the school if they’re being bullied and they’re not doing anything about it. All of those things can help also. But it’s a tough situation with the medical treatments being banned that for the kids who need them, we don’t really have great other treatments to help them. The Supreme Court is taking up the question soon, so we may know in the relatively near term if those bans will all go away. That being sad, it’s going to be a long time for all these hospitals to start their programs up again. So the sad reality is we’re seeing a lot of families move, actually. If you have the type of kid – and, again, some trans kids don’t have physical dysphoria and are okay and don’t need it. But for the kids who really do need that medical care, we’re seeing a lot of families, many of them can’t afford it, to be honest, or are desperately selling their houses, doing what they can, and moving to other states.
JEN: So one hesitation that I see come up from parents a lot when it comes to gender-affirming care, there’s this idea floating around largely being promoted in our legislatures that once you start affirming gender or you start therapy that affirms gender or any sort of anything that supports the idea of transition, like for example if I let my kid cut off their hair and use he/him pronouns, I’ve set them on this path that’s kind of like a conveyor belt that will lead them to the inevitable complete and total medical and legal transition. And is there a reason to be cautious about this?
DR. TURBAN: This is another place where I think it’s important to understand terminology because it turns out gender-affirming care is not a good term because it’s a little bit misleading about what it actually entails. So if I have a kid who comes to me who says they are trans or they’re questioning their gender, I’m not sitting down with them and saying, “You are trans. Let’s start this social transition and then you’re going to get puberty blockers, and then you’re going to get hormones.” It’s really all this, we sometimes call it exploratory therapy, where we’re not pushing you in one direction or another. So we’re not pushing you to be cis. We’re not pushing you to be trans. But we’re having you explore so you can understand what’s right for you. So no one is ever sitting down with a kid – at least that I know of, I certainly am not – and telling them, “You need to cut your hair and use a new name and pronouns.” We’re not pushing people down that path. But if they say, “It’s really important for me to try this.” Then I will facilitate helping them try that and making sure that they’re doing OK as they do so. The question has been raised about whether or not allowing a kid to use the new names and pronouns makes them more likely to continue to be transgender later in life. There’s a really cool study that no one ever talks about by Christina Olsen who’s this psychology professor at Princeton. She’s a McArthur Genius Award Recipient, brilliant psychologist, where she looked at this question of whether or not a social transition makes you more trans, for lack of a better word. And she found it does not, but rather the kids who socially transition are the ones who are quite trans to begin with, if you will. They have a strong disconnect between their identity and their sex. So for social transition, there’s not any evidence that that is going to make you more likely to continue to be trans, if you will. And also, even if you socially transition, you don’t have to do any medical intervention. So I have kids who are trans who say, I’m actually pretty okay with my body. I don’t need puberty blockers. I have a story like that in my book. Sam, who doesn’t fit into gender boxes, identifies as nonbinary, does go through some social transition exploration, never identifies as cisgender but says, “I’m actually okay with my body. I don’t need these medical interventions.” And that’s fine. We have plenty of kids where we support them through that process. Other kids, though, they have that severe distress about their bodies and they’ll eventually have blockers or hormones.
You’ll sometimes hear people say, “Well look, 95 – 98% of kids who start puberty blockers go on to hormones. Does that mean puberty blockers made them more trans?” There’s not a good research study looking at that question specifically. But what most of us think is more likely is we do this really rigorous screening process before they’re allowed to start the puberty blockers, so we’re pretty certain that they are trans to begin with. And we’re giving the treatment to the patients that we think are unlikely to change their mind in the future. So, that’s probably why the continuation rates are so high. But there’s not like a good study for that one.
JEN: Okay. I appreciate all of that. I’m going to jump a little bit to mental health. You touched on it before. But the rates of anxiety and depression are proportionally higher in kids who also experience gender dysphoria or some of that incongruence that you talked about. Can you address how that’s all connected because sometimes the argument is made, “You can’t trust them about their gender because they’ve got all these mental health issues.”
DR. TURBAN: That’s part of why we have this holistic assessment to figure out what’s going on. I’ll tell you the most common thing that we see is that the young person is trans, and then everyone is awful to them because they are trans, because we’re not accepting of trans people, right? They’re bullied. They’re reading all these things in the news about how trans people are dangerous or mentally ill or bad or dangerous to people in bathrooms. It’s really awful to see and it’s been getting worse lately, that I have patients who even live in places where it’s pretty accepting. I live in San Francisco. In The Bay Area, you’d think it would be pretty accepting. But I have kids that are horrified to come out at school because they’re seeing other kids getting bullied or there was a hate crime in their neighborhood or somebody went and tore down the pride flag at their school. There’s this kind of rise in anti-LGBT sentiment generally. And it’s not surprising that makes you more anxious and depressed, right? That being said, it’s a cautious field of medicine, before you can access these medical interventions, we screen for any other mental health conditions you might have. And then part of the diagnostic process is, seeing is this gender dysphoria or is this like a very unusual manifestation of something else? Could this be body dysmorphic disorder towards one’s genitals, for instance, very, very rare but a thing that happens. Psychiatrists are trained in knowing the difference between those things. so we differentiate them. But obviously the most common thing is these kids are more anxious and depressed because people are treating them poorly.
JEN: OK. So you touched on this before, but I want to talk about the why a little bit, if you know. So, as I talk to young people, especially my own child and their friends, one of the things that keeps coming up all the time is just the way we talk about things and world view. Younger people don’t seem to think about gender in this binary way that older generations do. And you touched on how this is true. But I’m wondering if you have any ideas about why?
DR. TURBAN: Why it’s different, that’s a good question.
JEN: Why did this evolve like this?
DR. TURBAN: This might be a better question for maybe a sociologist or a historian. But I can tell you my general view is that over the past several decades we’ve been talking about gender in a lot of different social movements, right, like through feminist movements, through LGBT movements. So, I think it’s things people have just been talking about more. And over time in social structures there’s been less of this expectation that you need to fit in this rigid gender box. I think a lot of cisgender people can relate to that, too. Let’s say you’re a cisgender woman but you were told you can’t be an executive because women don’t do that. Or you can’t play football because women don’t do that or it’s going to make you unattractive, you know all these ways that we were told that we can’t be ourselves. The same thing with young boys. You can’t like the color pink or you can’t like having friends who are girls. And over time, I think people have just been less interested in agreeing to abide by those rules that they have to live in those gender boxes. And they’re thinking about it more. We also, my generation, certainly the generations before me, we kind of had the fear in God of us about breaking those things. Like you would never dare say that you wanted to break gender norms because you were going to be bullied, your parents were going to be mad, there were going to be serious negative consequences if you so much as [inaudible] that. But there’s not as much of that fear in the younger generation, so they are talking about it. But that creates all this generational confusion, right? Because older generations, like you would never think about being nonbinary. You would never call yourself self nonbinary because you don’t fit into gender boxes. But younger people say, “This is how I talk about myself. This is how I’m expressing to you that I like both masculine and feminine things.” But then the older generation is like, “Whoa, are you trans and need medical interventions? Are you saying you want surgery?” And all these things are such a huge, disconnect when people are talking right past each other. So that’s why I wrote that op-ed in the New York Times recently that kind of gives this three-part framework for gender. It’s in my book also. And I encourage families, and I take care also to read the chapter that talks about that so that everyone can be talking about the same thing and not talking past each other because it’s just so common that different generations think about gender differently and then they’re not hearing each other and it turns into big fights.
JEN: That was perfect. Thank you. Before I leave my little section on mental health, I wanted to just propose an example. You have a client who comes into you with their parents, who’s expressing some sort of confusion or distress with their gender. What are the most essential things that you’re hoping parents understand before they leave those first couple of sessions?
DR. TURBAN: The number one thing that I try and get out right away is that it’s very normal for parents to be scared and have concerns and not be super excited about medical interventions. There are a million reasons to be scared. That’s all normal. And it’s really important that the parents have a private space, not in front of their kid, to talk through that. You don’t want to be sitting in front of your kid – your kid may or may not grow up to be trans. But let’s say your kid does grow up to be trans. And you, in front of them, were thinking through things out loud and said things like, “Oh, but don’t all trans people grow up to have horrible lives? Don’t they have high suicide rates? Won’t you never be able to get a job? Will you ever be able to find love?” These are things that come to parents' minds that are genuine scary things. But if you say that in front of your kid, I can tell you I have patients who are now in their 40s where that comment from their parent decades ago, that wasn’t their parents final thought, it’s not what their parents think now, sticks in their mind and impacts them. So I always offer to parents to have a separate space where I just meet with them where I want them to word vomit all their concerns and I’m going to validate that that is a normal parent reaction that I hear all the time. And then we can talk through it and I can give you information and then you can have your final thought that you take back to your child, that’s like your well-formed thought of what you literally mean.
JEN: Fantastic. We always encourage people to find peers for that too, like our support groups where parents are talking to each other and hashing out those fears. You can kind of panic in a group of people who get it and protect your kid from hearing some of that panic.
DR. TURBAN: Yes.
JEN: Okay. I want to jump to sports. The Olympics are just wrapping up and so there’s been a lot of extra gender in sports conversation. But you actually wrote an op-ed that I have been sharing for multiple years now about sports. And I’m hoping that you’ll just touch on that for us, the idea of trans kids in sports, this idea that there’s this epidemic of trans women, dominating women’s sports and what we need to do to solve that problem. How should we be thinking and talking about this?
DR. TURBAN: This makes me so sad because there just are not a bunch of trans women taking over sports. So in the Paris Olympics there are zero trans women competing – Zero. In the last Olympics, there was one trans woman who qualified. Laura Hubbard. She’s a weight-lifter. She lost her very first lift. She was not dominating the women’s category. And yet, this idea will not die. People truly think that trans women, they’re just like a ton of them taking over women’s sports and that women aren’t winning anymore. And then, they’ll say, “But Leah Thomas!” And you’ll say, “Yes, who else?” It’s basically Leah Thomas. And the way I think about it, and for full disclosure, I’m on the NCAA’s committee on competitive safeguards and medical aspects of sports. We have our own policy if you’re a trans woman competing in a women’s league, you need to suppress your testosterone to a certain level depending on the certain sport or a certain amount of time. So we do have rules around it. But I’ll be speaking as myself, not necessarily the committee. In the way I think about it is why are we creating rules to restrict trans women for sports when they are under-represented in sports titles. My philosophy is that trans people should be allowed to win sports titles proportional to how many trans people there are. That seems fair to me. And the reality is they’re under-represented in sports titles relative to how many of them there are. And to raise the question of why, right? It kind of suggests there’s not this huge biological advantage or else they’d probably all be out there winning, taking all the titles. But they’re not. So why aren’t they? And I think it’s because they have the deck stacked against them in a million other ways, their high rates of anxiety, high rates of depression. You’re dealing with stigma. You’re probably horrified to join the team to begin with. let alone join and be comfortable enough to really train and succeed at the level you’re going to become an elite title-winning athlete. So could there be a day in the future where all of that goes away and there’s not stigma against trans people and they have a level playing field in every way except their testosterone levels? I certainly hope so. I think that is the time when we should start restricting their access to sports. I don’t think it should be now when they’re underrepresented and one of the most marginalized groups in society and we’re going to bring more barriers to them living happy, thriving lives. I personally don’t think that makes sense.
JEN: This is just a personal curiosity. But how many of your clients do you think are even interested or have tried to participate in sports?
DR. TURBAN: Oh, almost none. Some, I have some patients who run track, play soccer. But I’ll tell you, it’s become a not fun experience for them because they don't want to win. They’re like, “God forbid I win anything because then it’s going to be this huge story.” I mean, it’s just so far disconnected from reality. Politicians have created this idea of trans people as these nefarious people who are winning everything in society and plotting to take over women’s sports. I can promise you that’s the last thing on the mind of any of my young trans women patients. They are trying to get through school, go to college, and not be bullied and harassed and physically attacked. That’s not where their focus is.
JEN: Yeah. Absolutely. So, I’m old. But I went most of my life without ever hearing about transgender children in politics ever. One of the most frustrating things to me is when they use the word, “Science” as they politicize the topic. But, stepping even back further from that, why do you think these kids are the target right now of so much political ire in conversation? They’re so benign. It’s so small and they’re so innocent and they’ve got this huge bullseye in every conversation.
DR. TURBAN: Well, I’ll give you one quick story that’s maybe interesting and hopefully not too much of a tangent. But that was my background too, right. There were no gay people out in my high school let alone any trans people out when I was growing up. So I didn’t know any trans people growing up. The first time I met trans people was when I was in medical school. It’s because I was doing a journalism project about trans people. And you know, I think that’s the experience for a lot of people because a lot of trans people weren’t coming out for the longest time and also they didn’t feel safe in a lot of communities so they had kind of their own communities. There wasn’t a lot of interaction. When I was at Yale, I created a curriculum for medical students teaching them about trans youth and gender-affirming care. And we tested their knowledge before and after. And their knowledge improved after the lecture. But we said, “Do you think it’s a good idea to give these young people these medical interventions?” And even though they knew the studies showed improvements in anxiety and depression, the percentage who thought it was a good idea to give them the treatment didn’t increase after they learned that.
JEN: What?
DR. TURBAN: Interesting. And so then, we had a young trans girl who volunteered to come talk to the medical students. Who sat there, she was 13 or 14 at the time. She had a puberty blocker and was explaining why this was important to her. And I can tell you all the medical students came up to me after and said, “I’m so embarrassed. I can’t believe I ever thought I was against this child’s medical care, like taking it away from them or making this poor kid’s life harder. This is just a little middle school girl that’s trying to live her life and this is important to her and has made her life better.” And so it happens all the time that if you meet a trans kid or if you have a trans kid – often your perspective changes because it’s like what you’re saying. You see these are not scary people. These are little kids. Why are politicians focusing on it? You know it’s interesting that I’ve noticed there’s a lot more interest in this among Republicans than Democrats. The Democrats don’t talk about it a ton. They generally support trans kids, but they’re not talking about it very much. Republicans are talking about it constantly. And the reason I think is that they’ve developed effective scary rhetoric that scares people and gets them to vote. They have these phrases like mutilation of children, indoctrination of children, that scares people and gets them to vote and so they’re going to talk about it more because it rallies their base of voters which is sad to me. I’d like to think maybe some of it they truly believe because they don’t know trans kids. But part of me thinks it is kind of a – I don’t want to use the word “evil”—but kind of a dark thing to be using kids because you know it can get people to vote for you even if you don’t think the laws are the right thing.
JEN: It is such a tricky thing because you’re talking about how if you meet trans kids you’re more likely to understand and be empathetic and compassionate. But we have this group of parents and the last thing you want to do is expose your kid to some of the hateful rhetoric and the people who are speaking it the loudest. So the isolation of your kids makes perfect sense to me as a mom. You’re trying to isolate them from the hatred. But also, without the exposure, I’m not sure exactly how we go about changing minds. If we can talk them into watching YouTube videos, I guess.
DR. TURBAN: Yeah. I mean, if you watch the state legislative debates you'll see it’s mostly cisgender people of older generations talking about this and there’s not a trans person in sight, certainly not a trans kid there to explain to them why this is important. And to your point, of course there’s not. What parent is going to take their poor kid to throw them in the middle of this heated discussion. There are some very brave kids who want to do it and props to them like Kia Shapley who’s gone and testified who’s spectacular. Nicole Maines is another great example. She’s now a TV star, interestingly.
JEN: There’s some amazing kids out there for sure.
DR. TURBAN: But when she was younger, she went and testified in the Maine State Legislature about a bathroom bill. I will say there’s another interesting thing. I read about this in CNN a while ago where you notice there’s a parallel between some of the anti-LGBT strategies in the 90’s and what’s coming back today. So this interesting thing that happened in the 90’s, I think it was in Colorado. I think it was amendment one or amendment two. But basically, a bunch of cities in Colorado were passing laws to protect LGBT people from discrimination. And there’s a tiny group of people who didn’t like that because they thought that LGBT people were a threat to the way they think about how the world should be. But they knew they were kind of losing because all these states were passing laws to protect LGBT people. And so what they did was they did a ballot initiative to change the Colorado constitution to make it illegal for a city to pass an anti-discrimination law. And they had two strategies that might sound familiar. Their first public education campaign was to call LGBT people dangerous pedophile groomers. Which you’ll notice has been back.
JEN: I was going to say that sounds familiar.
DR. TURBAN: Of course there’s no evidence, but it sounds scary, right? That’ll get people to vote especially if they’re not people who are going to go bother to read about it because they’re not personally invested or they think their personal investment is affecting their child. And then the other thing was they came up with this slogan and it was “Equal rights. Not special rights.” To make it sound like anti-discrimination laws were giving LGBT people special rights. That’s not what an anti-discrimination law does, right? It just makes it so you can’t disenfranchise one population. But that didn’t matter because it was catchy, right? “Equal rights. Not special rights.” And I was also at the time that civil rights people were hitting a wall with Affirmative Action. So they knew that majority white populations were in favor of civil rights until they felt like something was being taken from them, like Affirmative Action. So this “Equal rights. Not special rights.” Is like LGBT people are taking something from you. So that was their strategy and they won. They changed the Colorado constitution and it became illegal to pass anti-discrimination laws for LGBT people until much later the Supreme Court overruled it. But it’s back. You were just saying the groomer, LGBT people are dangerous to kids thing is back. And then I think the sports thing might be the “Equal treatment, not special treatment,” right? It’s trying to plead this idea that trans people are taking things from cis people, like they’re taking sports titles from cis women even though it’s not really happening. So my cynical side thinks a lot of this is actually very clever political strategy.
JEN: Just kind of regurgitated and recycled back at us again.
DR. TURBAN: Yeah.
JEN: You think we would learn.
DR. TURBAN: But, I mean, I didn’t know about this thing from Colorado in the 90’s. So maybe they knew most of us wouldn’t. That’s why I wrote the Op-Ed so people can now hopefully know.
JEN: Yeah. So when I was thinking about this question, I was like, this could be a whole hour discussion because I’m very interested in the idea of social construction and deconstructing and reconstructing things that better fit. And I keep seeing all over the place this idea that gender identity or gender is a social construction. I’m not positive I 1,000% agree. But I do agree. But I’m hoping you can talk about it in smarter ways and help me even understand my own thoughts better.
DR. TURBAN: Yes. Full disclosure, this took two whole chapters of my book. It is a fascinating question. It’s like the Nature vs. Nurture question of gender, if you will.
JEN: Yeah.
DR. TURBAN: How can I make this brief? I can do it. I promise.
JEN: You’re good. It’ll be awesome.
DR. TURBAN: So I would say the story goes back, in my mind, to this person named John Money. So John Money was a doctor who was working with intersex kids. Remember when I was saying earlier that for some kids their chromosomes don’t match their anatomy, doesn’t necessarily match their hormone levels? Turns out there are a ton of different medical conditions called Intersex conditions or disorders of sexual development, differences in sexual development. All different terms where those things don’t all neatly align. So that was his area of expertise. And he was doing this and he found in his limited research that if you had half those kids and you told the parents to raise them as boys and half those kids you told them to raise them as girls, it worked. It seemed to him that it worked out, right? If you just tell them they’re boys or girls and create a social structure around them that they’re boys and girls, they will identify as boys and girls. Gender identity as a social construct. He had that idea around the same time that feminism was on the rise. And, as you can imagine, that was a really appealing philosophy for feminists. Gender is entirely a social construct so we should have the same rights as anyone else. I would say modern feminists think about it a little bit differently. Men and women may have differences, but we should still have equal rights. It doesn’t matter if there are some of these differences that don’t impact our ability to be CEOs or whatever, or vote. But, at the time, that was a very useful idea. So his theory, scientific ideas, really took root in popular culture. And then it was this widespread notion that gender was a social construct. He, interestingly, got a letter from this family who told him that they had identical twin boys and one of them had a horrible accident during circumcision and his penis was burned beyond repair. He thought this was perfect, scientifically, because these are identical twins. So their genes are the same. “I’m going to tell the parents to have the one child have a vaginoplasty and raise the kid as a girl. And because gender is a social construct, that child will just identify as a girl, another one with the same genes that identifies as a boy and that will prove my theory.” He published for years that the experiment was working. But it turns out he was covering up that it didn’t. So the young kid who had the vaginoplasty had gender dysphoria. It was interesting, right? This was like a cisgender kid with gender dysphoria because born male was kind of raised socially to be female, but still felt male the whole time. So had this awful gender dysphoria – I’ll say – his whole life even though being raised as female and then very sadly, ultimately passed away from suicide and then a journalist uncovered the whole thing and it was this huge scandal and this really important lesson in psychiatry or psychology that gender is not just a social construct. As convenient as that may be politically in a lot of ways, it just isn’t or else his experiment probably would’ve worked, right? And then we’ve had more and more research suggesting that transness has this innate biological basis. I won’t bore you with the fine details. But suffice to say there are experiments you can do with identical twins and non-identical twins to figure out the degree to which transness is genetic or innate. And they determine around 70% it’s a thing. So there’s something going on in your brain that is innate and inborn that is your gender. And that is a thing, that again, I call this transcendent sense of gender. It’s hard to put into words, but it’s a feeling of maleness or femaleness. That being said, to your point, gender is also a social construct. It’s like a “Yes, and.” So the way I think about it is that you're born with this gender feeling that’s hard to put into words. And then you’re exposed to society and culture where you ascribe language to your gender identity. You relate to some gender norms or not others and then you build this complex sense of yourself that’s gendered. And that’s how young people think about it, right? It’s like this really complicated nuanced thing that’s like this combination of this feeling that’s hard to put into words, and how you relate to all these societally constructed things. And then that is your gender identity. It’s way more complex than just male or female if you will.
JEN: Yeah.
DR. TURBAN: So I wish it were a simple answer. But I will say it’s not just a social construct but there are social influences on how we think about ourselves and our gender, for sure.
JEN: I actually love the complexity of it all. And I love that the next generation is tackling the complexity of it. I find it all fascinating.
DR. TURBAN: They’re all over it. It’s a funny thing because there’s this idea in the political realm that the kids are the ones who are confused about gender and the adults are the ones who understand it. But really, my generation and older generations were taught not to think about it too hard. We really didn’t think about it much.
JEN: Exactly.
DR. TURBAN: And they’re thinking about it in this really nuanced way that’s interesting.
JEN: Okay. So, statistically, there seems to be more instances where the individual was assigned female at birth. Do we know why that is?
DR. TURBAN: Hum. That may or may not be true.
JEN: Oh, correct me, for sure, if I’m wrong on that.
DR. TURBAN: You’re definitely on to something. So there are a bunch of studies from gender clinics. So the clinics where young people are seeking medical interventions where it does seem that there has been a shift towards more people assigned female at birth than assigned male at birth. But I, time flies, I guess that was a few years ago now. I was looking at the CDC’s data where they’re not looking at kids who go to gender clinics, but just the general population of high school students. They interviewed the kids in school. And in there, it was pretty close to 1:1 trans assigned males to assigned females.
JEN: Interesting.
DR. TURBAN: And if anything, it actually seemed like there may be more people assigned male at birth. It’s a little tricky because, their data function, they don’t use the best way to ask about sex and gender. But I mean, it’s pretty close to 1:1; it’s hard to argue with.
JEN: So does that just mean more girls are seeking care?
DR. TURBAN: That’s what it seems like.
JEN: Or more identified female at birth, I guess.
DR. TURBAN: Yeah. So there are all kinds of theories about this. The republican – I hate to call it that – theory is that it’s like a social contagion and that people assigned female at birth, girls are more susceptible to peer pressure and social influence and so they’re like being tricked into being trans is the idea.
JEN: As a girl, that feels a little offensive to me.
DR. TURBAN: I always thought that way. It is a little offensive.
JEN: Like I’m more easily duped.
DR. TURBAN: Manipulatable, lady-brain theory. I think it’s pretty offensive. But if that were true, wouldn’t you expect to see that in the general high school population, not just in the medical clinics? So I don’t so much buy that theory. But people have different theories that maybe the medical interventions are more interesting or appealing to trans boys because they can get things like menstrual suppression. That’s the one medical intervention that you don’t need a psychological evaluation for because we prescribe to cis kids all the time. And that’s appealing and works really fast. Testosterone also works a little faster than estrogen. Estrogen takes a really long time to work. There’s also a lot more stigma for trans girls to seek medical care than there is stigma for trans boys to seek medical care, interestingly. So it is a true phenomenon that we’re seeing that in the medical clinics there's more people assigned female. But, it doesn’t seem to be true in the general population. And I think we’re still piecing together what exactly is happening there.
JEN: Interesting. I want to have conversations about misogyny and sexism and how all of these things play in. But I’m going to stay on topic. We have a lot of parents in our groups that talk about how they’re trying hard to be affirming. They’re doing all the things. They’re taking their kids to the appointments. But their kids are so mad at them. The kids are just genuinely angry with their parents. Is that something you commonly see in your practice and how do you address it?
DR. TURBAN: I do commonly see it. And this is why I think it’s so important to have spaces for both the parents alone and the kids alone. That there can be all kinds of things underneath that. One thing that I’ve learned from trans kids over time is that misgendering – using the wrong name or pronouns – on one level, that hurts because it feels like they’re not being seen for who they are. But often, it’s actually a lot of other stuff that’s going on at the same time when that happens. Like, when you use the wrong name or pronouns, you may all the sudden become the bully in school who threw them into a locker and was really awful to them, right? Or you might become like the person on social media who’s saying really hateful things about trans people. It might bring up all those scary feelings about how the world hates trans people and you’re like, “Oh great. The one person who I thought is my greatest protector, who’s going to love me and support me, my parent, is saying the things that the scariest people in my life are saying. Oh my God. Is my parent that person?” Often, the parent’s not. But you can see how the parents going through their own process of just understanding, this is new to them and they’re trying to wrap their head around it. But you can see why the kid maybe still feels that way. And so it’s nice to have a neutral – that can be a hard discussion for the parents to have with the kids to each other. So it’s really nice to have a therapist where I can get the parent’s perspective on what’s going on. I can get the kids perspective from what’s going on. And then an effective family therapist can kind of bring everyone together and turn to the kids and say, “Listen, I’ve heard your mom and I really, really think she is trying. And I can understand why for you it feels like she believes these awful things that are being said about trans people because she’s going through her own process of wrapping her head around this. But I can tell you, I really genuinely think your mother loves you and wants what’s best for you and is trying to support you and understand this.” And then I can explain to the mom, “I realize from your perspective it seems like your kid is biting your head off when you’re trying your hardest. But I was talking to your child and she told me the reason this is so hard is because it’s bringing up all this other stuff. And she’s just worried that you’re not going to accept her because she’s heard all of these stories of kids getting kicked out of the house or whatever.” And often, there’s a coming together that can happen, I would say almost always.
JEN: Almost always feels hopeful. So this might be another big one. But can you address the topic of trans-inclusive bathroom policies and bathroom safety. Again, I’m in a state where all of a sudden, schools are not allowing kids to use the bathrooms where even the staff at the school might know the children are the safest. Can you kind of gloss over that whole topic for us and explain what’s going on?
DR. TURBAN: So one of the oldest laws states are trying to pass about trans people were these bathroom bills. And they were bills that would require people to use the bathroom that’s on their birth certificate, basically. That’s not nice for a trans person. Google a famous trans person. Look up Nicole Maines. Look up Laverne Cox. These trans women, imagine telling these women that they need to go use the men’s bathroom and just imagine what that is going to be like for them. Imagine how people are going to treat them. If you know a trans person, it’s awful. And it turns out it’s been researched too. The research never makes it into the political debates. Maybe not once have I seen these research papers introduced even though they answer the most relevant question. So there’s a study published in one of the most prestigious journals in pediatrics called Pediatrics, interestingly, is the journal name. But they looked at kids who are in schools who had trans-inclusive bathroom policies and kids who were in schools who made them use the bathroom on their birth certificate. The kids who were forced to use the bathroom that aligned with the birth certificate – this is just a study of trans kids – they were dramatically more likely to have been victims of sexual assault in the past year. So laws that force trans people to use the bathroom of sex assigned at birth are associated with more sexual assault for them. People in favor of these laws, forcing trans people to use their birth certificate bathroom, would say, “But if you let trans people use the bathroom of their gender identity, they’re going to be more assaulting on cisgender people.” Right? That first study wouldn’t answer that question. Another study does answer that question. So, researchers at UCLA looked at places that had trans-inclusive bathroom policies, places that didn’t. And the places with trans-inclusive bathroom policies did not have higher rates of assault against people in bathrooms. So the inclusive laws for trans people don’t pose a risk to higher rates of assault against cisgender people and they protect transgender people. But scientifically, it’s kind of an asked and answered question.
JEN: It just seems like the most dehumanizing thing you can say to a person is, “By the way. You’re not allowed to use public toilets. There’s something about you that you’re not allowed in a bathroom.” That seems just really particularly cruel.
DR. TURBAN: And it all seems to be designed around painting this portrait that trans people are dangerous sexual assailants. The whole implication is that if you let trans people use the bathroom of their gender identity that they’re going to go sexually assault people. It’s not verified by the date. It’s verified if you know trans people in your life who are just trying to survive. I agree. I think it’s really awful and dehumanizing in spreading these myths. And then the awful thing is that it’s impacting these kids, right? I’m trying to take care of this 14-year-old trans girl and she’s like, “People think if I go to the bathroom, I’m going to sexually assault them.” How powerful is that for a 14-year-old to have to . . .
JEN: Way too much for a kid to carry.
Out of all of this, realizing that you’re talking primarily to parents and grandparents of LGBTQ people, what do you think is the most important idea that society needs to understand about all of this, especially as we move into another legislative season?
DR. TURBAN: I guess recognizing that these are nuanced questions. If somebody is trying to boil this down to a soundbite, like a politician, approach with skepticism. And also, it’s so easy to get caught up in these intellectualized debates – sports are the perfect example – you feel like you’re being logical and really thinking about it. But there was not a single trans person in the room while you were having this discussion so you kind of missed the reality of their experience and the point. So if you’re going to have a strong opinion about one of these things, please talk to a family that has a trans kid or talk to a trans adult who’s really impacted by it so that you can consider how these policies can affect them. Because, at the end of the day, these are laws about them. So to not take the time to hear their perspective and understand their experience, I think, is just mean – not fair. It isn’t the way that we should be making laws or policies.
JEN: I do want to thank you so much for coming, Dr. Turban, and sharing your time and your experience and your knowledge with all of us. I’m confident it’s going to help all of us be better supports for helping the next generation, particularly the ones who are living in our own homes.
DR. TURBAN: Thank you for having me and thank you for having such an amazing group of parents supporting each other. I think there are a lot of adults who really wish that their parents had had something like this.
JEN: We do have awesome parents, that’s for sure. Thank you.
DR. TURBAN: Thank you.
JEN: Thanks for joining us here In the Den. While we have you, we want to let you know about the inaugural LUV Conference coming up this October 18th and 19th in Salt Lake City, Utah. The conference is all about learning and connecting and creating a more supportive environment for LGBTQ+ individuals and their families. Get more information at www.luvwithoutlimits.org . That’s L-U-V- without limits.org. Or find the link in the show notes under the links from the show. We hope to see you there.
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