How Politics is Intruding on Medical Gender Therapy

Brian: Brian Lehrer on WNYC, back with us now Emily Bazelon, staff writer for The New York Times Magazine, co-host of Slate's "Political Gabfest" podcast, and Truman Capote fellow for creative writing and law at Yale Law School. She has a detailed new piece out this morning in The New York Times Magazine. Yes, the magazine comes out on Wednesday, if you see it online, it's only the Sunday magazine anymore in the print edition.

An article about the debate over gender-affirming medical treatments for teenagers. Now, this isn't about the right-wing culture war backlash, which we talked about last hour, though that factors into this story in some ways. This is a debate from within the medical community that provides care for trans teenagers who seek to transition. The title of the piece is The Battle Over Gender Therapy.

We're also joined by Scott Liebowitz, a child and adolescent psychiatrist, co-lead of the adolescent chapter of the new standards of care from the World Professional Association for Transgender Health or WPATH. Dr Liebowitz formerly led the LGBTQ committee of the American Academy of Child and Adolescent Psychiatry. Emily, great to have you as always, and Dr Liebowitz, welcome to WNYC.

Emily Bazelon: Thank you.

Scott Liebowitz: Thank you. It's a pleasure to be here.

Brian Lehrer: Listeners, help Emily Bazelon report this story. If you are trans or the parent of a trans child or teen, what does gender-affirming care look like for you or your child and what should it look like? WNYC 212-433-9692 or [unintelligible 00:01:51] @BrianLehrer. Dr Liebowitz, I want to start with you, Emily's story detail is the debate over a new version of the WPATH standards of care, which you co-authored/ By way of background, what types of guidelines have previous versions of the standards of care set for clinicians?

Scott Liebowitz: Oh, thank you so much for having me. The World Professional Association of Transgender Health has been in existence since 1979 publishing guidelines for serving transgender health and transgender people going back that far and the last set of guidelines was published in 2012, which was the seventh edition. Naturally, we are at a point in history where so much has advanced and the clinical need has in some ways outpaced other needs.

Our mission with the standard of care eighth edition is to ensure that we can provide healthy, proper care to young people meeting their needs. The seventh edition had a small section on child and adolescents which clearly at the time that was what was needed. However, now with so many more young people seeking gender-affirming care, it's important that we match where we're at as a field and that's why the guidelines are being published.

Brian Lehrer: Emily, with that as context, can you lay out the main intention that your article explores? What are the competing ideas from within the medical community about trans-affirming care and who's saying what?

Emily Bazelon: Yes. Sure. Just to make clear again, we're talking about people who are all gender affirming providers, they're all trying to support kids who come out as transgender or gender diverse. Then the question is how do you best help them? The debate starts with the question of evaluation. The new standards of care talk about the importance of a comprehensive diagnostic assessment. The idea there is that it's important to understand how a kid coming out as trans intersects with other issues in their life, with their background, with other mental health issues they may have.

That's where you start. That's one side of the field and then there are other practitioners who think there's just been way too much attention on questions of identity for trans people. They'd basically say people know who they are, including kids. What we should be talking about is how they want to be trans. What kind of- it's called embodiment goals do they have. That you should be focusing on these physical changes rather than trying to explore why someone is coming out as transgender. That's the debate.

Brian Lehrer: Some of the thorny questions you raise include could some of the teenagers coming out as trans today be different from the adults who transitioned in previous generations. For them, the benefits are well established and the rate of regret is very low. How many young people, especially those struggling with serious mental health issues might be trying to shed aspects of themselves they dislike? Emily, can you expound a little bit on what that means, that tension as you lay it out? Then we'll ask Dr. Liebowitz how that actually gets applied in practice?

Emily Bazelon: Yes. We're having a real rise in teenagers, particularly identifying as transgender and non-binary. There's an institute at UCLA called the Williams Institute. They just put out a new report, they're estimating 3,000 13 to 17-year-olds which is nearly doubled from a few years ago. We're seeing a lot more kids and then the question is why. One answer to that is the increased visibility of transgender people in the culture and that is very liberating for a lot of teenagers.

They are just seeing gender as having possibilities that I think were much, much harder to access in the past. Lots of kids are benefiting from those new choices. It is also true at the same time that there are some kids who are coming to this because they're on a quest, they're looking for something. This may not be the thing in the long run that turns out to be right for them.

Then the question becomes how does that factor into decisions that kids and parents make together about medical interventions because once you start taking medications, particularly hormones, that's changing your body in ways that you might feel really good about. Lots of the teenagers really benefit from that, but it also raises questions if you change your mind what's that going to look like for you later.

Brian Lehrer: Dr. Liebowitz, how did you and your co-authors approach questions like that in developing this latest generation of the standards of care?

Scott Liebowitz: Oh, well, so it's important for us that we took an approach that was simultaneously respectful of trans youth and trans people's rights and respect the fact that for any human one's gender identity can be any number of identities as it relates to their body. That is not what our job is.

We're not here to assess a young person's gender identity per se, rather we do believe that a comprehensive diagnostic assessment provides context for us to work collaboratively with families and parents to better understand how well a young person knows themselves? That goes into their decision-making capacity when it comes to long-term interventions that could be irreversible in nature.

Brian Lehrer: How do you assess whether they know themselves well enough to take that step?

Scott Liebowitz: Often it takes time. Often by doing a diagnostic assessment and having a better appreciation of the biological, psychological, and social factors that comprise a young person's overall psychological makeup and how they navigate through the world, we are able to first see, are there ways to better appreciate and understand how well they know themselves, how well this experience works for them, eliminate factors that potentially impact how a young person can conceptualize their identity and see what happens over time.

I do think time is important. Recognizing also that depending on what stage of development the young person is in also matters because some of the treatment interventions that we have are time-dependent in nature. Those are more reversible in nature. That's helpful. Often getting to know a family, working together, walking them through the basic steps to see how well a young person experiences their gender and how it feels for them is often an important part of the process.

Brian Lehrer: Emily, we had a caller earlier in the show who was concerned that activists are trying to get kids to identify as trans and that this might happen to some kids too quickly a pushback on the whole current wave of more people coming out as trans these days, including more young people as you cited in the opening statistics. In reporting this story, did you find any impulse from activists to say no? What Dr. Liebowitz just said is being too conservative, being too slow, let's go. Any political push to go faster with individual kids?

Emily Bazelon: I don't think that activists are out there trying to recruit trans kids. I don't think that is really the issue. When I talk to transgender activists and adults, they often emphasize this is one of the biggest decisions they made in their life and that it's really important to be very sure about it. I think the question here is what does it take to be sure. I think one thing I do hear sometimes from older transgender people is the sense that it is so hard to be trans still in our society. This is just a deep truth. It is really hard. It's also hard for teenagers that they can't really imagine people getting swept up in this, and having it turn out to be wrong for them. That I think is a little more complicated now, because of the influence of the internet, because of peer influence, but the notion that there are adults out there trying to persuade kids in a suspect way. I just have not seen that.

Brian Lehrer: Chris in Brentwood, you're on WNYC. Hi, Chris.

Chris: Hi, good morning. How are you?

Brian Lehrer: Good. What you got for us?

Chris: My son, he's 19 now, and his mother and I had made a discovery that something was up with him. He first came out as bi, and then he came out as trans. We put him in a counseling session with family group. He didn't like that. He had individual counseling for years. Through that, he went on hormone therapy. Eventually, he got the top surgery that he desired.

People, they say it's hard for them to let go [unintelligible 00:11:26] their child as they were, but it's so much harder for them to live as they are in the wrong body.

The change is so dramatic. I can't even express. For people to say that, people are trying to target these kids is just crazy. It's crazy. I know my son, [unintelligible 00:11:48] born as a female, he was always my son no matter what, because that's how he acted. That was his personality his whole life.

Brian Lehrer: Chris, I'm almost crying. Thank you for your candor and your love through the emotion-

Chris: Thank you.

Brian Lehrer: -that we all hear in your voice.

Chris: Thank you for supporting them.

Brian Lehrer: Can I ask, when you first started in therapy since you said that was the first thing that you did as his identity was starting to change or be expressed, what was the therapy like? Was it purely open to discovering who he was, was it trying to push her at that time back into a more traditional gender identity? What was the beginning of that like?

Chris: The beginning was tough because the family sessions he wasn't really into. The private sessions we could see the behavior changing, we could see the anger subsiding, and we could see as he was accepting who he was and realizing who he was, and understanding that it was okay, and going through that with a therapist and then being able to come home and talk about it. It [unintelligible 00:13:11] difference in the world. It really did. For parents who are going through this, you need to listen to your children because ultimately they do know who they are.

I don't think social media influence and all that is a factor. My parents, they have a hard time dealing with this. I tell them all the time there's no way that a kid is going to make this decision on their own because this journey is not easy, from start to finish it is very, very difficult. I don't think anybody's going to choose to do that for whatever reason. They're doing it because that's who they are.

Brian Lehrer: Chris, thank you so much for your call really. You sound like a great dad. Dr Leibowitz, since you as a child and adolescent psychiatrist this is your field, what were you thinking as you heard that story?

Scott Liebowitz: Well, I was really blown away by your courage, Chris, for sharing your story so publicly, and it mirrors the story of so many families across the world quite frankly. As a child and adolescent psychiatrist, I would say that he's absolutely right. When we work with young people to support them and support their exploration of who they are and what feels best for them, and all the factors that go into that, an important part is to really factor in their family. If you approach the individual without taking into account the family and understanding the family's perspectives and meeting all family members where they're at, and oftentimes family members are not always on the same page or aligned for various reasons.

Different families communicate their feelings in different ways. That's exactly part of the story that goes into what our guidelines are highlighting, is the importance of including families and meeting parents where they are at. As we all know that when you're working with minors making treatment decisions that what distinguishes a minor from an adult in the medical system is the fact that their parents need to offer the consent, provide consent while the young person provides assent.

Again, it's important that families support their young people in a way that provides them the space to be who they are in that moment, and also leave room for them to evolve and grow in the future. That's okay without foreclosing on a particular path, yet at the same time, it's really important to affirm a young person where they're at in that moment. We really do emphasize the family approach.

Brian Lehrer: Let me get one more caller in here. Brant in Bay Ridge, Brant, we've got about 45 seconds for you. Thank you for calling.

Brant: Yes. I just wanted to agree with the guests and previous caller. I'm in my late 30s, and this stuff just didn't exist when I was a kid. I knew as far back as I can remember that I was trans, I didn't have a word for it. I did not know it existed. At a certain point I learned about gay people, but that didn't solve anything for me. It was very confusing growing up because I never had the language for it, and I just didn't know that it was a thing. Having access, having visibility the way that I've seen change just since I've been a kid is really remarkable. I'm very lucky that I live in New York City because my access is different than it would be in so many other places in the country.

Brian Lehrer: Yes. The guy who called from Brentwood that's in the Islip area out in Suffolk County, it may be a lot more difficult for his son than perhaps it was for you in New York City. Emily, you want to give us the last word in 20 seconds. Sounds like you have some material here for a follow-up article.

Emily Bazelon: Well, thank you. Yes. I think this point about people's different experiences based on where they live is so crucial. It is really different to be transgender or exploring gender identity in the American City than in a rural area.

Brian Lehrer: Emily Bazelon's article in the New York Times magazine is called The Battle Over Gender Therapy. We also thank Dr Scott Leibowitz who is a child and adolescent psychiatrist and has just been the co-lead of the adolescent chapter of the new standards of care from the World Professional Association for Transgender Health. Thank you both so much.

Emily Bazelon: Thank you for having us.

Scott Liebowitz: Thank you. And Commack born-and-bred, thank you.

 

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