- [Woman At Lectern] Good evening.
- [Audience] Good evening.
- Thank you.
I am delighted to welcome you
to our Annual Conference lecture
and the 35th year of our Day-Garrett Awards.
We're especially pleased to welcome
our honored guest, Dr. Betty Morningstar,
Dr. James Herbert Williams,
their families and friends,
our faculty field advisors,
field agency representatives and supervisors.
And our lecturer for this evening, Dr. J. Michael Bostwick.
Annual Conference is one of our
most important summer events.
It is a time when we celebrate the achievements
of our Day-Garrett Award recipients,
and recognize those who have made
significant contributions to the school.
Also, it is a time when we're able to join
with all of you to work together
in advancing professional education.
During our Annual Conference we explore ways
of continuing our dialogue, as we affirm the excellence
of Smith's clinical social work education
and ensure its responsiveness
to people throughout the years.
We thank you for being here with us,
for your commitment and for the many contributions
you make to clinical social work education at Smith.
We look forward to the year ahead
with every expectation for much success.
Before we move to the Day-Garrett Award,
I want to thank Carolyn du Bois,
Katelin Lewis-Kulin,
the SSW staff,
and everyone else who contributed
to the wonderful work and job that was done
in organizing the conference.
So let's give Carolyn and Katelin and staff a hand.
(applause)
I'd like to also add the thanks
for the workshop leaders and students.
I know that there's a lot going on with continuing education
and the experience of really looking at
how we support our students
in their field placement settings.
So I'd like to give the workshop leaders
and all the students who participated a hand as well.
(applause)
The Day-Garrett Award was established in 1978
as a award of distinction to be awarded annually
to one person or several persons
who have been outstanding contributors
to professional social work,
and who have been significant members
of the Smith College community educational experience.
The award is given to those individuals
who in the judgement of the committee have personified
in their lives and service to their community,
the high purpose of professional service
for which the school has been renowned for 95 years.
The recipients are chosen by an award committee,
a faculty, field representatives, and trustees.
The Day-Garrett Award honors
the extraordinary service and achievement
of Florence Day and Annette Garrett.
Florence Day was director
of the School for Social Work for 14 years,
from 1942 to 1956.
Under her directorship,
the tradition of Monday night lectures began,
and a program of advanced study was initiated in 1949.
Students remember her fondly as a nurturer,
a wise person, one who really listened.
Annette Garrett was associate director of the school
from 1935 to 1957, 22 years.
She was an exceptional teacher,
whose books became classics, which still endure.
Her book on interviewing is in its fourth edition
and has been translated into 20 foreign languages.
To present this year's award,
I am pleased to introduce to you
Smith College Provost, Marilyn Schuster.
(applause)
- First I want to welcome everyone this evening and tell you
that our new president, she's been on the job for 19 days,
Kathy McCartney is very sorry
she can't be here this evening.
She's out raising money for the college.
And also, I was told very strictly not to go off script,
but I can't resist adding a sort of belated toast
to the praise of Carolyn,
that we heard earlier in the evening.
And to just say that one of the many things
that I've appreciated about her leadership at the school
is that the School for Social Work
and the college have grown closer together.
We now have more programming together.
And that the shared values
of the school and the college
are certainly something that we've shared for a long time,
but that have deepened during her leadership.
So now for the first of the Day-Garrett Awards.
For distinguished service to the School for Social Work
and the social work profession, Dr. James Herbert Williams.
As a graduate of the Smith College School for Social Work,
oh, yes. (audience laughs)
(applause)
You didn't know it was a hot seat, did you?
As a graduate of the Smith College School for Social Work
and an esteemed social work professional,
with 30 plus years of experience
as a scholar, educator, and leader
in the field of clinical social work,
you are a source of great pride for our school.
You were one of the first members of your family
to attend college, graduating with a BA in sociology
from Grambling State University in 1972.
You went on to earn your MSW here
at the Smith College School for Social Work in 1975.
An MPA from the University of Colorado in 1989.
And in 1994 you became the only member
of your family to earn a PhD
when you completed your doctoral studies
in social welfare at the University of Washington, Seattle.
You are Dean of the Graduate School of Social Work
at the University of Denver.
And the first recipient of the Milton Morris Endowed Chair.
You are the current president of the board of directors
for the National Association of Deans and Directors
of Schools of Social Work.
And this year, you received the University of Washington
2013 School of Social Work Distinguished Alumni Award.
Your international commitment includes work
on the United Nations-GSSW sponsored
conflict-resolution initiative in Kenya,
helping the members of various tribes to learn to peacefully
address issues arising from their changing context.
You have served on two commissions
for the Council on Social Work Education,
and as a member of the Society for Social Work and Research,
Board of Directors.
Prior to you appointment to the position of dean in 2007,
you were the Foundation Professor of Youth and Diversity
at the School of Social Work
in the College of Public Programs
at Arizona State University.
Your funded research includes grants from the
National Institutes of Child Health and Human Development,
The National Institute of Mental Health,
the Danforth Foundation,
the National Institute of Diabetes
and Digestive and Kidney Disease,
and the Departments of Justice, Education,
and Health and Human Services.
Your scholarship has been published
in prominent health and social science journals.
Your research scholarship and community engagement
have focused on health promotion and disease prevention,
health disparities, economic sustainability,
human security, conflict resolution,
delinquency and violence, mental health services
for African American children in urban schools,
disproportionate minority confinement
of African American youth in the criminal justice system,
community strategies for positive youth development,
and social issues of the African American community,
as well as K to 12 academic performance,
youth violence, delinquency prevention,
adolescent substance abuse, race and gender differences,
and mental heath service needs
and utilization patterns in urban schools.
Dr. Williams, your life's work has been shaped
by a family legacy that values hard work
and embodies resilience.
Your contributions as a leader in research and scholarship
have enriched not only the social work profession,
but the world at large.
You are a blessing to this school and to our profession.
It is with great pleasure that we bestow
upon you the Day-Garrett Award.
(applause)
- Thank you.
Whoa.
(audience laughs)
It's always very weird and a little odd
to sit there and have someone talk about you.
It's almost like a out of body of experience of like,
boy, whoever that person was they did a lot.
(audience laughs)
Thank you to the committee, to the selection committee.
I'm very honored and very touched.
I arrived on this campus in 1973
as a 22-year-old kid directly out of undergraduate school.
And my eyes was opened tremendously
from all the wonderful knowledge
that I learned while I was here.
I've truly tried to tell people that education
is your ticket to and opens your eyes to the world.
I've had an opportunity after being educated here.
It opened doors and opened my eyes to the world.
And it's coming from a very humble beginnings,
and always still thinking of myself
in a very humble place, even today.
It really is an honor.
I really cherish my experience that I had here at Smith,
and the education I got here at Smith.
And some of the people.
I think back today and I still think of the names
of Helen Pinkus and the people that followed her,
that was very instrumental, and who,
shaping my ideas around sorta social work
and the work that I'm doing.
I'm very humbled and very honored.
Thank you, Carolyn.
Thank you to the committee
for this wonderful, wonderful honor.
I will cherish it always.
Thank you very, very much.
(applause)
- Dr. Betty Morningstar.
(applause)
Scholar, educator, activist,
philanthropist, and practitioner.
You have been a leading advocate
in the field of clinical social work and a quiet force
in the lives of people on every corner
of the globe for 30 years and counting.
You are a stalwart supporter
of social and economic justice,
and unimpeded access to services for all.
You earned a bachelor's degree in psychology
from Smith College in 1971
and continued your education
in the Smith College School for Social Work,
earning you MSW in 1977 and PhD in 1989.
Your have worked as a psychotherapist
in private practice in Brookline and Newton since 1983.
You have taught at both
the Simmons College School for Social Work,
and the Smith College School for Social Work.
And in addition to your social work degrees,
you earned an MA in religion
from Andover Newton Theological School.
And you are a core faculty member
for the Advanced Certificate program
in Contemplative Clinical Practices,
here at the Smith College School for Social Work.
You have contributed to the social work profession
in so many ways, including but not limited to,
your contributions as a longstanding member
and leader in the Academy of Certified Social Workers.
You have worked to promote, develop, and protect
the practice of social work and social workers.
You're an exemplary leader, currently serving as
President of the Massachusetts Chapter of NASW,
and the Chair of the Social Work Reinvestment Task Force,
and previously having served as the first
Vice President of the Massachusetts Chapter,
the Chair of the Awards Committee
of the Massachusetts Chapter,
as well as a member of the nominating committee
of the National Office of NASW.
In these many leadership roles,
you have not only upheld, but also advanced,
the strong social justice and advocacy mission of NASW.
Your work with NASW enhances the professional growth
and development of its members,
helps to create and maintain professional standards,
and advance sound social policies.
Additionally, your professional contributions
include numerous publications and presentations including
Lesbian Parents: Understanding Developmental Pathways 1999.
And J. Laird,
Lesbians and Lesbian Families: Multiple Reflections.
Stories that Transform: Narrative Approaches
to Spiritually Oriented Clinical Practice, in 2010,
in Volume 80 of the Smith College Studies in Social Work.
You have presented on topics such as,
the impact of violence and of the nuclear threat
on psycho-social development,
and adolescent and adult sexual identity development
throughout Massachusetts and nationally
at NASW conferences and symposia.
You have served as chaplaincy intern
at Hebrew Rehabilitation Hospital and SPARK Center,
the Children's Medical and Mental Health Center
of Boston Medical Center.
And you have been actively involved
with Keshet, a national organization
that works for the full inclusion of LGBT Jews
in all aspects of Jewish life,
serving on the advisory committee
and the development committee.
You also serve on the advisory board
of Creative Alternatives of New York,
a drama therapy organization
that serves clients who are dealing with complex trauma.
And you are a member
of President's Council at Smith College.
A second generation Lion of Judah,
you have carried on the philanthropic work of your family.
Your generous financial support
of the Smith College School for Social Work
advances the mission of the school
and helps support its position
as a leader in academic and clinical excellence.
Dr. Betty Morningstar, you've contributed greatly
to the lives of many through your life
of service, activism, and advocacy.
In recognition of your service and dedication
to the School for Social Work and the profession,
we are proud to present you with a Day-Garrett Award.
(applause)
- Wow.
For starters, I'm a little overwhelmed.
But, thank you, Marilyn and Carolyn,
and Caroline and all of the faculty
and committee members that,
that's not mine, I hope. (laughs)
I really am so pleased and honored
and grateful to be receiving this award
from the School for Social Work.
As you, I guess probably have gathered,
I really kind of grew up here.
I was an adolescent when I first sat in this very room
for lectures as an undergraduate.
So it's my home away from home.
And I really feel
a strong connection to the school,
to the School for Social Work.
It, as you also heard,
I'm second generation Smith,
so I really kind of started coming here
when I was a little kid.
And so, I'm just so grateful for all of the
wonderful learning and support,
and incredible intellectual stimulation
from both the college and graduate school years.
I like to think of my time
in the masters and doctoral programs
as a kind of funny holding environment.
Some of you might know that phrase
from their social work education.
At the same time, the gentle push
to get out there and actually do the work,
so I've had all of that here.
And I am incredibly grateful
for the many opportunities I've had
to serve in the social work community.
All of which got started here
at this school, in this room,
that brings back many memories.
I won't even begin to tell you any of them,
or we'd be here all night.
So just, thank you.
That's the only thing I can figure out
about how to say how thankful I am.
And I do want to just thank my families members,
my entourage who has joined me here tonight.
My wife, Jeanette Kruger.
My son, Will Morningstar.
My sister-in-law, Faith Morningstar.
And my dear friend, Harriet Fink.
And having said that,
enjoy the lecture and thank you for being here.
(applause)
- And now I will turn the lectern over to Carolyn du Bois,
or du-Bwah, as we say in my former life,
to introduce Dr. J. Michael Bostwick.
- All right, greetings all.
And thank you once again.
Let me just add my thanks to the field crew
and to our field faculty supervisors
and directors of training who are here this evening.
It is my pleasure this evening
to introduce to you Dr. J. Michael Bostwick,
who will be presenting the Day-Garrett Award lecture,
which is entitled: Sex, Gender, Intersexuality
in the Olympics and the Real World.
Let me tell you a bit about Dr. Bostwick.
The resume was 44 pages long.
(audience chatters)
And there was no fluff in it at all.
Dr. Bostwick received his bachelor's degree
in art history from Yale University.
Then got another bachelor's degree
in zoology from the University of Hawaii.
Then went on to med school.
Completed a medical degree at Brown University.
And then went on to complete
what is really quite an extraordinarily, I think,
impressive course of training which included
an internship and junior residency in pediatrics
at Mass General Hospital.
A psychiatry residency at Cambridge Hospital where he then
was named Chief Resident of Outpatient Psychiatry.
Then completed a fellowship in consulting psychiatry
at Brigham and Women's Hospital.
And in his spare time went on
and completed psychoanalytic training
at the Boston Psychoanalytic Society.
It's really quite remarkable.
Since 1996, Dr. Bostwick has served
on the faculty of the Department of Psychiatry
at the University of Texas in San Antonio.
And at the same time,
as consulting professor of psychiatry
at the Mayo Clinic in Rochester, Minnesota,
where he then became director of the medical school
of the education program in psychiatry and now serves as the
Assistant Dean of the Mayo Clinic School of Medicine.
Also, somehow in all of this, he has 15 years service
in active and reserve duty in the Air Force,
where he holds the rank of Lieutenant Colonel.
And maintains numerous academic
and professional affiliations,
including membership in the American Board of Psychiatry,
the Academy of Suicidality,
the Academy of Psychosomatic Medicine.
He is board certified in psychiatry,
geriatric psychiatry, addiction psychiatry,
psychosomatic psychiatry and is a
Diplomate of the National Board of Medical Examiners.
He's a prolific writer.
He's an author of 91 articles, I counted them.
A book on psychosomatic medicine and 25 book chapters.
He's a reviewer, an editor,
or a editorial board member of numerous journals.
Clearly a gifted, and oftentimes recognized,
with honors for his teaching work,
his mentorship and his consultation to psychiatrists.
And he's a highly sought after speaker,
both internationally and nationally.
He's presented across the world on topics
which have included suicidality, sex and gender,
depression, empathy, hopelessness and despair,
and schizophrenia.
With topics, and I just have to give you
some of the highlights because I was amused.
Some of the topics of these presentations go as follows:
Trampled By a Zebra.
Which has to do with rare diagnoses.
Hiccups Were Not A State of Mind.
Bugs Are Not Us.
My Brain Is Catching Up To My Brain.
And my personal favorite,
which I imagine earns you the love of your colleagues,
Physicianhood As Potential Personality Disorder.
(audience laughs)
He's an extraordinarily gifted teacher,
writer, researcher, and clinician.
Please join me in welcoming Dr. J. Michael Bostwick.
(applause)
- Let's see.
If I'm so accomplished, why am I so anxious?
(audience laughs)
Er, the first thing is they hid the mouse.
Okay.
I think I'm anxious because the topic is anxiety provoking.
I find this such, anything related
to sexuality and gender and sex,
to be just full of opportunities
to trip, to screw up, to offend.
I hope to be intriguing and entertaining
and provocative and not offensive (laughs),
but it's a challenge because people
have very strong feelings about these topics.
In any case, I have a disclaimer.
Number one, I'm a Euro-American.
Now let me explain that.
Caucasians, I actually know a couple of Caucasians.
One is from Armenia,
and the other is from Uzbekistan.
And these are Caucasian peoples,
they are not European peoples,
and they have made it very clear to me
that I am not them.
So I'm a Euro-American.
I'm also male which is a dangerous thing
to be sometimes at Smith College,
as well as other places. (laughter)
Although I have to warn you
that you may only be perceiving me as a male.
Underneath this appearance I could be something else.
And thirdly I'm a psychiatrist,
which is by definition a very, very scary thing.
Actually, I'm not a trained analyst,
but I have been analyzed,
so I've been terrified by an analyst, but I am not one.
(audience laughs)
So with those disclaimers,
we'll proceed to my own experience.
This is a bracelet that I wear.
That I've worn since I was 17.
And much to my surprise,
I learned when I was a college student,
from one of my classmates, that I was gay.
Which was very interesting to be told that I was gay.
I thought that was something that I got
to tell other people that I was or wasn't,
but I learned that it was simply
because I wore this signifier of gayness, a bracelet.
Did you all know that?
(audience chatter)
That's changed a little bit,
but in the 1970s in New Haven,
wearing a bracelet meant that you were gay.
Apparently I was the last to know.
All right.
So let's get started, if we haven't already.
On this topic intersexuality and sexuality and gender,
I actually got my start in the U.S. Air Force.
Now I went to Brown Medical School and I had no money.
Unfortunately this was the year
that Ronald Reagan had killed the
National Public Health Service Corps,
because I would have done that.
But I ended up in the Air Force,
which was especially ironic because
I was raised in an Air Force family,
and I have a very difficult relationship with my father.
But there I was in the Air Force.
And if you want to learn about marginalized people
and people who are challenged by the culture they're in,
a great place to do it is in an organization
that has strong boundaries and challenges people
who are not meeting their expectations.
So this was a patient who I first met as a man.
And I was given the task of proving
that this person was crazy.
Because they, 19 years into their career in the Air Force,
had been discovered to be working
at the base as a man, going home,
and becoming a woman and becoming
the vice president of their child's PTA as a woman.
And that boundary transgression was so unacceptable
that another military person called their commander
and they ended up being sent to mental health
to be proven that they were crazy.
Well, I tried really hard, (laughs)
but this person was not crazy in the slightest.
And in fact, I believed may have managed
to be the first person who was allowed
to retire as a transgendered person
from the military with full benefits.
And largely that was because
they had the goods on the military
and threatened to go to the New York Times.
Which has happened on numerous other occasions
involving people in the military
around issues of sexuality and gender.
In any case, that's where I got my start.
And what I know is not the result of my training
because there was none of that in my training
in Boston in the '70s.
It's what I've learned along the way taking care
of several dozen folks who were trying to sort
these issues out for themselves.
Now, Caster Semenya.
How many of you know who this person is?
Okay.
I'll tell you more about the story later,
but suffice it to say that Caster Semenya
can really challenge our assumptions
or our ideas about what
a woman or a man should look like.
And the story, I'll go into it in detail later,
but basically this is a person
who is likely intersexual, although no one knows for sure,
except for a very select committee
that decided whether or not she could compete as a woman.
So the objectives of my talk are to give
definitions of sex, gender identify, and gender behavior.
To explore the differential of intersexual diagnoses,
of which there are many.
So it means really that individuals with these diagnoses
have very different experiences and very different lives
that we need to take into consideration.
How many of you have read Middlesex by Eugenides?
Okay, so you know something about a person
who thinks they're a girl and they turn into a boy
or something when they reach adolescence.
I'm gonna introduce the concept
of fetal brain masculinization.
Now, I was warned to not be a (stammers),
there's a term, I don't have it quite right,
biologist isn't the term,
but I was warned to be careful about
being too reductionist about biology,
but I think it's very freeing actually
to have people finally looking at brains
and seeing that there are, in fact,
neuroanatomical and neurobiological correlates
to sexuality, to gender, to gender expression, et cetera.
And then I'm gonna talk about
a case in the news, Caster Semenya.
And finally, show some video clips of my own patient,
and tell you a little about her
and how she came to see me
and how as a psychiatrist it was the first and only time
I've ever ordered chromosomes on a patient.
Not something you typically do
in a traditional psychoanalytic training,
"Tell me about your mother,
"and can I check your chromosomes?" (laughs)
Not what you usually do.
And then we'll have a discussion.
How do we define sex?
It's really, really challenging.
There are objective, scientific approaches.
But there are contributions from anatomy.
Contributions from physiology,
and genetics, endocrinology, psychology.
There's no absolute definition.
And one of the things that kind of intrigues me
is that even the scientific literature seems to think
that if you show up and say you're a man or a woman,
and you'll be studied as a man or a woman.
Now I would contend that since we don't
routinely check chromosomes on people,
and we don't routinely study
much of that what they tell themselves to be,
our literature on men and women is probably flawed
because it includes all kinds of surprises.
And that'll be my patient when I tell you about her.
Gender is a subjective thing.
It's fluid, it's a personal thing.
It's also an interpersonal thing.
No matter how you express your gender,
you have to confront everybody else around you
who is interpreting your gender,
expressing their own gender and challenging your gender,
or agreeing with your gender.
It's quite a fluid place.
It's a bio, psycho, socio, cultural construction.
It has elements of all of these things.
And they all come together and collide together
in ways that can be quite challenging.
There is a core gender identity, usually.
People know what their core gender identity is.
And typically it's either male or female,
although there are folks who are somewhere in between.
It's this personal sense of maleness,
femaleness or in betweenness.
And regardless of how you present yourself
or how you behave, very often you know
who you are at core in this way.
And you may get into trouble
when people who are talking to you about that
don't agree with your own sense of who you are,
which is really kind of offensive actually
to be told that you're not who you think you are
because somebody else knows better.
There's been a lot of bad work done based on that premise.
For most people it's well established by age three.
A child of three, no matter how they're behaving or acting,
can typically tell you whether they think
of themselves as a boy or a girl.
And then the gender behavior issue
is really a separate issue,
and one that needs to be taken into consideration as well.
Now, in many cultures, ours included,
there are ways that we expect
boys and girls to typically act,
ways that they should act we impose upon them.
One of my favorites is a cartoon.
This is a cartoon by the author of Maus.
You know, the cartoon strip about the concentration camps.
And he had a child,
and was trying very hard to raise his girl
in a liberal, gender-free way.
So he did a comic strip where he showed her
with a fire truck that she had wrapped up in a blanket
and was rocking like this, like a baby.
(audience laughs)
Now, talk about a child asserting her
rather stereotypic gender role with a fire truck.
But again, gender behavior is culturally based,
and historically specific.
One of the fun things to do is to look
at the role of pink and blue.
Which has varied even in the last hundred years,
between which was a masculine color
and which was a feminine color.
Right now, it's blue and pink,
but a hundred years ago it was the reverse.
So you can see how these things
are fluid and change as well.
Which can be quite confusing.
Gender roles are taught by demonstration and expectation.
But again, the reality is that what you're being taught
may confront or rub up against
who you feel yourself to be.
And depending upon who is teaching you,
and who is demonstrating for you,
they may not take that very well.
So it's a challenging, challenging area.
Gender is a social construction.
And it's so pervasive that in our society
we've gone to assume it's bred into our genes.
Just the very fact that it's a pervasive belief,
means it must be in the genes, right?
Do you all agree with? I hope not.
No, these days we like to say
that things that seem obvious are genetic.
Most people find it hard to believe
that gender is constantly created
and recreated out of human interaction, out of social life,
and it's the texture and order of that social life.
Yet, like culture, gender's a human production,
and we're all always doing gender.
And even if you're radical about gender,
you're still doing radical about gender.
You have to do it because otherwise
you're going to go through the world being done,
I would say. (laughs)
That sounds fun and strange, doesn't it?
But, so keeping terms straight.
Sex is what science says you are.
If you can buy that, we'll go with that.
Gender is who you believe you are and how you express it.
Sexual orientation is whom you desire.
And again, it's a third separate category.
You cannot assume, for example,
that because I have a bracelet
my mother gave me when I was 17
that I am therefore gay.
Maybe I am gay, maybe I'm not.
But I have a bracelet and that's apparently,
it goes in the second category rather than the third.
Although they could be related, but they might not be.
Sexual orientation is independent of sex.
And we do know that gender atypical boys and girls
are more likely to have same sex attractions,
but not necessarily.
So again, it's all about a world
where you can't make assumptions.
The assumptive world does not apply here.
Now the John Joan case is one that
I think is an extremely powerful
and important case to talk about.
Are you all familiar with this case to some extent?
John Colapinto wrote about.
These were a pair of Canadian twins
that were born into a Mennonite family
in rural Canada in the 1960s.
And these were identical twin boys.
And at six months the boys had phimosis,
meaning a constriction of the foreskin of their penises.
They went to have circumcision and one of them,
in an unfortunate, very unfortunate accident,
had his penis burned off.
And this is a real problem if you're a boy
or a man to have your penis burned off.
I think you would agree.
According to the very prevalent notion of the time,
expounded by John Money at Johns Hopkins University,
nature didn't matter, nurture was everything.
So if you simply took a child at a very young age,
and you raised them in the gender
that you wanted them to be, they would become that thing.
Now what made this case much more complicated
is that John Money didn't really study John and Joan,
they were proving his theory.
And they were the perfect proof
because they were identical twins.
And so he reported that it was going very, very well
with this twinship that he had created
of a boy and girl, identical twins.
In reality it was going terribly.
Joan was extremely unhappy with this plan.
Was fighting it from the moment
that she was put in this role.
Was in some ways stereotypically more masculine
than her identical twin brother,
and was ripping off the girl clothing that was put on her,
refusing to do the girl thing she was asked to do.
When her parents were instructed
that at every moment they should treat her as a girl,
that if they did not, they would ruin her
and ruin her chances of a proper identity.
Now this was the optimal gender approach,
and it was prevalent and is still,
there's still remnants of it around.
I still encounter people, colleagues,
who believe that this is true.
And the story ends up with Joan,
who by then is now 14,
has been taking estrogens for two years
and has had enough breast development
that he has to undergo a mastectomy as a teenager
to revert to being the boy that he always was.
Okay, you got that story straight?
And so this is a picture on the right of Joan become John.
And another picture here of Joan become John.
Now the story is actually really, really tragic
because it actually probably destroyed
the lives of both twins.
In his mid 30s,
the boy-boy twin killed himself.
And two years later,
the girl-boy twin killed himself as well.
So it's really an incredibly tragic story.
Now again, this is the work of Reiner,
who has some, you think my resume is strange,
this person is trained as a child psychiatrist
and a urologist.
Sound like a bad joke,
what do a urologist and a child psychiatrist have in common?
(audience laughs)
In any case, he was a product of the money
at Johns Hopkins universe but didn't buy it.
And he studied 16 chromosomal males
who had colloquial exstrophy,
meaning that they were born with testicles,
but without any, their abdominal wall was not there.
So they're missing their private parts basically
and had to have something done
to deal with the fact that they were basically
wide open in their belly like a bad horror movie.
And according to the mores at the time,
they were all raised as girls.
The surgeries were done and they were turned into girls.
Except for two, his parents refused to go along with that.
So they had the reparative surgeries,
but raised the two of the 14 as boys.
Now Reiner followed these boys up many years later
in a New England Journal article.
And again, reminding you, normal internal testes,
disrupted external genitalia, normal brains.
Don't forget, normal brains.
I once had a schizophrenic patient
who kept attacking his penis
because he said he wanted to destroy his lust.
I did not tell him that he should be
shooting himself in the head,
because he had shot and cut himself in the genitals.
But the brain is important, it's very important.
16 of the 16 people demonstrated
male-typical gender behaviors,
even though they'd been raised, 14 of them as girls.
Two of the 16 were raised as boys.
14 of the 16 were surgically altered to look like girls.
Eight of the 14 became males in adolescence.
Lived as males, identified as males.
Six of the eight had sexual reassignment surgery so that
they could be physically manifesting their masculinity.
Five of 14 continued to live as females.
Three of the five had an unclear sense
of themselves or gender identity,
but were tending to think of themselves as male,
and one refused to talk about it.
Now I'm surprised that more than one didn't refuse
to talk about it because I think
I'd be pretty pissed and wouldn't want to talk about it.
But the point of this study,
which I think is really, really important,
New England Journal 2004,
is it really, really, I think,
shot down the optimal gender doctrine.
In a way that makes that doctrine
of John Money just completely unacceptable.
And Reiner's continued to go on to work
with populations, in this case,
well, I'm not sure quite what to call these folks,
but they speak to, he has things to say
about transgendered folks, about intersex folks,
and about people who have these congenital anomalies
that don't, do not in fact,
tell you what you should do with them.
So they're unpredictable identifications.
That was Reiner's point.
That routine male assignment of genetic males to female sex
because they don't have a penis
can result in unpredictable identifications later.
Clinical interventions in such children
should be re-examined, the light of these findings.
That is don't do anything.
Let the child grow and tell you who they are.
You can do that surgery stuff later.
It also brings up the notion that sex hormones
do organize the prenatal brain.
So future sex reassignment decisions
should be made with maximum sophistication
in regard to the implications,
psychosocial and psychosexual brain development,
as it is influenced by the intrauterine hormonal milieu.
Now I want to say here
that we come up against the limitations
of what we know with how the brain is sexed.
So we don't have a explanation
for how transgender works in the brain,
but we have the fact that it exists.
And the notion that somehow we know
and can make decisions for people
based on what we know, we don't know.
We don't know.
Reiner is making observations based on
what he saw with these 16 people
who are raised in the wrong gender.
There's also good evidence.
This is from Sheri Berenbaum, who's a psychologist
who has studied, again, masculinization,
which by definition includes feminization of the brain.
The point is that the brain is genderized.
Is that right? Sounds like blenderized.
But in any case, that something happens
in utero to lead to something.
And that there is good evidence
that exposure to high levels of androgens
during prenatal development can result
in masculinization of activity,
and of occupational interest,
sexual orientation, and some spatial abilities.
Smaller effect on pre-gender identity, but still there.
Now again, this would mean potentially
that someone who had a core gender identity as a female
could nonetheless be much more interested
in masculine activities and perhaps choose
a same sex partner, more likely.
The brain knows.
Reiner again, saying, "Clinical decisions should not be
"based on anatomy or correctness of sexual function,
"but on what the brain wants to do."
You know, people manage to work out their sexual function.
They don't need to have the focus
be simply on building them an organ that will work.
Which again, is sort of the Money approach.
And by and large, the organ that will work is a vagina
because it's too hard to build a penis.
That's the reality of surgery, make 'em into girls.
Which I think is offensive to women,
as well as offensive on lots of levels.
But anyway, back to the brain being the critical organ.
And the one that we actually don't understand terribly well.
There's a clinical threshold.
And these are from the Harry Benjamin's
Standards of Care from 2001.
There are updated standards that came out in 2011.
I tried to read them for pithy quotes
and they simply aren't there. (laughs)
From what I could tell.
They're very prescriptive without being very philosophical.
So the notion here was that
a clinical threshold is passed
when concerns, uncertainties, and questions
about gender identify persist in development,
become so important as to affect
how a person functions in their life.
I think we could probably all agree with that.
And such struggles start in the preschool years
and can go on through old age
with many, many different forms.
They come about because people
are unhappy with their anatomy,
or what their body looks like.
If they feel themselves to be a woman
and they have all these male parts, yuk.
As what happened with a patient of mine
who was a genetic female
but very much felt himself to be a man.
Was totally disgusted with menstruation
and with those breasts, and it was very bad.
And in fact, I'm quite proud of myself
because this person was rejected
for a mastectomy by a large insurance company,
and I appealed it as a congenital disorder,
and they got the surgery done.
And it hasn't happened again,
but that one time it seemed pretty cool
that we could do that.
So now I'm going to play the first of the clip
from a patient of mine.
And this was a woman who was referred to me
with concerns about whether or not
she was actually really a man, okay?
So we'll have three different short clips,
and then some things in between.
And if it works, it will run.
Tell me a little of your story.
How did you come to see me?
What was going on?
- Well, I had been going to my endocrinologist
and just expressed to him that I was
having problems resolving issues of sexuality.
And he suggested that I should talk to you.
And through a series of referrals anyway,
I got to you.
- [John] Was there a piece in there
also about gender issues?
- Well, at the, I did explain to him
that when I was born
that I had had surgery
because of some ambiguous genitalia.
And that I felt that that was an issue,
and I was just dealing with confusion
as to whether I was a lesbian,
whether I was straight because I had been married.
I had conflicting issues with a church
I'm currently going to.
And basically just confused.
- [John] What was the connection in your mind
between your confusion and the ambiguous genitalia?
- Well, I think a lot of it was
because of my involvement in the church,
I felt that I was expected to think and behave
in a way very consistent with
what would be for lack of a better term, a woman.
And I don't always think and feel that way.
And that caused great confusion for me,
and 'cause I didn't know what to do with that.
- [John] When you say you don't think and feel
like a woman, what do you mean?
- It's hard to describe.
I think a lot of it is in the way
I interact with other people.
With either gender.
A lot of times I feel more comfortable
hanging around with guys than I do with women.
I don't have a lot of interest
in what I refer to as girly activities.
But it's been a problem because
as I present myself as female,
I can't cross into just either world easily.
It's not like I'm accepted hanging out with the guys
because they view me as a woman.
So it's just sometimes quite difficult.
- [John] So you don't want to hang out with the girls
because you don't feel comfortable with them as a girl.
- Correct.
- [John] And you don't want to hang out with--
- Doing the nails and the hair
on a Saturday night with your girls.
No, that's just not, that's just not me.
- [John] And you're not permitted to hang out
with the guys because they think of you as,
- They think of me as a woman.
- [John] As a woman.
- So obviously they wouldn't include me in that group.
So it's, it's, tends to be difficult.
- [John] What do you think of yourself as?
- Well, I'm not unhappy to have,
I'm not unhappy being a woman.
It's not like I have a desire to become a man.
I think of myself,
at least in the way my mind operates,
as more masculine.
In the way I deal with other people,
in the way I deal with situations.
I tend to be at least,
if a personality profiles that we do
through work and stuff,
I'm a driver and implementer.
I just feel,
I feel I think like a guy in a lotta ways.
- [John] And if anatomy weren't an issue,
and what would you be at core?
- I'd be a male at core.
No question about it.
- I think it's interesting how many stereotypes
she puts out there trying to figure out who she is.
So intersexuality is what I wanted to talk about some.
And it's when there's a disagreement
between the phenotypic and the gonadal sex.
So what the body looks like versus what the gonads are,
are not adding up to what generally is called normal.
For a male pseudohermaphrodite,
there's testicular tissue, but female external genitalia.
And for a female pseudohermaphrodite,
there's ovarian tissue, but male external genitalia.
Now I can already tell you,
there'll be lots of diagnoses coming.
I'll try not to belabor any of them,
but there are many, many different conditions
that fall into intersexuality.
A hermaphrodite is someone who
has both testicular and ovarian tissue.
So it's actually a tissue diagnosis,
not a descriptive diagnosis.
And by the way, in her story she talks about
how testicular tissue was removed.
She learned that only 50 years later
when we were actually able to get the lab report
that she'd never seen
from the naval hospital where she was born.
So with hermaphrodites, again it's a tissue diagnosis,
so you can look male, you can look female,
or you can have an ambiguous phenotype.
That's not the way we usually think of it.
But that is actually the definition.
And the whole point of intersexuality
is its diversity, not pathology.
Again, back to that sociocultural construction.
The level of pathology, the level of medical involvement,
the level of psychological involvement
or social involvement that's needed
to help folks who are different,
is a diversity issue I think, not a pathological one.
Male pseudohermaphroditism is complete
or partial androgen sensitivity.
And this is a condition in which
the individual has normal testes
and normal testosterone production,
but the testosterone doesn't do much.
In other words, you have to have receptors
that already receive that testosterone
produced by the testes in order to have
the things develop and evolve
that are testosterone related.
Interestingly, what actually masculinizes the brain
is estrogen, a breakdown product of testosterone,
which I just think is kind of fascinating.
But with a complete androgen insensitivity syndrome,
these are actually women who often look like
stereotypically fabulous women
because they have Barbie figures.
They have narrow male hips,
they have long, long legs.
They have proportions that are male,
but they don't have any of the male parts.
But there are also folks who have partial receptor responses
so they have bits and pieces
of the male masculinization going on.
There can be no brain masculinization,
probably with a complete androgen insensitivity situation.
And there can be partial brain masculinization.
There can be a female gender identity
or a male gender identity, or something in between.
The phenotype, the body may be female,
or it may be ambiguous.
Again, because there's a range of receptor responses,
and there are probably many versions of this condition.
5-alpha-reductase deficiency is a diagnosis from Middlesex.
So this is a condition where there are normal testes
and normal testosterone production.
There's normal brain masculinization
and normal male gender identity,
but the body is not really responding
because of this failure to convert testosterone
to dihydrotestosterone, the body doesn't masculinize
until puberty when there's so much testosterone
that finally the body masculinizes.
And there are cultures because
this is an autosomal receptive condition,
a condition in which this is just sort of known.
In several populations around the world,
where they're just people who turn into men
when they get to puberty and that's okay
because we've seen this before,
we know what it is, we understand it.
The point about Middlesex is that
they've left that part of the world,
and they're in the U.S. where nobody really gets it.
Male pseudohermaphroditism occurs
with a testicular dysgenesis,
one or both of the testes are inadequately developed.
Incomplete fetal masculinization,
not because you have an ovary,
but because you have a testis that isn't working very well.
You can have mixed gonadal dysgenesis
where you have more than one cell line going on.
That is you can have a XY line and an XX line,
or an XY line and an X.
You can have a mosaic basically
which leads to various things in between.
And in fact, the patient here
is a mosaic as she'll tell you.
The most common mosaic is actually 46, XY,
which is male, correct?
You know what 45, X is?
It's Turner syndrome.
And Turner syndrome are women who are typically very short.
Often have some other characteristics,
including a broad shield chest.
Certain characteristics that are quite obvious.
And in fact if you look at this patient,
she looks a little bit that way,
and she's barely five feet tall.
And one of the comments she made was,
"I make a terrible guy because I'm so short."
In any case, this mosaicism is common.
And again, it can manifest as someone
who is male, female, or in between.
If you look at fetal ultrasounds and you see
that the genitalia are developing abnormally,
you may find a lot of this.
If you take a bunch of kids that are just born
and you check their chromosomes,
you may find a lot of this,
but they look completely normal phenotypically.
So you can have an incomplete
to full fetal masculinization.
So congenital adrenal hyperplasia
is another example of pseudohermaphroditism.
And this is where the andrenals
are producing too much masculinizing hormone.
So not even the sex glands, but the adrenal glands.
And you end up with a female.
Typically a female gender identity,
but maybe a fused labia,
maybe a masculine habitus,
maybe a very large clitoris.
So on the way to a more masculine expression.
Because remember, genitals all come from the same place.
And they just develop along different pathways.
Normal ovaries but too much androgen coming from somewhere.
Which this could also occur with the mother,
for whatever reason,
that's taking androgens during the pregnancy.
Partial to full body masculinization occurs.
This is actually probably fairly common in athletes,
very good female athletes.
Female gender identity,
but maybe increased male typical behavior.
And maybe more likely to choose a same sex partner.
Again, back to that idea of brain masculinization.
In this case occurring because of adrenal production,
or hormones that the mother has taken during the pregnancy.
So this is a little, a second clip of Cindy.
Who again, I should have told you,
at the time of this tape was in her late 40s.
I met her when she was 48.
And how long have you known that?
- Well, when I was raised,
I had surgery at approximately six months of age,
where they restructured my clitoris
because I had a hyper clitoris.
I did have a vagina.
And they also did surgery to remove
what they referred to as testicular tissue,
although this was back in 1954.
And I don't know exactly what tests they were able to do.
I haven't been able to get medical records
to find out exactly everything that they did.
As I was growing up,
I have an abdominal scar.
My parents explained that I had a hernia as a child.
And you know, 'cause I had asked
about this fairly large scar.
And they told me that I wouldn't be able
to have children though.
They did give me that piece of information.
But I never really questioned it.
I know growing up, as I look back in hindsight,
I had a lot of feelings towards
other women that were maybe not sexual but more paternal.
I think one of my earliest memories is
when I was in third grade,
standing on a hill overlooking the school yard
with two little girls and I can even remember their name.
Nikki and Leanne, they were in first grade.
And I had my arm around each one of 'em on each side,
and I just felt so protective and not maternal,
but more paternal of these two little girls.
So I basically went through life believing
that I was normal as a female.
Had boyfriends.
Sex is, you know, high school.
I had my first lesbian experience
probably about a year or so out of high school.
But then met a man and got married
and was married for 16 years.
He knew of my past experiences and that was okay.
Sexually the relationship was fine.
I've never had a problem with that.
It's not like there was ever a problem
achieving orgasm or anything like that.
But I know that my fantasy life
was more geared toward thinking
of being with another woman
as opposed to with a man.
My parents told me after I had been married
for several years about the surgery I had as a child.
And their comment was, "Well, you're a big girl now,
"I guess we can tell you this."
And so that was pretty shocking for me at that point.
And I spent a lot of my life after knowing that information,
what I refer to as my freak issues, I felt like a freak,
that you know I didn't know where to fit in.
I eventually divorced after about 16 years of marriage.
And came out as a lesbian,
and had a couple of long-term lesbian relationships.
And it wasn't until recently
that I had a chromosome analysis done
where it was discovered that I was XY
and also XO mosaic.
- [John] Tell me about how you came
to have a chromosome analysis
and what that was like for you.
- It was interesting because
after I had started therapy,
- [John] With me.
- with you and you had suggested that we find out.
And you're the first person
who's ever even suggested that.
I thought that was kind of interesting.
And I remember waiting,
'cause it was almost two weeks before I got the results,
trying to figure out what results I really wanted to see.
Part of me wanted,
part of me wanted XY because
I felt that's just exactly who I was. (laughs)
But part of me was really afraid of that.
I guess at that time I wasn't really
too conversant on issues of mosaics
and you know I really didn't have
as much information as I do now.
So it was really interesting,
and when I found out it was, that I was,
that I was XY and XO mosaic
I kinda, I went home,
and I thought about it.
In some sense it was even more confusing to know about that
because you know presenting myself as a female
but having chromosomes with XY,
it's like I think it almost added to the confusion.
So it was a dichotomy.
Part of me was really expecting that,
but once I got that information it was like,
well now what do I do?
- I think you can hear some of John Money
in the way this person was raised, right?
Learning in her 20s,
partway into a marriage about her history,
having it just be a hernia until that point
to explain a lot of things that were very confusing for her.
So in some, sex versus gender, sex chromosomal.
Anatomic, that's about as good as medicine can do.
Gender identity, intrapsychic gender.
You know who you are in other words.
Gender role, interpersonal and sociocultural.
Sexual orientation, both intrapsychic and interpersonal
because presumably if you have sex
with someone else it becomes an interpersonal phenomenon.
(audience laughs)
We were having a conversation earlier today about,
well I won't, anyway.
Caster Semenya (laughs) (audience laughs)
in the news.
Female gender identity.
That was made very clear.
Male-typical childhood behaviors also made very clear.
She grew up in I believe a village in Soweto.
Not Soweta, in the part of Africa
which was an apartheid place for African people.
And she grew up running barefoot
through her entire childhood
because the family couldn't afford shoes.
Had internal testes, we think.
We do not know.
Broad shoulders, narrow hips.
She has a muscular, flat chest.
Signifiers.
A baritone, gruff voice.
Now all of this came out in these reports about this,
then in her late teens runner,
who had just won an international race
with the fastest time in the year.
800 meters, the fastest time that year in the world.
And there are three questions for you to think about then.
Is Caster a woman?
You don't have to vote, you can just think about it.
Should she have been permitted to run
in the Olympics as a woman?
And should health insurance be expected
to cover treatments specific
to transgendered and intersex people?
And this last question is actually
more directed to the medical sttudents
and the residents that I teach.
Trying to raise some awareness about this
because as I've already told you,
I had to appeal a decision for one of my patients
to get the treatment they needed.
So in the Olympics there's been sex gender confusion.
Actually mostly only in the modern games.
It really wasn't a problem in the ancient games
because there were no fig leaves.
(audience laughs)
And the way that you knew
that you were dealing with men,
primarily in the ancient games is because
they had their parts out there for all to view.
Okay, I don't mean to be,
well, I do mean to be a little funny about that.
But I permit you to laugh on this serious topic.
Actually it's sort of funny.
In the Victoria and Albert Museum,
there is a picture of,
there's a statue not unlike David.
And that central fig leaf there,
was created in the Victorian era
so that when the queen came to the museum,
they could cover up the private parts
with a piece of plaster so she would not be offended.
And then when the queen had left they could remove it.
From what I've heard of Victoria and Albert's sex life,
that was not necessary.
(audience laughs)
The modern games started in 1896.
Women entered the modern games in 1912.
And it's been a really sad history ever since
of trying to establish who's a woman and who's a man.
And the big concern was
that somehow men would fake being women for advantage.
There's never been a case of a man
who faked being a woman for advantage
that has been actually proven.
There have been some allegations, but no proof.
And the history really is very, very sad.
In the 1930s, you all know who Stella and Helen are?
Stella and Helen were American runners.
And they both looked a little masculine.
So Helen accused Stella of being a man.
And at that time what happened then was
that you examined, and this is still the case,
you have to make an accusation, and then,
so Stella got examined and Stella was found
to in fact be a woman.
Well, Helen was not examined.
But several decades later she died in the crossfire
of a bank robbery and at the autopsy
they found that she had ambiguous genitalia.
So since I am talking to a bunch of people
who are therapists, the power of projection
shows up quite profoundly I think
in the Stella versus Helen story.
In the 1960s women were forced to parade nude
in front of judges, largely men,
to determine that they had the proper parts.
That's sort of a modern version with women
of the ancient version with men
of if you had the right parts,
you were allowed to compete as a woman.
Or in the case of the women,
if you didn't have the wrong parts,
you were allowed to compete as a woman.
In the 1960s through 1990s,
there were a variety of lab tests.
And as I've already sort of hinted
to you with all these diagnoses,
lab tests are extraordinarily unreliable.
The sensitivity is low, the specificity is low,
they're fairly worthless.
So we had Barr bodies, they didn't work very well.
We had SRY genes, they didn't work very well.
Because of this problem
that there were too many examples
of people who had missing Barr bodies,
or had Barr bodies that are whatever,
and they turned out to not have
the diagnosis they were supposed to have.
At this point, all this has gone out the window
for a panel of experts.
And the panel of experts convenes from multiple disciplines,
ranging from psychology to anatomy to endocrinology,
and they all decide whether the person
who's been challenged is a man or a woman.
Do you like that?
Would you like to be on that panel?
(audience chatter)
Scares me.
So anatomy, physiology, genetics,
endocrinology, and psychology
are all represented on this panel
to decide that athlete's fate.
So, back to that question.
Are we looking at a man?
Are we looking at a woman?
Are we looking at a person who's neither a man nor a woman?
Think about it.
Two more pictures of Caster.
Again, on the left,
that picture is from the time when she won that world race.
And after she was accused of being a man by her colleagues,
she went home to South Africa,
which was determined to prove to the world
that she was actually a woman.
So for the first time in her life,
she was dressed up in a dress,
makeup was put on her face,
and she was put in high heels,
which hurt her feet very much.
Put on the cover of a magazine
as sort of a glam person,
to sort of prove that she really was a woman.
I don't know quite what to think of this,
except I think it's fairly appalling.
But it's right there with the gay Mormons
and the people with one strap gowns at the bottom.
So what's your assessment?
What are you thinking?
Again, I won't take a poll,
but this was quite a challenging situation.
Oh, my daughter added that.
(audience laughs)
My daughter is very clever with things that I can't do.
Now I put this picture up here
because one of these women is the one
who accused Caster Semenya of being a man.
And to my eye, they all look fairly gender atypical.
I mean, it's sorta the kettle calling the pot black.
I think.
I don't know if you'd agree,
but I think that these women
have remarkable muscular definition.
Remarkably low measures of body fat.
And are remarkably slender.
Interesting that she was selected out.
You might also wonder, of course,
about the racial issues involved with that.
So a woman among woman, or what?
Now again, I think in the culture right now
there's really a great confusion
about what a man looks like and what a woman looks like.
Maybe that's a good thing.
But you just pick up any,
you go to the airport and pick up all these magazines,
and everybody's got six packs.
Men, women, whatever.
I guess the bikini means the person on the right is a woman.
And the fact that the person on the left
doesn't have a bikini means they're a man.
(audience laughs)
If you have a better strategy, let me know. (laughs)
This is LeAnn Rimes, the singer.
How working out saved her.
She's since gone on to talk about her depression,
but here she had very impressive
muscular development as a woman.
So, which is the real Caster Semenya?
These two pictures are up there.
I think I've tried to make the case
that the person on the left is the real Caster Semenya.
And the person on the right is an attempt
to pander to societal, sociocultural stereotypes.
And maybe Caster Semenya does like dressing that way,
but it is ironic that she didn't have to do it
until she became a world figure.
South Africa was very much determined
to have her be allowed to run as a woman.
Now, by the way,
the end of the story was
that after I think something like 10 months,
that panel of experts decided she was in fact a woman.
They didn't tell anybody why she was a woman.
Which is actually very good for her privacy,
but which is not very good for our education.
And she went on in the 2012 Olympics
to earn a silver medal in the 800 meter race.
So one of those people who was a woman,
but not challenged, beat her, for what that's worth.
And by the way, that time that she had was remarkable,
but it was not by any means the lowest ever for a woman.
So once again you've got to wonder
about why she was singled out.
So we have a final clip from my patient.
How could your parents have done it differently
if they had told you earlier that, about this,
what would that have freed you up to be here to do?
- Well, I've done a lot of reading,
and I know that a lot of people advocate now
to take children and if possible
let them interact with other intersexed children,
or at least get them into
some kind of a counseling situation.
Obviously a young child can't necessarily
understand the issues of intersex,
but to help them at least feel positive about who they are.
It would have been a really nice thing
if my parents would have done that.
As a child I was dragged to the doctor frequently
for what I can only tell was deciding
how my bone growth rate was going.
But here I was a little child,
I'd be taken into these huge conference rooms
with all these doctors in their white coats,
and no one told me anything.
They'd just kinda look at me and measure my wrist,
and then I'd be taken out again.
It was like, that was really scary as a child.
And no explanation whatsoever.
And I never asked the questions either.
- [John] Well, how could a person in your situation
know what questions to ask?
Is that even possible?
- I think that's a good point because
you have nothing to base it on.
You have nothing to base.
You know if, without intervention of a professional,
I would not have known what questions to ask at all.
- [John] So at this point, what are the questions to ask?
- That's a good question. (laughs)
I guess
the questions that I have is basically
how to fit into the world that I live in.
The people I come in contact every day
know nothing about intersexuality.
If I were to come on and say, "I'm intersex,"
they'd probably look at me like, what?
Or use the term hermaphrodite.
You know.
I think their interpretation of hermaphrodite
is somebody that's got a six inch penis and a vagina,
and can have sex with themselves.
(audience laughs)
You know, I don't think that they
understand exactly what it means to be intersex.
To have part of you look one way,
and yet for me, my brains works another way.
It's quite difficult.
- So I will intend it to end with the idea
that it, in fact, is quite difficult, challenging.
So I'm not sure what's supposed to happen now.
- [Voiceover] Take some questions for a bit?
- Okay.
- [Voiceover] You could clap now.
(applause)
- You can see why he's a Day-Garrett professor.
(audience laughs)
- [Voiceover] Thanks.
- You're welcome.
I welcome any questions.
(audience member mutters)
Well, actually that's a great question,
and I can give you an example
that is really quite challenging.
A person who has manic depressive illness in his 20s,
who is Somalian, in my community,
speaks four languages because
of the multiple relocations that went on in his childhood.
Ends up in the U.S. with bad bipolar illness.
Three hospitalizations in the last six months,
and I'm asked to comment
on whether this person is transgendered.
Now as I talk with him,
they are living in a community that,
a small town with a small Muslim community,
with a very, very conservative mullah,
who has absolutely condemned
anything related to homosexuality.
So this person is being abused in their community
by other men of the community for being different.
They have found their way as a cosmetologist,
and are allowed, up to a point, to interact with women
doing their hair, doing their makeup and such,
but at some point it becomes uncomfortable
because they're a man.
They come wanting, they've been suicidal
and psychotic three times in the last six months,
to talk about having surgery to become a woman.
Now complicating matters further of course,
is in Iran right now it's not okay to be gay,
but it is okay to be transsexual.
That is you can have an operation
if you're a gay man to become a woman
because that's believed to be a disease,
but homosexuality is believed to be a sin.
So there's an example of a very complicated mix of things.
What I said was you have to get your bipolar illness
under control because this person
was not compliant with care
before we can even begin to deal with this.
And we have to be able to talk about
whether the issue here is that you are
completely unaccepted by your culture
and feel condemned by Allah,
or whether you really are in fact
someone who is a woman born in a man's body.
So there's an example that I think
cuts across many of the things we've talked about,
and illustrates how challenging it is
to come up with an answer.
Partly as well because depending on
which culture you're dealing with,
attitudes about masculinity and femininity
are more or less fluid.
And things can happen to you because
you're in the wrong culture.
In this case, in African, Islamic culture,
transplanted to the U.S.
I don't know if that's a, that's like, kinda like,
it gives you an idea of the complexity, yeah.
Other questions?
Have I stunned you all into silence?
(audience laughs) Ma'am?
- [Voiceover] How is your client in that video?
- My client now.
My client now interestingly ended up
in this very small, fundamentalist Christian church,
in which the pastor said, "I don't know what to do with you.
"The scripture does not advise us.
"You can either be a celibate for God,
"or you can marry a man."
Which wasn't a very good answer.
What my patient decided to do
was actually to take her 90-year-old mother in
and help her in her waning years.
And decided for now to be celibate.
But because of her Christian beliefs,
but also because she at least now understood
why she felt so confused and no longer feels confused.
That is she has now adopted an identity
as an intersexed person with a mosaic set of chromosomes
that explain this sense of discordancy inside of herself.
Again, not somebody I could ever have found to be crazy,
although I did treat her with Sertraline
for her depression (laughs), which helped.
I want to emphasize too,
I've probably treated about 25 people,
which makes me some kind of national expert at least.
It's a little bit astounding really,
but I think the challenge
with working with folks who present
with these sorts of issues is listening.
And trying to help with a narrative,
and a story, and a solution that will work for them.
I don't have an answer to each
one of these questions at all.
It's varying, with younger kids now it's much easier
because they're not so self-hating.
Although I did just see a patient this week,
a married man with a child
who has made the transition on the
4th of July of this year.
And nothing happened.
Nobody got upset, nobody got excited.
They just accepted this person
as the woman that he is, she is.
And so she came to see me
to talk about how much she hates herself
for being the way that she is.
So (laughs) you know, the issues change.
And what she said was, "I've been so busy
"making the transition that I didn't have to face
"the part of me that really hates
"what I'm putting my family through,
"and hates that I'm not normal."
So the work is moving on now to,
I'm actually gonna put this person
into a group, a mixed group.
I've treated several people now
in Rochester, Minnesota,
where we do not have a transgendered community of any size.
By putting them into my regular group,
where people actually tell them they're okay.
And so then that seems to really help.
People you wouldn't expect, by the way.
- [Voiceover] Could you explain a little bit more
about moving forward, how different
ethnic organizations are going to be doing
groups with people and certain,
Caster Semenya (mutters),
only time this is going to happen
with the Olympic Committee (mutters)
inclusion for (mutters).
- Well, it's a great question.
My understanding of where we are
is with that panel of experts
who will consider each case individually.
The standard, there have been Olympics
in which they've tested everybody, all the women,
and found any number of people,
a dozen or more who had chromosomal abnormalities,
but nobody suspected them.
There was a famous runner in the 1980s,
Jo-La Perez who turned out,
when she was accused to be a complete
androgen insensitivity, XY chromosomes.
It ruined her life, it ruined her marriage.
It ruined everything.
At this point it's about you accuse somebody,
and they get investigated.
It's not a great standard.
Obviously it's not a great standard.
In the case of Caster Semenya,
they did come up with I think a good answer.
But there's a whole lot of fussing
and bothering about your testosterone levels.
And what that means, and as I've pointed out,
you can have a testosterone level of a million,
but the receptors don't respond.
That doesn't do anything.
So we don't really have a good standard, we don't.
And really, it really is a witch hunt.
You point out that somebody looks strange,
and then they get investigated.
And maybe they get taken off the circuit for a while,
while a bunch of experts secretly sort out what's going on.
And that's why I made the comment that I think for her,
it would be nice to know what they decided
because it would help to set some precedent.
But for her privacy they didn't do that.
So we really don't know what she has, or what she is,
or what they came up with for an explanation
for this very gender atypical presentation.
So the answer really is that there is no standard
right now other than this panel of experts.
And I can tell you the state of the science is such
that there really isn't an obvious conclusion
that I think we could draw.
One other thing I probably, uh-huh, sure?
- [Voiceover] Can I ask with regard to
like your earlier point about a child
making the decision about identity (mutters).
Is there actually a clinical medical guideline involved?
- Well, I think there is increasingly consensus
that you should not do anything irrevocable
with a child until basically they're, almost an adult.
There are many examples of gender atypical boys,
for example, who may go so far as to present as girls,
but then in adult adolescence cast that off
and decide to present as men.
I think where we are right now
is let the child express themself as they are,
but see if that identity that they've adopted
is in fact going to be a permanent identity or not.
There's a woman named Dianne Berg
at the University of Minnesota,
which has a very important human sexuality center,
who works almost exclusively with children
who are gender atypical.
And again, trying to minimize the damage,
which this person spoke about.
That nobody told her anything.
Nobody exposed her to anything.
Nobody discussed anything.
But to not do anything irrevocable
until the child is ready essentially as an adult
with capacity to make that decision for themselves.
And again, if you read the popular press,
there was an article in People magazine two weeks ago
about a 12 year old who is well on her way to surgery.
But there are other examples
of children who present as girls for a long period of time
and then decide, I mean perhaps to be a gay man,
or to be just a man, but often a gay man.
A book by, written 25 years ago,
called The Sissy Boy Syndrome,
speaks to some of this from a different era,
by Richard Green, might be worth looking at.
But I think right now let's do no harm
by not doing anything like
fashioning genitals that you want this child to have.
And focusing much more on their interpersonal development,
on their brain, than on their parts.
You know, it seems to be a particular
American preoccupation with having the right parts.
The bigger the better if you're a man,
and I don't know, you know I'm going with that.
(audience laughs)
And in fact, ironically,
just because I think this story is amusing,
the person I showed you at the very beginning,
my very first patient, did go to Canada
and did have gender reassignment surgery.
And come back and said, "Yes, it went very, very well.
"They had a lot of tissue to work with
"because I was really big as a man."
Which I thought was very funny
because here was a woman (laughs)
coming and bragging like a guy might.
You know, some of that gender bending was going on.
(audience laughs)
And in fact, apparently it was a very successful surgery
for the very fact that there was
a lot of tissue to work with.
(laughter)
And I hope it's okay to enjoy what I do
because the stories are so amazing. (laughs)
I mean I try to hear them with humility
and with interest and that seems to work pretty well.
Um-hmm?
- [Voiceover] Thank you.
I feel that you've moved on the one end
to the questions that are coming
(mutters) what Caster is (mutters)
and I (mutters).
I don't know what (mutters).
If she prefers or what program you prefer,
but you know, for me the answer is very clear
that she is whatever (muttters),
and I think that that's really (mutters).
That's something that I thought
maybe I wanted you to say in response
(mutters) and with that,
I'm wondering, given that you've prevented
some bias (mutters) you're coming from has
in your own area and a male psychiatrist
and how you would answer those
particular identity (mutters).
That while sort of the scientific world
as you presented doesn't have a good answer,
or a (mutters) answer,
where we also know that
the implications of (mutters)
and you'll get answers within your (mutters)
and have (mutters)
who are gender variant
and who have (mutters)
expressing their identity and hearing it,
and so I'd ask if you could talk about
in understanding that this is
a sociocultural and socially constructed phenomenon,
how do you in concrete steps in your practice
work towards humanizing the individuals
that you are working with,
and whatever way that they have to (mutters)
And so if there are some suggestions
for (mutters) and do you ask all of your clients
(mutters), you know, what pronoun
are you supposed to use?
- I do.
Maybe I shouldn't say that quite...
I try to listen for gender variance,
and then to react or respond to it.
I try to, I let people know that they have
to help me understand because I really don't
know who they are until we talk about it,
and try to co-construct an understanding.
Now with Caster Semenya,
the New York Times ran an article very early
where her people back home,
her family, her aunties, they all knew that she was a girl.
They also knew that she was a girl
who played with the boys.
They knew that, that was what they knew.
And there wasn't a problem from their perspective.
So in essence, what it really boils down to
is what are we really about having
testosterone people in one camp,
and are we gonna put people
in a camp based on their testosterone level?
I mean, it gets pretty, pretty crazy.
I already told you that my experience has been
that no one person that I've worked with is like any other.
And I put that out there.
And the choices they make
are not like any other either.
And what always seems to come up
in one way or another is the way
that they feel estranged from the culture
that they're a part of.
And can we find a way for them to feel connected?
You know, I put the fact that
I'm a white, or a Euro-American male psychiatrist out there,
because those are problematic signifiers as well.
Could I possibly understand the challenges
of folks who come to me with these issues
because of what I look like?
But I already alluded to the reality that you really
don't know what's underneath my pink shirt, you know?
So I think we have to face our own limitations
as people who are doing gender.
And we have to try to expand our minds.
And often frankly, to expand the minds
of our patients or our clients.
Because at least with the person
I just told you about who has made the transition
and is now discovering how much she hates herself,
that's the culture internalized.
So, you know, I'm not giving you
a very clear answer because I don't think I have one.
What I've learned from being willing frankly,
to see these folks and in my community
people refer these folks my direction
because they don't necessarily want to see them,
is to be open and to do my best to be open.
And occasionally I'm confronted with my own biases,
maybe explicitly by the person that I'm with,
and we have to work that out.
But having had psychoanalytic training
and being psychoanalyzed myself,
that's the nature of the work.
You create an alliance hopefully
in which you can sort these things out.
And certainly if I'm encountering somebody
whose sexuality, whose gender expression
is different from my own,
there are going to be many opportunities
for empathic failures that we're gonna have
to work on and try to sort out.
I don't know if that is a helpful answer,
or if I'm dodging some part of the question you were asking.
Is there more to it?
- [Voiceover] Well, I suppose that's what I'm asking.
That sort of is there more to,
yes there are the potential for empathic failures
and sort of the (mutters),
but also, you know,
what are your forms when it comes to assessment?
How do you balance, work to maybe--
- Well.
- [Voiceover] Get to the place
that perhaps (mutters).
You might have a difference in your areas too and--
- Well, and I work in an organization
with 2,000 physicians and 40,000 employees.
We did this year have an LGBTI,
I may be leaving out some signifiers,
task force to work on exactly those things.
So right now we're working on adjusting our forms.
We're working on changing our bathrooms.
We're working on identifying,
actually my belief,
you can take this any way you want,
but I believe that we need to identify people
who are willing to do this work.
Not assume that everyone will do this work.
Because there's nothing more offensive than having
someone who's trying to be cool working with you.
So what we're working to do
is identify a panel of providers
who are comfortable engaging in a clinical encounter
with a person who identifies as gender variant.
And then at least setting it up so that
the providers are interested in seeing the patients,
and the patients feel that at least the provider
wants to see them, does that make sense?
I'll tell you an anecdote which absolutely enraged me.
I had a patient who wanted to start,
let me get this right,
a male to female transgendered person
who wanted to start estrogens, female hormones.
I called up the endocrinologist on call
and I said, "What should I do?"
And he said, "Oh, it's really simple.
"It's really, really easy."
What you do is you do this and you do that,
and then you order this test and you do that,
and anybody can do it.
And I said, "Well, how about I send this person to see you?"
And they said, "Oh, no, no, no.
"I'm not a specialist in that."
Literally, literally.
Now I wanted to, I don't know what I wanted.
I wanted to do something to his gender.
But anyway. (audience laughs)
That's an example of the kind of challenge that we face.
Luckily another member of his department,
another endocrinologist is being funded by that department
to go get training in centers
where people are doing this work.
So that we will have someone identified
who wants to work with folks
and who knows something about what they're doing.
'Cause there are two parts.
It's one to be open to it,
but there's another to actually know what you're doing.
And those two things are not necessarily
the same things either, right?
There are a lot of well-meaning people
who do terrible things to their clients and patients.
And there's part of that story here too I think
when we hear about this pastor.
Who really doesn't have a very good answer
for this member of his flock.
So to make a short, the summary is this,
we have a committee, we're trying to change the way
that we offer access to people with gender variance.
And are hoping to identify a panel of providers.
I already have an underground panel.
I know who they are, they know who I am.
But to make it explicit so that there is,
when someone calls on the phone for a clinic
at this institution they will be directed
to people who want to work with them.
What happens then is when you refer them
to a sub-specialist as invariably
at a place like Mayo Clinic you will,
they have the advocacy of the person making the referral.
Because a heart's a heart, you know?
So that's kind of where it is.
It's a work in progress at our place.
We just had this committee in the last year.
Just got the endorsement of our clinical practice committee
to come up with a better model
within the past six months.
- [Voiceover] Thank you.
- Thanks.
- [Voiceover] Thank you.
- Okay, thank you.
(applause)