- Hello, my name is Arlene Istar Lev.
I am a social worker.
I'm going to be talking today about
Clinical Skills Working with
Gender Nonconforming Children and Transgender Youth.
The first thing I just want to do is
I just want to introduce myself so you get a sense
of who I am and what my work is.
In addition to being an adjunct here at Smith College,
I've also been an adjunct at
the State University New York at Albany
in the Social Welfare program
for a little over 25 years now.
I also teach at Empire College.
I teach a wonderful course called
Sex and Gender in a Cross Cultural Perspective.
My primary work is I am a therapist in Albany, New York.
I run a business called Choices Counseling and Consulting.
You could find us online at www.choicesconsulting.com.
I've been an addictions counselor
for about 30 years and I'm also am a gender specialist.
The work I'm going to be talking to you about today
is some of the work we do.
Working with transgender folks and specifically working
with children, youth and families.
Okay.
I've written two books.
I want to talk about them just a little bit for you.
The first book I wrote is called,
"Transgender Emergence: Therapeutic Guidelines
"for Working with Gender-variant People and their Families."
The book came out in 2004.
I'm working on a second edition of it right now.
It was the first book in the field of transhealth
and transgender studies that came
from a clinical perspective looking at how to work
with gender variant and transgender people
from a nonpathologizing perspective.
It also is immersed in a family systems orientation.
So it looks not only at the transgender person
but also the people who love that person
and ways to clinically assist families
in the healthiest emergence when
gender issues surface in a family.
The second book,
"The Complete Lesbian and Gay Parenting Guide."
I always joked is not really complete at all
but it is a guide.
Also the title of it is a little deceiving
because the working title I wanted was
how queer working with lesbian, gay, bisexual,
and transgender families.
At the time that the book was published,
they were very nervous about putting
the word transgender and bisexual on the cover of the book.
They thought that it would not sell.
That was the title that they came up with
but I do want you to know that every chapter in the book
looks at issues for transgender people
who are becoming parents, seeking parenthood,
fighting custody battles for their children,
and managing the daily issues of family life.
Okay.
So, my clinical stance,
this is in general.
Working with all people who are gender-variant,
transgender, transsexual, is that gender-variance
is a normal expression of human diversity.
That there is nothing specifically about
being transgendered that is pathological.
We could have a whole conversation
about gender dysphoria and the DSM.
We're not going to have that conversation today.
That doesn't mean that people don't have issues
or struggles in their coming out process
and certainly in managing the complications
of life in a transphobic culture.
But that gender-variance itself is a normal expression
of human diversity.
That societal oppression is what causes the "disorder."
I'm referring there to the old DSM diagnosis
of gender identity disorder.
It's not the gender expression
that is actually causing the challenges
but it is the social oppression.
Now, I will say that gender dyphoria
which is the new diagnosis in the DSM-5 exists.
Meaning that transgender people experience dysphoria
or I should say some transgender people
experience dysphoria.
That doesn't make it a pathological disturbance.
And that family acceptance or rejection
is a core issue for trans people
integrating their gender identity into their lives
in productive and meaningful ways.
So how your spouse, how your children,
how your parents, and to a larger extent,
how your community and your job,
and your family, how they treat this process of emergence
is going to affect people's ability
to integrate in healthy ways.
My philosophy, my theory is that supportive systems
based therapy for gender-variant and trans people,
and their families will assist in the development
and maintenance of stable healthy families.
To translate that, what I'm saying is that being transgender
and specifically, in terms of this workshop today,
being a gender-variant, gender atypical child
or being a transgender youth.
That our goal here is the maintenance
of healthy family relationships
while the child develops and explores, and stabilizes
an identity which if you think about it,
is really what we're doing with any family that's raising
any children in any circumstances.
Transgender emergence is defined here as
a normative life cycle event, a stressful one
but part of the developmental process.
What I'm really saying here is families deal with stuff.
They just do.
They deal with parents ...
Any set of parents that are raising children
are going to go through rough spots.
Families divorce.
Families deal with the birth of a child
that has a disability that is surprising and shocking.
People have to cope with that and learn to cope with that,
and learn how to reframe that,
and learn how to welcome their child.
Their child needs to be raised in a family
that is loving and supportive.
The work of gender needs to become part of
the overall work that when we think of any kind of struggle
that a family would go through in any kind of way,
unemployment, financial stress,
health crisis in one of the parents.
That our goal is development and maintenance
of healthy, stable families and seeing
this as part of a developmental process.
So the specific clinical stance
in working with children and youth,
is to nurture the emerging gender identity
of children and youth regardless of
whether it is typical or atypical.
Part of what I'm saying here is that to be a good parent,
to be a good therapist in working with children,
that all children regardless of whether
their gender development appears to be typical
in the ways that we expect gender to be
for boys and girls or whether that development is atypical,
our goal is to nurture the emergence of gender identity.
To specifically develop protective strategies,
to support children and youth who are living
in hostile environments.
Many of the children and youth that we work with
are living in very hostile environments
that either have parents that are supportive
or in many cases,
they have very supportive parents
but they're in communities and educational situations
that are supportive.
The third one is to support families and social institutions
to become more gender-flexible
so that gender nonconforming children
are integrated within their families
and within their communities.
To support those parents and institutions
that are already advocating for their children.
Since they are often isolated and under public scrutiny.
We could argue and we're going to talk a little bit
more later about the different kinds of parents
but there are parents who are very, very
supportive of their children.
They often are scorned sometimes by their own parents,
sometimes by community and neighbors,
school systems that are difficult,
so our job is to really have their backs.
On the other hand,
we need to be challenging families
that are less supportive of their children
so that we can help to integrate these children
into their families and their communities.
That work that the clinical stance is from an article
that I published with Laura Alie.
Gender nonconforming children and youth
are first of all an emerging population.
That 15 years ago, I've been working
with the transgender community for over 25 years.
Specialist, I have folks coming from hundreds of miles away
to come to my practice.
I would say 15 years ago,
we had seen a small handful of transgender youth
and virtually no families that were dealing with issues
having young children that were exhibiting gender-variance.
Of course, it's an emerging population.
It's not a new issue.
One of the pieces we have to really look at
is what is happening in our social communities
that is creating a space finally for transgender people
to be out where people are talking about it.
Twenty years ago, when I said the word
transgender in a classroom,
nobody knew what I was talking about.
Ten years ago, a handful of students knew
what I'm talking about.
Now, every student knows what I'm talking about.
This has become part of our social and community.
It's in the media.
Families are more sensitive to these issues.
I also think part of what's happening is that
there are parents, there is a group of parents
that when their children come to them
to talk about these issues,
they're not shutting it down.
I really do think a decade ago,
if a child came to a parent at five years old
and said, "I really think I'm a boy not a girl, mommy."
I think most parents would've said,
"You know, honey, that's just not true.
"Go clean your room."
I just think we would've been really not listening.
I think parents are listening more than they ever did.
That children are coming out younger and younger.
We have many families that we work with
in my office that have children that really began
to clearly identify as the opposite gender
than the one that they were born in
at five and six years old.
There are unique ethical issues working
with children and youth who are gender nonconforming.
What are the ways that I'm going to frame
this workshop today is really looking at
some of the ethical challenges
that come up for us as professionals
when families are coming for us.
I always joke parents come in and they're sort of,
"Tell me, is my child really transgender.
"Tell me, is my child really a boy or a girl?"
This is not like pee on a stick.
I can tell you whether it's a boy or a girl.
It doesn't work that way.
It's a complicated process that takes months and years
of their own development as a human beings
to understand who they are.
I mean I'm not telling them who they are.
They're telling me who they are
but this brings up a lot of ethical challenges for us
that I want to really make sure that we're looking at
and talking about those.
It's important to know when we talk about ethics
that there is almost no research
on treating transitioning children.
We have a population of young children today.
They're socially transitioning.
Sometimes as young as five or six,
often seven, eight, nine, ten years old, prepuberty.
I want to be clear I'm not talking about hormones.
I'm not talking about surgery.
I'm just talking about social transition
where they're changing the pronouns.
They're changing their names
and they're often going to school in the opposite gender
from the one in which they were assigned at birth.
But we really don't yet have any research
on how these affirmative practices are going.
Research is ongoing right now
but it's going to be another five to ten years
before we really do have good research.
We do however, have growing evidence-base research
on transgender youth.
We have excellent research on young teens
who are properly assessed, who begin a transition process,
who start on hormones and most of this comes out
of The Netherlands, and following a group
of young transgender youth
over a period of five to ten years.
It's important to know,
these kids are doing phenomenal.
With proper screening and treatment,
transgender people are able to come out
and actualize their identities at much younger ages,
and the results that we're seeing
are really quite phenomenal.
I have two quotes here that I just want to share.
The first one from Esben Pirelli,
who is a therapist in Norway.
"Children with gender dysphoria
"are referred to in the literature as gender disturbed,
"but it might be better to ask
"why some expressions of gender disturb?"
What is it about children who exhibit cross-gender behaviors
or express cross-gender desires,
or the little girl who wants to cut her hair very short,
the little boy who likes to play with girls,
things and toys, and clothing.
As we'll talk about people are much more uncomfortable
with little boys doing this.
We have to look at why do some expressions
of gender disturb us?
The second one from Gerry Mallon whose been working
with transgender youth for many decades.
Why are gender-variant children
so disturbing to people, especially parents?
What is it that happens to us as parents
when children are exhibiting gender-variant behaviors?
Just a couple of things before I dive in
to talking specifically about children and youth,
what I want to do is just frame this
because I know that many of you who are listening to this,
I know some of you are gender specialists
and are curious about what I have to say about this
but some of you who are listening
have absolutely no background
at all in working with transgender people.
I want to just create a blueprint for looking at this.
When I'm using the term transgender,
it's as a general term which includes a lot of people.
Sometimes some of those people might not want
to be included under that rubric.
We'll talk about that in a second.
Most simply transgender people cross over,
that's what the word trans means,
the commonly held boundaries of what society
deems appropriate for males and females.
In the broadest sense of the word,
we're looking at men who are more feminine
in their appearance or dress or manner,
than we think men should be.
Women who are more masculine in their appearance
than we think women should be than
what our image of women is in our culture.
I want to say cultures because
this is really true cross culturally
or the rules are different cross culturally
in each different culture.
It is true that virtually every culture,
men and women have different expectations
of dress and behavior and even emotional life.
In the loosest term,
transgender includes everybody that's deviating.
In the most specific terms,
when we're talking about what people refer
to as the transgender umbrella.
We're looking at people who are gender-variant.
We're looking at people that are gender atypical.
Some people prefer that term
and people who are gender nonconforming.
Nonconforming is I think a less judgmental term
than either variant or atypical.
It could infer people who are purposely nonconforming.
But when we're talking about children,
we're talking about people who, for lack of a better word,
I'm going to say naturally
or authentically are nonconforming
just as the child's identity is emerging,
what they're interested in does not seem to be typical
of what we expect boys or girls to be interested in.
People who are transgender, people who are transsexual,
I'm going to talk more about that in a second.
People who are cross dressers generally,
when we're speaking about cross-dressers in this culture,
we're talking about men who wear women's clothing
because in our culture, in US culture
and western cultures, western-European cultures,
the expectation is that women can pretty much
these days dress anyway they want
and the social ramifications are less.
Now, I want to be really clear when women deviate
to an extreme place.
There are absolutely pressures socially
and I would argue limited job opportunities,
and there are definitely ramifications in employment
and in the social world.
There's no question about that
but not to the extreme that it is for males who cross dress.
Generally speaking, when we use the term cross-dresser,
we're talking about people who are born as males,
who are living as men and who wear women's clothing
for pleasure, wear women's clothing some of the time.
Not all of the time, sometimes wear women's clothing
because it's erotic for them.
Sometimes just because they like dressing
in women's clothing.
I want to really be clear that the reason that women
have so much more freedom of dress today
than men do is because of feminism.
I think sometimes that gets lost.
This one's in a classroom, I asked,
"Why do you think women have more freedom?"
Nobody could find the answer.
To me the answer is so obvious
that the feminist movement created a set of freedoms
within an oppressive culture
that women have in terms of dress today
that most men do not have.
Intersex, two-spirit, a word use often
in Native American cultures to express
the overlap of male/female identities.
Often used also to include people we would call
lesbian, gay or bisexual people.
The belief system is is that two-spirit people
carry the spirit of both men and women.
That gives them a unique position
within their cultural context of understanding
the social world in which they live in.
The term transmen, we're talking about people
that are born female
that are transitioning or living as men.
The term transgender women, male to female.
People who are born male and are living as females.
Some people prefer the term transmasculine
or transfeminine and looking at it
as a spectrum of gender of which direction
people are moving in.
Gender benders, people who bend genders.
Sometimes because it's fun
and they enjoy doing that.
They like to mix gender and people who blend gender.
Some people identify as bigender,
being both male and female
or containing both of those of parts.
Gender queer, a term I will identify more deeply later on
but also this idea of the overlap between
both male and female as well as the overlap
between sexual orientation and gender identity,
and third sex.
This umbrella is a broad umbrella.
I do want to say one thing about the word transsexual.
I'm not going to be using that term a lot today
because I think it's a complicated term.
It's a heavy term to be putting on children and youth.
I think it's a perfectly lovely term
for people who want to use that term as adults.
Transsexuals are people who believe that
their physiological body does not represent their true sex.
Most transsexual people desire sexual reassignment surgery
or what we more often called these days,
gender confirmation surgeries.
Again, it doesn't mean that children and youth
are not thinking about things or talking about these things.
I also think it's important when we're talking
about transsexuals particularly post-transition adults.
People prefer to simply be referred to
in the gender that they're living in as men or as women,
not as transsexual women or transsexual men,
regardless of their surgical status.
Now, certainly, I could say a lot more about that
but I'm not going to because I want to have us focus
more on children's issues.
I do want to talk for a second about genderqueer.
Genderqueer is a new term used,
I want to say primarily with folks under 30,
although I once said that at a workshop
and had somebody raise their hand
and said, "I'm 40 and I identify as genderqueer."
I don't want to limit it to that.
It's a relatively new term
that looks at gender identities other than man or a woman.
Sometimes people use the term non-binary.
Outside of the gender binary system
that poses people as either male or female.
It's an overlap or it can be use as an overlap
of looking at gender identity.
My core sense of gender,
how I know myself to be male or female.
And my romantic sexual orientation,
my attraction to males, females or both.
Sometimes people talk about two or more genders
using the term bigender or pangender.
Bigender meaning two.
Pangender meaning all which there includes
also transgender identity so you know
that one sexual attraction is to men
specifically transgender men for example.
Non-gendered, people who identify as not having a gender
being agender, and moving between genders.
Having fluidity of gender, third gender, or other-gendered.
Genderqueer, Julie Tilsten says,
"To queer something is an emergent process
"of disrupting expected norms in such a way
"that new possibilities emerge and standard,
"unquestioned practices become open for interrogation."
What I'm going to do is show you a video
called, "Put this on the Map,"
of young people talking about genderqueer
and talking about these overlaps
and the truth is that they say it so much better
than I can say it.
What I'm going to do is I'm going to go over
looking at what is sexual identity.
I'm going to be looking at four specific
components of sexual identity.
Biological sex, gender identity, gender role expression
and sexual orientation.
I want to be clear that I'm not using
the term sexual identity in the way
that we use it colloquially
that as a synonym for sexual orientation.
Sexual orientation are desire for men or women
or both or neither is part of our sexual identity
but it is not actually in the way that I'm using it.
It's not actually a synonym for it.
I've tried to find another term besides sexual identity
to talk about this but it's difficult.
So I don't know what other term to use
that is encompassing in the way
the term sexual identity is encompassing,
and all of these terms are part of the handout
we have on definition so you can look at that.
Multiple components of sexual identity are sex
which includes our chromosomes,
our physiology, our genitalia.
Our gender identity, our sense of our self
as a man or as a woman so core sense of self.
It's very unusual for someone not to
have a sense of themselves as a man
or as a woman, as a male or as a female.
Again, this may or may not hook up
with your physical body parts
but that core sense of I know who I am,
I think is almost universal.
Our gender role, how masculine or feminine we are,
how we perform or dress or the manners we have.
Our sexual orientation,
the directionality of our sexual desires.
One of the ways I think about sexual orientation
is walk into a party.
Are you more attracted to men?
Are you more attracted to women?
Are you more attracted to ...
Are you equally attracted to both
or are you attracted to both?
Are you attracted to neither?
I really want to point this out
because I'm going to ...
this part I'm going to be doing now
and probably 10 or 15 minutes,
I have spent three or four hours
just sussing out these different parts of self,
the sex gender identity, gender role,
has nothing to do with actually talking
about our erotic identities,
about what we do in bed,
about what we like to do in bed,
about what positions we like,
how playful or unplayful we are.
I always joke, I'm happy to come back
and talk about what we do in bed.
No one ever hires me to do that.
They always want me to talk about this
but I think that we need to be looking at the fact
that when we talk about sex,
we could talk for hours about this
and not actually ever get around
to talking about our actual sexual behaviors.
Okay.
Biological sex is the physiological makeup
of the human body,
referred to as our biological or a natal sex.
Natal meaning where it starts
so we're born and we are identified or assigned
as either a male or a female, a boy or a girl,
Our biological sex is very complex
includes our genetics and our hormones.
and includes our morphology, what we actually look like,
our biochemistry and our anatomy,
As well as how these things affect
not only the physiology of the body
but also the differentiation of the human brain.
My trick question is always how many sexes are there?
I know if you're taking a test,
you would know the right answer is two.
Sometimes people start thinking three.
Well, I guess intersex people are a third sex
in different cultures around the world.
People actually identify five sexes or six sexes
so the idea that there's only two sexes
is not a universal idea.
But for our purposes here,
what's important to understand is
that approximately two percent,
1.8% is the statistic that I've heard
of infants born are born with ambiguous
genitalia or an intersex condition.
The difference there is that sometimes
people can have an intersex condition
that does not necessarily change their physiology
so you wouldn't necessarily know that at birth.
Or you can be born with ambiguous genitalia
that would highlight to the medical professionals there
that something is different with this child.
In the culture that we live in here in the US,
most children that are born with intersex conditions
are assigned a female sex.
I just want to make it really clear
that all children are assigned to sex.
We think about it like we have a sex
but actually we're all assigned a sex.
The children who are assigned female
that have ambiguous genitalia
or some kind of intersex condition,
it's generally done because people ...
When I say people here I mean medical professionals
determine that the boy's penis is going to be too small.
Sometimes they say, too small to urinate standing up.
They surgically operate on the child
to become a girl.
This is a area of absolutely huge conflict.
It's a topic I could probably talk about
for an hour without stop.
I don't want to do that.
What I do want to do is just make a couple of points
is that intersex people are generally
an invisible population.
Usually, when I have an audience and I ask
how many people here knows someone who's intersex?
I get maybe one person raising their hand
and even that's unusual.
We don't talk about this.
Oftentimes, children are reassigned
and the parents never talked to the children about it.
Lots of times, the parents are very poorly informed
when they are given permission
to have the child have surgery.
You know when doctors come in,
when you have a new baby born
and say there's a problem and we need to do surgery,
very few parents are in a position at that point
to be saying, "Wait. I want to go home
"and do some research about it."
I wrote an article called intersexuality in the family
where my brilliant suggestion about
how we need to reform the treatment
of intersex babies is point number one.
Encourage the parents to take their baby home
and get to know their baby and love their baby.
There are almost no medical situations
that require immediate ...
I would say there are no medical situations
that require immediate surgery.
There are some situations that require treatment
but not surgery.
There's no reason to be doing surgery on newborn babies.
What we need to be doing is bonding with children
and having parents become educated about what to do.
Hopefully, that will be a change that
we will see in the decades to come.
Most of them are assigned female.
The trend that's preferred these days is intersex.
Sometimes you'll see the term DSD
or disorders of sexual development.
That was a term developed with the hope
of being able to talk to medical professionals
in this field in a language that maybe
they would understand more than terms like intersex.
Some people find the term disorders
of sex development very offensive
and it's been suggested particularly by Mickey Diamond
that we use the term instead differences of sex development.
What I want to say is really
the most important clinical issues.
As a therapist in this field is looking at the impact
of early surgeries on later sexual functioning
and what happens with the medical trauma
in the invisibility.
This is a population that's dealing with
a tremendous amount of shame.
I want to be really clear that being born
with an intersex condition
is not in anyway a psychosocial crisis
and may not have any challenges with the child
in terms of gender identity.
I know that that sounds bizarre.
It seems like of all people, this population,
shouldn't they really have trouble
with their gender identity like it's unclear
whether they're boys or girls.
That to me speaks more than anything
of how we really understand that gender identity is core.
That regardless of what one's genitalia looks like,
people have a sense of whether they're boys or girls.
The real issue is we need to focus in on here
has to do with sexual functioning,
medical trauma, family communication around these issues.
Hopefully, looking at ways we can change the system
and get more family therapist, social workers,
child psychologist into the consulting room
when babies are born with these conditions.
Okay, the second area I want to talk
about is gender identity which is where
we're going to spend most of the day today.
Gender Identity.
Gender is a social construct
that divides people into "natural" categories
of men and women that is assumed
to derive from their physiological bodies.
What I'm saying is the baby is born,
we look at the baby, we say, "Is it a boy or a girl?"
Actually, these days we do that on a sonogram
long before the baby is born.
What are we looking for?
What we're really looking for is a penis.
If we see a penis, we say that's a boy.
If we don't see a penis, we say that it's a girl.
Then we make assumptions about who that child
is going to be based on their physiological body.
Now, for most people, our gender identity
is congruent with our assigned sex
meaning you're born, look at the sonogram.
Look at the sonogram.
They say it's a girl.
Here's your new baby.
Your baby's a girl.
We dress the baby in pink.
We do a whole bunch of socially construed ways
of raising that ways child to be a girl.
Most of us say, "Yeah, I'm a girl. That's okay."
We're not really in argument with that.
A small percentage of the population,
how small is questionable.
It says that identity is not congruent with who they are.
Again, what we're going to be talking about
is sometimes people are aware of this at very young ages.
Gender role is the expression
of masculinity and femininity.
What we used to refer to as sex roles
for those of you who are listening
who took women studies classes back in the '70s and '80s.
Gender role is probably a clearer term.
Gender roles are socially dictated and reinforced.
That means that the society we live in
tells us what roles girls and boys should play.
Now, you know I'm in my mid50s and growing up,
in the time that I grew up,
it was very, very clear.
There are little children's books
that says things girls like to cook
and boys like to do sports.
That system is breaking down a little bit
again, thanks to feminism.
But it still exists in very harsh and strong ways
that we often forget that.
Gender roles are also enacted and performed.
What I mean by that is consciously or unconsciously,
we all wear our gender.
We literally, dress in the morning
and we put on our gender.
We put on earrings
or when we go to the store to buy eyeglasses,
there's a male section and a female section
of what eyeglasses boys and girls should wear.
I just was looking the other day at the eye store
and they had glasses for very little children.
There was pink and there was blue.
These ways of dressing ourselves,
when women say, "I shop at this store
"but I never shop at that store."
What is it?
What is it about those stores
that those are not my kinds of clothing.
I don't dress like that.
I don't look like that.
That so much of what we think of
when we think of how we dress is actually gendered.
We're all wearing our gender.
We put it on in the morning.
We shop for it at the mall.
What kind of haircut you have,
what your eyeglasses look like, your shoes.
I have to say this even our socks,
our socks like what is it about our socks
that have to be gendered.
If you go into the boy's department,
socks are black, socks are blue,
socks are brown, socks are green,
and sport socks are white.
That's what socks are.
You go into the girl section,
socks are all kinds of things
and their stripes and their colors,
and they're bright.
They have lace on them, why?
Someone's going to say, "Well,size."
Well, you could just make them in wide variety of sizes.
I mean that's just ...
Why do we have to mark these things as gendered?
Our mannerisms, how we move ourselves.
Research has shown that when women talk
and again, the more feminine, the more girl-like,
we tend to move our wrists more.
We tend to, when we turn, we don't just turn our head.
We turn our bodies.
We know that women have a little more swing
in their walk when they ...
Some women have more swing in their walk when they walk.
As I'm saying this, I encourage you all to notice this.
When you see a woman or a young girl,
who we perceive of as less feminine.
What is it that we're perceiving?
What is it that we're looking at?
And often what it is is that she carries
her neck and shoulders, her arms and her hands
without these movements.
Those movements actually create an image
that in our culture becomes more masculine.
It's a little hard for me to do that
because that it's not my gender expression.
So it's a little harder for me to do that.
If I wasn't sort of stuck on a film right now,
I often get up and I do a little walk back and forth
to show how those movements change,
how we actually perceive people.
That's where that stereotype comes from,
that gay men have limp wrists is because of that image.
Well, first of all, an image that falsely connects
gender expression and homosexual behavior.
We'll talk about that in a minute.
But the other thing is that it also ...
The assumption is that someone who is a man
who is moving more fluidly is perceived of as more feminine.
Okay.
Gendering can be conventional
meaning it follows the rules of the culture
or people can purposely bend those rules.
That gender rules change from society to another society,
from one culture to another.
In contemporary US culture,
women have tremendous freedom of dress compared to men
who still have a very limited repertoire
of what they can and cannot express.
If you think about it,
if you're in at a conference or you're in a classroom,
and you look around at the way women are dressed
in any social gathering somewhere between 50 and 75
or 80% of the women are wearing pants,
which 50 years ago really
would've been considered cross-dressing.
We've really shifted how we view gender roles
and what the rules are.
Gender identity and gender role
are two sides of the same coin.
That's something John Money said years ago.
Meaning that people have a gender identity
and they express it in their gender role.
I have a sense of myself as a woman
and I wear clothing and choose ways of behaving
that illustrate myself as a woman in the world.
However, gender role may suggest that I'm a female
but it doesn't confirm it.
It doesn't confirm it.
That we perform our gender role
in order to tell people what our gender identity is.
Except we know that lots of people
are hiding their true gender identity.
What I mean here is that the (mumbling) man
who lives as a man, who feels himself to really be a woman
may be very closeted and not out,
and not showing that to the world in any way.
Dr. Jamison Green, the president of
the World Professional Association for Transgender Health,
has said, "I change my sex
"so you could see me as I see myself."
I just want each of you to think about that for a second.
What would it mean for you if you are exactly who you are.
You know who you are but when you were out in the world,
walking through the world, everybody else saw you
and used the other pronoun to identify you
that they didn't see you.
What would it take for you to want to be congruent
with your inside and outside so people see you as you are.
Okay.
The last category here is sexual orientation.
I always say that after we talked about gender
and gender identity and gender roles,
sexual orientation is just really easy.
Like who are you attracted to?
Do you like girls?
Do you like boys?
Are you asexual that you're not really attracted
to people in any particular kind of way?
Or you don't want to act on that?
Are you bisexual or pansexual
that your interest are not really controlled
by whether people are male or female
that that's not really not the thing that limits,
limits is a good word there,
your sexual orientation.
Some people refer to people who are heterosexual
and people who are homosexual as people who are monosexual.
Okay.
A couple of points that I just want to reinforce here.
Sex and gender are not the same thing.
That's really as we move into talking
about children and youth,
sex is about your physiology,
gender is about your inner sense of self.
When parents have a child who is identified,
assigned at birth as a boy,
they have expectations of what child gender will be.
But if we really examine the fact that
these are two separate parts of self,
there's really nothing pathological happening with the child
who happens to be born as a male or a female
but is expressing a gender identity that is not matching
their physiological sex.
That sex gender and sexual orientation are ...
That these categories we're talking about
are not polarities.
When we look at the reality that the two percent
of the population is intersex,
then this concept of male and female as opposites
doesn't really make sense.
When we look at the fact that transgender people are here.
They exist.
They're part of the human family.
Then the issues of man and woman,
of these opposites that there are men and there are women.
There are people who are feminine.
There are people who are masculine.
There are people all the way through the spectrum
that have complex ways of seeing these intersex,
gender-variant, cross gender, androgynous
and/or bisexual people are made invisible.
I just want you to look at the slide which really ...
This is heuristic way of really identifying this
for those of you that think in pictures more than words.
We grew up.
We live in a world that says
that male and female are opposites.
That you're either a male or you're a female.
That you're either a man or you are woman.
That you are either masculine or feminine
and we accept again, as I said, a number of times
but it just bares repeating that the expectation
is that females can go a little bit more
to the masculine side without it being a problem.
Males and boys are kept much more in a smaller box
of what is acceptable behavior.
Sexual orientation that people are either heterosexual
or homosexual that these are inborn identities
in the brain that were born with them.
Despite the fact that we know that people are fluid
throughout their lives
that many, many, many people are bisexual, are pansexual.
I'm sure that virtually everybody that is listening to this
has known somebody in your life who was solidly heterosexual
for the first 30 years of their lives
and then came out.
It is also true that many of us know people
who are gay or lesbian-identified who then fell in love
with someone of the opposite sex.
It's a nice concept to think that these are just inborn
but in reality, there is actually a lot of fluidity
about sexual behavior and sexual orientation and identity.
This next slide looks at and the best way for me
to talk about this if you're familiar
with the Russian Matryoshka dolls,
the little dolls that one goes inside of the other,
inside of the other, inside of the other.
That when a baby is assigned male at birth,
the assumption is is that they are a man.
That they will grow up to be a man.
That the assumption is is that males, men are masculine.
In the world that we live in,
if you are a masculine man based on the fact ...
All that is based on the fact that you have a penis.
That you will therefore naturally
be attracted to feminine female women.
Male masculine men are naturally, naturally,
that's the sort of they're in quote
attracted to feminine female women.
I mean that is the jigsaw puzzle pieces.
That's the parts that go together.
That's the assumption we live in.
That's the culture that we live in
is that these things are first of all opposites,
that they are built inside of each other naturally.
I often tell a story that when I adopted my older son,
I became within a week the mother of three footballs.
Now, you know the fact that my son was 10 days old
and probably many years away from
potentially playing football,
for the record, he actually never did.
I gave away those footballs.
It was clearly a social message.
All of those footballs came from men in my lives.
They all came from heterosexual men in my lives.
Most of whom I've partnered
with close female friends of mine.
The message was really clear,
listen you lesbian who is raising a child.
I just want you to be really, really clear
at the time I was a single parent.
We just really, really want you to be really, really clear
that this child is a boy.
Boys need to be raised as boys
and here's the football to give you a tool,
to work with you here that the expectation we have as men,
is that you will raise your son to be a male masculine man
who will be absolutely be attracted
to female feminine women, and be heterosexual.
This is really deeply ingrained in our culture
and how we see things.
You know the story I often tell is
I was with my younger son at the eye doctor once.
We're sitting in the waiting room.
He's playing on the floor.
He's probably all of three years old with a little girl.
They're being very, very cute with each other.
They're hugging each other.
The other mom turns around to me
and says, "Oh, they are so adorable.
"Maybe they'll get married someday."
Now, besides all of the incredible heteronormativity
of talking about the sexual and future romantic
attachments of three-year-olds,
you and I know that she never would've said that
if it had been two little boys doing the same thing.
Look at how sweet they are.
Maybe they'll get married someday.
This heteronormativity, this assumption about one's body,
one's gender, one's sexual orientation
and what is appropriate is built in
to the very framework of our culture.
What I'm really saying more than anything else
is that there are multiple and diverse ways
of experiencing and expressing gender, gender role,
and sexual orientation that the boundaries
of all of these categories are fluid.
They're mutable and that this is not a binary.
Okay and here's a wonderful picture that describes that
in more fun ways than my little boxes.
The genderbread person which shows you gender identity.
Woman, man, or in the middle, we have gender queer,
gender expression, feminine, masculine.
In the middle, androgynous.
Biological sex, female, male.
In the middle, we have intersex and sexual orientation,
heterosexual, homosexual and bisexual.
If you look at the genderbread person,
what they're saying is our identity is in our minds.
Our orientation is in our hearts.
Our expression is how we dress ourselves up in the world,
and our sex is between our legs.
Okay.
What is the difference between
sexual orientation and gender identity?
This is from Diane Ehrensaft.
She says sex is who you go to bed with
but gender is who you go to bed AS.
When we talk about gender expression,
this genderqueer overlapping gender expression
and sexual orientations,
some research has found that transgender people
have unique ways of looking
at their sexual orientation labels.
People talked about being a transgender lesbian
or a heterosexual lesbian, or someone who is omni sexual,
I really like that term.
People who are attracted to genderqueer people.
I love this one.
Bisexual, when I'm dressed in female clothing
but otherwise, I'm heterosexual.
Again, I could spend hours literally talking
about how people view themselves,
how these different components of identity mix and match
in individual people to make sense of how they see
their sex, their gender,
their gender identity, their gender role.
The point I want to make here is this is very, very complex.
It's not as simple.
When we're talking about small children
and we're talking about small children saying,
"I know I'm not a girl. I'm a boy."
That who these people are going to grow up and identify as.
That the options that are available to them
are much broader than the options
that were available for many of us.
It's going to be a process of how they come
to define and experience themselves.
I also want to say that
there's a fluidity of these components.
This fluidity does not mean that one can change people
from the outside in.
So I want to be really clear about that.
I'm not talking about reparative therapy here.
What I'm talking about is that the reality of human being's
lives is that throughout the course of a life,
people often change their sense of identity.
We need to acknowledge that this is not just
about digging structurally to the core and finding out
exactly who we are as much as it's a process
of continually emerging into a sense and understanding
of who we are that develops and changes throughout
our life times in various and sundry ways.
Our job as clinicians is to support people
in emerging identities
and it's not just emerging identities internally
but as the culture changes,
more possibilities become available.
It's also important to realize that changes
in one area of identity can impact changes
in another area of identity.
For example, if we go back to the slide
that look at the different ways,
the components of identity.
I'm going to use a personal example here
to contextualize this.
I am a female.
You're going to have to just take my word for that.
I'm telling you that that's true.
I was born a female and I have a female body.
I am a woman.
I identify as a woman.
I'm comfortable with the term woman.
I want to be really clear here.
I'm not always comfortable with what other people think
a woman is or a woman should be
or how a woman should behave
but I'm comfortable with the term woman.
On the spectrum of masculine and feminine,
I'm more towards the feminine end
but certainly, there's lots of women
that are way more feminine that I am.
Okay.
But I would identify more to the feminine side.
I identify as a lesbian.
I am a female, a woman, a femme would be actually
how I would use the term for my gender identity.
I'm attracted to women.
My partner is also born female.
You have to take my word for that.
She identifies as a woman
but the word woman is a little more complex for her
than it is for me but she definitely uses that term.
If she has to choose between man or a woman,
she would use the term woman.
Her gender identity and expression is far more
to the masculine end of the spectrum than mine is.
She identifies as a lesbian.
Okay.
So, if she were to come to the conclusion
to tell me to identify as someone who is in transition,
female to male.
She was to say, "I've determined
"that I want to live as a male."
She would still be born female
although her identity would be male.
She would identify as a man.
She would identify possibly as a transman.
She would ...
I'm using she pronouns here because she's a she to me
but he would identify as a transmale
probably would no longer identify as butch
but would still identify as masculine.
But the term lesbian no longer fits does it.
Let's, for the sake of argument, say
that his gender identity, that his sexual orientation,
I'm sorry, is the same as it always was.
Right now, she likes women.
After transition, he was still primary attracted to women.
For the record, that can change too
but let's say that he is attracted to women.
That would sort of technically make him heterosexual, right?
It's a man who's attracted to women.
But what does that do to my sexual orientation?
For the sake argument, we stay together.
We're in a relationship still.
I still identify as a lesbian for the sake of argument
but I'm involved with a man.
The point of this illustration is that
this stuff is complicated.
Would my identity change from lesbian to bisexual?
You see here with the word genderqueer
is just this lovely term that just erases all
the complexities of it and allows both of us
to take on a term that still maintains a queer identity
and doesn't get into any of the confusing details of
are you a lesbian or what?
So all of that stuff.
It's a lovely term in that sense
but the point of my illustration is really to give you
the understanding that changes in one part of ...
The components, I always wanted to get sort of a mobile
that can I turn around that changes
in one part of identity can create potential changes
in other parts of her identity,
and how people resolve those or understand them
is completely unique and individual
so the image I just created of that couple.
Couple A might look like that
and identify as heterosexual.
Couple B might look like a transguy,
partner who used to be in a lesbian relationship
and they identify as genderqueer.
The third group of people might identify ...
How people are going to identify themselves
is going to be different.
Just in finishing this section up,
I want to say that gender is the elephant in the room.
People minimize gender nonconforming expression.
They look at the very masculine female person
and they say to her a butchdyke,
"Oh, I never really noticed you were masculine."
This actually happened to us.
Not realizing that they're actually insulting you.
Why didn't you realize it?
Why don't you see me?
These adorable pictures here are my children
when they were younger.
When the little boy is playing with jewelry or dress up,
is carrying himself in a certain way,
we say, "Is he gay?"
We're talking about little, little children.
Again, confusing sexual orientation and gender identity.
The other one is my younger son's attempt to put on lipstick
at about, I think, he's about two or three years old there.
We confuse sexual orientation and gender,
we confuse gender identity with gender expression.
We need to stop doing that.
Okay.
This is what people see gender as, black and white.
This is really what gender is
and I think this ability of helping people to see
that they can determine their own gender
and gender expression.
My goal here as we move in to talking about children
and youth is really to decenter heteronormativity.
Heteronormativity, I'm defining here
as an organizing principle that shapes our views
of what is normal, what normal people look like,
what family should look like that there's a husband
and a wife, and two children, and a dog.
It's okay to have a dog.
Based on heterosexual and gender normative assumptions
that there is institutional prejudice that reinforces it.
There's the boy's bathroom and the girl's bathrooms.
There's boy's toys and girl's toys.
That there's internalized shame that people
who are different particularly around gender feel bad
about themselves and that when they come into therapy,
seeking help that we, clinicians, come to the session
with all sorts of clinical assumptions about what is normal,
what is healthy and that's based on heteronormativity.
I want us to stop doing that because
we're going to have a lot of families coming in
with gender diverse children that we need
to be looking at in different ways.
Okay.
Now, let's focus on specific issues that children and youth
are bringing in to therapy.
Children and youth expressing gender-variant
or gender deviant behaviors have historically been
understood to be suffering from severe psychopathologies.
The belief system was that gender issues
were caused by the encouragement of cross-gender behavior
by mothers, and/or the absence of strong father figures
in the daily family life.
Again, when we talk about heteronormativity,
we talk about Freud in psychology.
The assumption here is that in order for a girl or a boy
to develop in appropriate ways as girls and boys,
that they need a mother and they need a father,
and who express opposite gender roles
and men should be strong and women should be nurturing.
There's a whole set of of rules that we,
not only as clinicians but as the lay public,
has sort of internalize at what is normal.
When children are exhibiting behaviors that don't fit that
the assumptions that we have for them.
We immediately start to pathologize it.
Again, girls can get away with a whole range of behaviors
before anybody gets really worried.
Boys have a much limited repertoire of what they're allowed
but this image of strong father figures
and nurturing mothers, for those of you listening,
who have studied the long and painful history
of reparative therapy for gay and lesbian people.
Understand that these are recycling of old models
of treatment of how we treated gay and lesbian people
until really the removal of homosexuality
from the DSM in 1973.
This idea that gay men became gay
because they didn't have strong fathers.
Now, almost nobody, there's still a handful of people
out there but almost nobody really buys
that kind of bullshit today.
We know that gay men have all kinds of fathers.
They have strong masculine fathers.
They have no fathers.
They have loving fathers.
They have gay fathers.
They have feminine fathers.
The diversity of parents raising children
is as diverse as any other group of people.
Of course, now we have many, many children being raised
in same sex homes, the lesbian parents and gay dad families.
Don't seem to particularly have any more children
that are gender-variant than any other group of people do.
I trust on some level that everybody listening to this
knows that this older models are crazy
but I don't know that we always realize how much
we still think about, always still assume parts of them,
and how we look at families.
I think there's a lot of subtle ways
that this still determines how we see people.
The treatments, interestingly enough
and I've always found this to be fascinating.
If you look at this literature that the theories
of gender acquisition really come out as
a psychoanalytic or psychodynamic background
about proper boy-girl behaviors.
All of the treatments are all behavioral
so I always find that kind of an interesting
little theory blend there.
The treatments have been justified on four grounds.
Number one to eliminate peer ostracism.
I just want you all to think about that for a second.
Really, that's what we do.
If you have an African-American kid
who's being picked on in school,
we change the African-American kid?
No.
We change the system so the system is less racist.
So the child has more ability to thrive in that environment.
If a child who uses a wheelchair
is getting picked on in school,
what do we do?
Throw out the wheelchair?
Ban the children with disabilities from going to school?
No.
What we hopefully try to do is create
a more accessible environment both physically
as well as emotionally and psychologically
in terms of what people understand about disabilities
and about human diversity.
It's a very odd idea that we're going
to eliminate peer ostracism of gender-variant children
by changing the gender-variant child.
I really think we need to look at
their psychological thinking about that.
That we treat the underlying psychopathology.
Again, if you're familiar with this literature,
the theory here is that the parents have psychopathology.
The theory is that the parents have mental health issues.
That the mother wants her little boy
to be very feminine in some way.
That the father is not rising up
to his masculine responsibilities.
That's a theory.
If we think that the family is pathological,
why are we treating the kid?
I mean if we really think the family is pathological,
and I'm not saying these families are pathological,
I want to be really clear.
But if that's your theory,
then it seems like you shouldn't be treating the kid.
You should be treating the parents.
I want to say that they are very blatant.
These people who work on these behavioral treatments
that they want to prevent homosexuality.
They say that blatantly now.
Homosexuality is no longer a diagnosis in the DSM.
I think the majority of the western world
is moving into an understanding that sexual orientation
is just part of human diversity.
But somehow, some people are still thinking it's okay
to be treating young children to limit the possibility
that these children will grow up to be gay
or lesbian, or bisexual.
The last one is to prevent
gender identity disturbances in adults.
I know that this is confusing
but many of these folks that are working on
these behavioral treatments see homosexuality
and transsexualism as a continuum.
Slight gender variance becomes homesexuality.
Extreme gender variance becomes transsexualism.
So we're trying to eliminate
this whole spectrum of behaviors that I already told you
are actually two different components of behavior.
But in their mind,
they're actually part of the same spectrum.
The WPATH standards of care
and if people are not familiar with WPATH,
I strongly encourage you to go to the website,
the World Professional Association of Transgender Health
and look at the standards of care.
I will have a small disclosure here
that I was part of the committee that wrote
the standards of care and I really like them.
I feel really good about them.
Anybody who's working in this field should almost
pretty much have memorize the standards of care
in terms of clinical treatment
because it is really the guidelines.
It is the standard of care.
It helps us determine proper and accurate care
for both adults and children and teens
who are dealing with gender issues.
The ethics of reparative therapy are the treatment aimed
at trying to change a person's gender identity
and expression to become more congruent
with the sex assigned at birth
has been attempted in the past without success,
particularly in the long run.
Such treatment is no longer considered ethical.
I want you to hear that.
That the standard of care written
by the international organization who,
oversees is too strong a word,
but who sets the bar for what
good transgender health looks like
is saying that reparative therapy,
that trying to take a gender-variant child
and making them nongender-variant is A, doesn't work.
It has not been successful.
We've seen that in studies
and that it is no longer considered ethical.
This quote may seem slightly out of context here
from Susan Golombek's work.
Susan Golombek did some of
the early work on lesbian parents
because in just a sentence or two that contextualize this.
Back in the day, not that long ago,
25 or 30 years ago, lesbian women who divorced their ...
Women who were divorcing their husbands
because they were coming out as lesbians
were very rarely allowed to maintain
custody of their children.
Lots of different researchers,
Susan Golombek did the work in the UK.
Charlotte Patterson did a lot of work here
in the United States of looking at
how does the sexual orientation of a parent
affect the sexual orientation
and gender identity of a child.
This was something Susan Golombek wrote
when she began.
It's important to note that without this research,
the idea of lesbian and gay parenthood
would not really exist today in the way that it does.
That adoption, and donor insemination,
and same sex marriage, marriage equality would not
really have happened without us setting the stage for this.
Susan Golombek says, "Whether or not the gender development
"of children in lesbian families would be expected to differ
"from that of children in heterosexual families
"depends on the extent to which it is possible
"for parents to influence
"the gender development of their children."
Now, I love that statement.
I find it incredibly humorous as a parent
of a now, 18-year-old and a now 14-year-old.
I can barely get my kids to eat vegetables.
I can barely get them to shower.
I can barely get them to do their homework.
I think I'm a pretty good parent.
I think my kids are doing relatively well.
It is very difficult to influence our children.
I have lots of opinions about everything
from how my kids like to wear their hair,
to how my kids like to dress,
to who their friends are,
to what things I think are important
for them to study or what studying means
or how long they should study
or whether or not and how much sleep they should get,
or how much pizza they should eat.
I try really hard to influence them
and I guess my mother try to influence me.
In the end, we all become who we are.
The point here is that parents have incredibly
little influence over who their children are
in terms of gender.
It just doesn't work that way
that you can want your little boy to play football,
for example, and then you have a little boy
in front of you who tells you who he is.
Who he is may not be somebody who likes to play football.
Our only choice as parents is whether we listen
or whether we don't listen.
Diane Ehrensaft says that,
"Parents have little influence
"over their children's gender identity
"but extensive influence over
"their children's gender health."
That's really the place that we're starting from here
is what is the work that we're going to do
to assist children in developing healthy gender identities
regardless of whether they are typical or atypical.
This next few slides that I'm going to do,
I put together a number of years ago
with a colleague of mine, Dr. Irene Sills
who is a pediatric endocrinologist in Syracuse.
This is how do our clients, families, children come to us?
What do they say?
My three-year-old boy insist on wearing
his sister's ballet costume.
He wants to wear it to school.
I don't let him but I can't stop him
from wearing it around the house.
Is there anything wrong with my son's hormones?
says the parent.
I saw my daughter go into her brother's underwear drawer
and put on his underpants.
In fact, I've seen her do this multiple times.
I scolded her and she cried.
Why is my daughter doing this?
My ten-year-old daughter has just started growing breasts?
She tells me she wants to cut them off.
She says she doesn't want to wear a bra,
get her period, or do anything feminine.
Is my daughter gay?
Again, we see there the overlap of gender
and sexual orientation, and the confusion of the parent
trying to figure this out.
My teenage son ran away from home
and has been living in New York City.
He's been taking estrogen pills
from some people he knows who are not doctors.
He says he is a woman and wants to have surgery.
How can I help my child?
What did I do wrong?
Why is my child like this?
Is there something wrong with my genes?
My husband's genes, the father's chromosomes?
The sperm donor's genetics?
I love that one.
Is my child gay?
Can you fix it?
Will he grow out of it?
Should I make her wear girly clothes?
Should he play more sports?
My husband blames me for not disciplining him.
My wife blames me for not accepting him.
My mother wants me to send him
to a treatment deprogramming center.
My priest or minister wants me to exercise or heal him.
The school won't let me let him wear those clothes.
The Department of Social Services
or Child Protective Services won't let me
let him wear those clothes.
Luckily, we're not seeing that as much as we used to.
There were some cases back 10-15 years ago,
where CPS really did step in and remove children
who were gender-variant from their parents.
Parents are coming in.
They're upset.
They're disturbed.
They want us to help them figure out what is going on.
What do we know?
How will we able to help them?
One of the things that we know
is that most adults who are transgender tell us
that they knew when they were young.
I think that's a really important thing for us
to keep in mind.
That most transgender adults did not come to
that realization at the age of 20
but at three, or five, or seven, or nine,
they knew that they were different
and they knew it had something to do with their gender.
They may not have had the language for it.
They may not have had words for it.
That over and over again,
adult transgender clients tell me
they prayed to God that they would wake up in the morning
in the opposite sex.
The other thing that we know which is a contradiction
is that gender nonconformity during childhood
does not inevitably continue into adulthood.
There are lots of children who are atypical as children
in terms of their gender expression, their gender role,
their gender play, their choice of clothing,
how much they are like or unlike
other boys or girls their own age.
But when they go into puberty, this changes.
When they go into adulthood, it changes.
Very feminine woman as I used to be a tomboy
when I was a kid but that just changed.
We could have all kinds of conversations about
obviously society's reinforces
and supports those kinds of changes.
But accepting that many, many, many people
are expressing themselves in a way that is
more or less authentic to who they are.
That we need to understand that although
most transgender people knew when they were young,
not all gender-variant children will grow up
to identify as transgender.
So sorting out those populations become
I think an important part of work that we're doing.
Many gender nonconforming children actually identify as gay.
We have a lot research to back this up.
There's a lot of criticisms I could give about the research.
The research was done first of all 25 years ago
when options to be transgender did not exist
in the same way they do now.
The research took place at time that as these young children
were growing into adulthood,
they were also was the hayday of the early days
of the gay liberation movement.
Coming out as gay was a happening thing at that time.
There was a place for them to be
where coming out as transgender really in the mid80s,
there may not have been as clear a place to be that.
We have some evidence that children
who are gender nonconforming, that some of these chldren
grow up to be gay.
We have some evidence that some of these children
grow up to the be trans.
We have evidence that some of these children
grow up not be gay or trans,
and seem to exhibit fairly typical gender identities
as well as a fairly heteronormative sexual orientations.
We also know that children and youth are vulnerable
and their identities are still shifting and forming.
We have increasing evidence that the brain
does not really reach its full maturity
until the early 20s.
The joke in my household with two teenage children
is why are they behaving that way?
Well, they have no frontal lobe.
That's why they're behaving that way.
I don't mean that in a disparaging way
as much as I mean it in a sort of gallows humor
as a parent trying to survive my children's adolescence.
There really is a truth that they are developing.
They're trying to figure out the world
and they're doing that in the best ways
that they know how.
We'll just share a clinical story many years ago.
I was working with young boy.
He's about 14 years old.
He had come to me because
he identified himself as transgender
after he had gone online
and looked up some information.
I had gone to his parents who were not well educated
about this issue but were pretty supportive
but wanted him to go to therapy.
They didn't really want to talk about this at home.
I was given my job to explore this with him.
We spent a number of months in therapy
talking about sexual orientation,
talking about gender identity,
and there was one point in therapy.
You know I'm just going to share this with you
because I know that talking about one's gut as a therapist
is probably not evidence-base research.
But I've been doing the work I do for a long time.
My gut was telling me for a number of reasons
that I didn't really think that this young person
was "really a girl" in the way that people talk about that.
But I thought he was dealing with sexual orientation
and being attracted to males but he was a young developer.
He hadn't really hit puberty yet
and was not able to really identify sexual orientation
but that's kind of where I thought this was going.
At one point in our clinical conversation,
I'm going to name a town here when I say this
that may or may not be a town all of you know
but the point of the name of the town
is that it is a small town.
That's the point, relatively small town.
He says to me in session,
"I'm not like any of the other boys I know.
"I'm not like any of the men that I know."
We talked about how and why and what does that look like.
I'm just more gentle.
I like more pretty things.
I'm interested in the kinds of things I'm interested in
from horticulture to art are just not the kinds of things
that any of the boys I know are interested in.
They're all interested in sports.
I'm not interested in sports.
I said to him the world is full of a lot of men
that are like that.
He said to me, "Not in East Greenbush."
I said to him, "You're 14 years old."
"In a few years and I know when you're 14,
"18 feels like a really long time away
"but in a very few short years,
"you're going to be able to leave East Greenbush
"and go out into the world.
"I assure you that there
"are men in the world who are like you."
He said, "It seems that maybe I should hold off
"on living as a girl until I have more life experiences."
I don't want you to hear that story
because that's an unusual story.
The majority of people that come to me
with gender issues determine and I agree
that they are indeed transgender.
However, we defined that term and that social
and medical transitions are a good thing.
But I want to share with you that story
because children and youth can only work
with the knowledge that they have access to
which means that it's a knowledge in their immediate world
as well as the vast amount of information
they're getting online but as we all know,
where they're going online
and where they're getting information
may or may not be accurate.
It may not show all of the options
that are available for them.
What do we know?
We know that trans children and youth
who cannot actualize themselves are at high risk
for mental health problems and addictions.
We have excellent research,
more on LGB than LGBT but the T knowledge
is increasing the researches.
It is increasing all the time.
Children who are in repressive, oppressive social situations
are at high risk for depression.
They're at high risk for anxiety.
They're at high risk for homelessness.
They're at high risk for HIV.
They're at high risk to drug and alcohol abuse.
They're at high risk for getting beat up in school.
They're at high risk for being abused.
That we know that LGBT youth
often feel isolated and vulnerable.
We know there's a high incidence of substance abuse
among these population that there
are school violence directed at them.
We know that there's a high risk of pregnancy
which again may seem contradictory
that a young girl for example who identifies as gay
might have a higher risk of pregnancy
than a straight girl.
We talked about the limitations of the frontal lobe.
Sometimes because the girl identifies as a lesbian
or because she identifies as genderqueer,
or because she identifies as transgender,
she's actually not going to take the same precautions
regarding pregnancy as a girl who is heterosexual would do.
Because in her mind, I'm not really straight
so I can't get pregnant.
It's not always clear but again, the frontal lobe,
we know that young people do not think
using their frontal lobe that they do a lot of
their thinking from their emotional centers.
They may or may not be using the same kind of precautions.
Risk of HIV infection at great vulnerability of prostitution
and being runaways, and school-leavers,
and all of the research that we have
shows that this is more intense for children of color
than it is for white children.
These are pretty serious issues of concern.
Okay.
Let's talk for a minute about the trajectory
of gender nonconformity so what happens?
We have a child who
is exhibiting gender nonconforming behavior.
What is this likely to become as a the child matures?
Historically, most of the studies we did were with boys.
Some of that had to do with funding
and some of that had to do with the fact
that more parents bring boys in to treatment
because again, boys have a much smaller repertoire behaviors
that are considered normal,
that are considered heteronormative for them to behave in.
When they step outside of those,
they're much more easily brought into treatment.
I'll give you an example of that.
I had a family come to see me.
I don't want to label the family
but they were a incredibly heteronormative family
in terms of how gender was seen in their family.
Dad worked at a very typical male profession.
Mom was a stay at home mom.
They were definitely a family that believe
that women cook and men mowed lawns,
and et cetera, et cetera.
They had four children.
A youngest one of whom was exhibiting in their eyes
enough gender nonconformity that they brought him in
to see a specialist.
In my interviewing the family,
and my working with the child,
I, basically, saw nothing about this child
where that was atypical at all.
He seem like a pretty typical boy.
He dressed like a pretty typical boy.
He identified as feeling like a pretty typical boy.
The only thing that was different about him
was that he really liked to play with barbie dolls.
He would steal the barbie dolls from his sister's room.
His father would punish him for that.
His punishment became this increasing issue
in the family where he was really being
highly reprimanded and spanked
for stealing these barbie dolls.
He still kept stealing the barbie dolls.
They were concerned that these meant
have really serious meaning that
they wanted me to figure out.
My treatment plan, a brilliant therapist that I am,
was that they should buy him some barbie dolls
and stop worrying so much about what that means
that a boy would play with barbie dolls.
I mean the idea that that was really the only thing
about this child that could be considered
at all gender nonconforming.
But here, Diane Ehrensaft's quote I said earlier
about gender health.
That this child is being made to think bad things about
who he is and what he likes.
He's being forced to question his gender
in a way that he was not questioning his gender.
He just wanted to play with barbie dolls.
Sometimes parents make a bigger deal about this
than is necessary.
That's something we also need to look at.
The newer studies are actually looking at
both girls and boys which is good.
Studies being what they are,
these range of what we're seeing
but somewhere between 12 and 27% of the boys and girls
that have been on studies on the last 5 to 10 years
show a persistence rate of gender dysphoria into adulthood,
about one out of four kids.
However, and this is really important,
the persistence of gender dysphoria into adulthood
appears much higher for adolescents.
That means when you see a child who is five years old
who is gender nonconforming,
there's a one in eight or one in four chance
that this child will continue to be gender nonconforming
through childhood, through adolescence and into adulthood.
But when you see a child who is already a teenager
who is entering their teenage years,
who is expressing gender dysphoria.
Who is expressing pain and discomfort around their gender,
there's a much higher chance that that child
is going to grow up to identify as transgender
and request tranmedical treatments
to support a gender transition.
This is the work of my colleague, Kelly Winter.
What Kelly Winter says is that when we look at
the research of desistance.
In other words, what they mean by desistance
is which children actually stopped
so we have a gender-variant child and then the research
is showing that if one out of four continues.
That means three out of four don't continue.
Those are the desistors.
Those are the children who go on again to develop
what somebody out there considers typical, normal,
heteronormative identities regarding their gender.
What she's saying is that
we've conflated a number of issues,
we've conflated in a number of subsets
of populations into one.
Now, one of the first ones I just want to mention
is a number of these kids just drop out of treatment.
To conclude those children as desistors,
I mean we don't know that
because their parents pulled them out of therapy
or because they didn't want to go back to therapy.
Of course, tells us nothing about whether or not,
they have a typical or atypical gender identity
five, or ten or fifteen years later.
That's something we need to know.
What Kelly Winter is saying is that
the conflated subsets, the nested subsets
and she's here talking also about for some reason
little Matryoshka dolls seemed to be very important
in the gender for people that talk about gender.
That one inside of the other that we're confusing children
who are socially transitioned with children
that are gender dysphoric with children that are diagnosed
with gender identity disorder or gender dysphoria.
with gender nonconforming kids.
That these are really different populations
that children who are gender nonconforming
may indeed be gay, may indeed be straight,
may indeed grow up to have or not have gender issues,
that children depending on where you are,
the children are being diagnosed.
So are we looking just at a population who is diagnosed
who fits diagnostic criteria.
Are we looking at a broader range like that child
who wants to play with barbie dolls.
Are we looking at children that are in pain?
We talk a lot about gender dysphoria.
We don't talk enough about gender euphoria.
Not all children who exhibit a typical behavior are in pain.
Actually some of them are quite happy
with their gender-variance.
So who are we looking at?
Are we just looking at people who transitioned
as young children into teenage years.
Or are we looking at children that are growing up
in homes who are socially transitioning
would not be possible for a whole bunch
of different kinds of reasons.
They are again, they appear to be desistors.
They appear to be people who are normative
but we don't really know the outcome of that down the road.
Okay.
There are three potential outcomes
that I see for gender nonconforming youth.
One is that gender variance is an expression
of gender diversity and its potentiality in all children.
Meaning that all children, all children are capable
of exploring gender at little boys are as interested
or potentially as interested in playing with glitter
and wearing high heel shoes and playing with lipstick.
And little girls are capable of exploring and being
interested in things that are traditionally
considered masculine whether that's carpentry
or mowing the lawn or playing sports whatever that is.
We need to broaden the definitions and understandings
of what gender-variance means and understand
that in a gender-health world, in a healthier world,
that all children will express a diversity of genders.
That gender variance can also be an early expression
of homosexuality or bisexuality.
Now, again, we have really good research
that shows that this is true but even research aside,
we have the narratives and stories
of thousands of gay and lesbian people
that talk about being gender variant as youth.
These are not people who identify as transgender
but they are people who identify as gay, as lesbian.
In some case, bisexual who express and talk about,
again, in a colloquial way, we always knew,
they always knew.
There's actually a website that shows pictures
that people posted of themselves as young children.
The little boy who is sitting on the bed.
He's about seven years old drinking a glass of water
in what is perceived of as a feminine position,
the little girl who is in the cowboy outfit.
Looks like there's a little butch
and the gay and lesbian community takes
this great pride in saying,
"Look, we always knew that
"I was different from a younger age."
Of course, what they're really talking about is gender here
not sexual orientation because these issues
get conflated in our cultural understanding.
They're often used as signs to say,
"Yes, I always knew I was gay."
Look back studies show that there does seem
to be some evidence that and I want to be really clear here,
not all of us who are lesbian or gay-identified
expressed gender-variance but a certain portion of people
who grew up to be gay or lesbian also exhibit
gender variance in childhood and youth.
The third one is that gender-variance
is an early expression of transgenderism
with or without gender dysphoria,
with or without gender dysphoria.
I make the point I made earlier about gender euphoria.
That sometimes when we're looking at children
who are expressing gender-variance particularly,
I'm going to say extreme gender-variance,
it is often an expression of transgenderism.
Part of our goal is to figure out which group
these kids belong to is to help them understand
which group they belong to
and help their parents understand the fluidity
between these identities.
Here's the controversies we have.
How do we assess that?
What assessment tools do we have to look at, to talk to ...
I remember talking with a female child a number of years ago
who is ten years old, who said, "You know I know I'm a boy."
I said, "Well, how do you know you're a boy?"
She said, "Because I like to play football."
I'm not sure that liking to play football means
that you're definitely a boy
but that was the only language this ten-year-old had
to talk about her identity was actually something
that really is not about identity but it's about ...
I mean if we change the world
so that girls could play football,
and there was a girl football team,
would you still want to be a boy?
How do we assess this?
I think here's that ethical dilemma for us as clinicians.
What if we're wrong?
What if I'm making decisions for families?
I'm not making the decision for families
but I'm the expert.
The families are coming to me to talk to me.
What if the advise I'm giving
or the judgments that I'm making
or the assessments that I have
or the evaluation that I provide for this family is wrong?
How do we support parents?
How do we advocate in schools for parents?
How do we protect children from violence and abuse?
There's a lot that we don't know.
Most importantly,
we don't know the outcome for any children.
We don't know for sure what any child outcome
is going to be because we simply cannot know that.
What we do know is that all children
are hindered by binary views of gender and the socialization
that comes from that.
I'm going to show you a video here
of children not gender-variant.
Children talking about gender ...