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Brian Lehrer: Brian Lehrer on WNYC. By now, you've heard about the Supreme Court's decision yesterday upholding Tennessee's ban on gender-affirming care for minors. We covered it as it was breaking yesterday morning. This ruling has major consequences across the country as 25 states currently have passed similar laws. On yesterday's show, we extensively discussed the legal side of the story. Now, we'll look at the impact this decision will have on children and their families who are in this category.

Joining me now to share his perspective is Dr. Jack Turban. He's a psychiatrist who treats transgender adults, adolescents, and children. Some of you may remember last year, we had him on the show to talk about his book, Free to Be: Understanding Kids & Gender Identity, which explains the experience of trans kids in his practice and the treatment processes for gender dysphoria in children. He's back now to talk about how this ruling will affect the kinds of families that he works with. Dr. Turban, thank you so much for coming on. Welcome back to WNYC.

Dr. Jack Turban: Thank you so much for having me back.

Brian Lehrer: Often, when we talk about this subject, we get comments from listeners who question how children even know that they're transgender. You want to start there? How do children know that they are a different gender from their sex assigned at birth? How do they come to experience that and come to that conclusion?

Dr. Turban: Yes, we have research from cisgender kids that they start to realize their own gender and the gender of others and start to put language to that, usually between the ages of three and five. Kristina Olson at Princeton has done some interesting research finding that's quite similar process for transgender kids. They come to that understanding of themselves at a similar time. That being said, I think what people often miss is that it's not a quick process to start any of these medical interventions for gender dysphoria.

A young person would need to have understood their trans identity for years before being candidates for any of these interventions. Before being a candidate, you also need to undergo a comprehensive mental health evaluation with a psychiatrist like myself or a psychologist who's really going into all the details of understanding what these interventions mean, what they do, what they don't do, side effects, implications for what your future life will look like, involving parents really closely, et cetera.

Brian Lehrer: People not involved with individuals or families with transgender minors may wonder, "The government's concerns are about minors receiving gender-affirming care. It doesn't affect adults who are seeking to transition." This, they say, is out of concern that they're not old enough to make these life-altering decisions about their bodies. Why is gender-affirming care offered to minors? Could they not just wait until they're adults to make these choices?

Dr. Turban: Yes, I think what people miss in thinking of it that way is the real-life experience of these young kids, right? I have teens who are so distressed about the way their puberty is progressing and their body developing in a way that doesn't align with who they feel themselves to be. It can be so extreme that they can't shower. They can't go to school. Some are so distressed by their voices that they're not speaking.

To leave a young person in that situation without any support for many, many years until adulthood can be extremely dangerous and damaging. The other thing that's important to keep in mind is that puberty blockers, for instance, these medications we sometimes use to temporarily pause puberty to have more time for a kid to decide next steps, those are reversible.

You can start a puberty blocker and then later stop them, and you'll go through your birth puberty. On the other hand, if you just go through your natural puberty, those things can't be undone, right? In particular, as your voice drops, we can't really change that later. Other major physical changes that come from puberty may require surgery later in life. While the puberty blockers are reversible, puberty itself is not. That can really provide a ton of relief, being able to pause that for young people.

Brian Lehrer: Related to that, I think often our minds go right to surgery when thinking about gender-affirming care. Do minors receive surgeries under any circumstances, or let's say prepuberty minors receive surgeries under any circumstances, or only the kinds of reversible puberty blockers that you were just describing?

Dr. Turban: Certainly, no surgeries for prepubertal kids. There are some kids who have disorders or differences of sexual development, what people call "intersex conditions." That's an entirely separate field of medicine. They actually do conduct surgeries for very young children. Within my field of taking care of trans kids, we absolutely do not offer surgeries to young kids. Genital surgeries are usually not considered until adulthood.

There are some cases where trans teens have really severe dysphoria about their chest development and may want to have surgery to remove chest tissue. That, obviously, is a huge decision that would weigh the potential risks against the potential benefits and a whole team. You need a mental health professional, a surgeon, usually a pediatric endocrinologist working really closely with the family to decide that on a case-by-case basis, but that's definitely not routine.

Brian Lehrer: Can you talk about the diagnosis, because you're a psychiatrist, of gender dysphoria and how else it's treated in children without the so-called gender-affirming care that's now banned in half the country? Is therapy not a sufficient treatment, or what would a therapy-only approach look like in states like Tennessee now?

Dr. Turban: Yes. For many years, people thought that you could do these therapies to try and push people to identify with their sex assigned at birth, essentially to try and convince trans people to identify as cisgender. They were tried for many, many years. Those therapies were not successful. In 2019, our group published a study where we looked at trans adults who were exposed to those practices, and found that if you were exposed, you are more likely to have attempted suicide later in life.

If you had been exposed to those types of talk therapies before age 10, so as a very young child, then there was an even stronger association with having suicide attempts later in life. At this point, every major medical organization, including the American Psychiatric Association, strongly recommends against those practices. They're illegal in half of US states. They've never been shown to be effective. We can do therapy for other coexisting conditions, right? If you also have obsessive-compulsive disorder, you could do a therapy called ERP. If you also have generalized anxiety disorder, you could do cognitive behavioral therapy, but there isn't any evidence-based talk therapy for gender dysphoria itself.

Brian Lehrer: My guest, if you're just joining us, is Dr. Jack Turban. He's a psychiatrist who treats transgender adults, adolescents, and children, and author of the book, Free to Be: Understanding Kids & Gender Identity. We're discussing with him some of the practical implications of the Supreme Court ruling yesterday, which upheld Tennessee's ban, and by implications, the ban of half the states in the country on gender-affirming care, as it's known, the medical kind of treatments like surgeries or puberty blockers for minors. 212-433-WNYC is our phone number as we have time for just a few calls or texts. Craig in Morganville, you're on WNYC with Dr. Turban. Hello.

Craig: How are you doing? I understand this ruling is horrible, but there are other issues that they have to address within it in more details. The stat that you said that a child at three to five knows that they're not supposed to be a girl or a boy, I got to tell you, there's something up with that data. They barely know what it is to play certain games. I get it. They might have some issues to what they're thinking, but I highly doubt that they actually know what is supposed to be what at that age with anything. I think you're doing your cause a disservice. I get it. There is a problem, but that age range is just too small and too young. Thank you for your time.

Brian Lehrer: Craig, thank you for your call. Talk about that age range, three to five, Dr. Turban.

Dr. Turban: Yes, so the first research I was citing was actually of cisgender kids, so not even thinking about transgender kids. If you have any three to five-year-olds in your life, they probably can tell you if they're a boy or a girl. What Kristina Olson at Princeton has found is that for transgender children, that seems to be, again, the case. She published a study recently where she followed prepubertal children who asserted a trans identity.

She followed them for five years. Five years later, 98% or 98.5% of them still identified as trans at follow-up. We have a study of trans adults where we asked them when they first realized that they were transgender. Somewhere around 70% of them realized before the onset of puberty. Usually, it does seem to be in this prepubertal range. Sometimes people do realize later after the onset of puberty or later.

I think maybe what the caller was maybe reacting to emotionally was the thought that a three to five-year-old would be getting any of these medical interventions, but that's just not the case. For a very young three to five-year-old, to your point, they are very young. They might still be going through understanding themselves. The most we would do at that age is play therapy to let them, in a non-directive way, explore and talk about these things, make sure they know the difference between gender roles and gender identity, et cetera.

Brian Lehrer: I think another skeptical caller about some of this, but moving up the age range to some degree. Carmen in Flushing, you're on WNYC. Hello.

Carmen: Hi. Thanks for taking my call. As a high school teacher, I had increasingly students enter ninth grade saying that they're switching their gender. They had a new name or several names. We've always respected that. Interesting thing I noticed is that by the time they reach senior year, which is around 17, 18 years old, many of them, I mean, I would say around a dozen, if not more, have switched back to the original gender that they were assigned at birth.

Just seeing that firsthand has made me very wary of giving them this gender-affirming care. Had they started it at 14, 15, I think they would have made some considerable changes to their body that I don't know are reversible. Just on that firsthand witnessing of that change, I think it's a good idea to wait until they're after 18 or further developed physically. Thank you.

Brian Lehrer: Thank you, Carmen. What do you say to that high school teacher?

Dr. Turban: Yes, I would say it sounds like none of those kids did start medical interventions. I think it gets to a really important point that we're not talking about one type of kid, right? The kid who comes to my office who, since they were in elementary school, knew they were trans and are so dysphoric towards their body that they can't shower and they can't go to school. They're so upset about their voice that they can't speak.

That's a very different kid than maybe a kid in high school who is gender non-conforming or doesn't like gender roles, so maybe adopts a new name and pronouns, but it's kind of fine with their body and isn't seeking out the medical interventions. It's true that we have patients come to us who ultimately are not appropriate candidates for medical interventions. It sounds like that may be the types of kids that you are seeing.

Brian Lehrer: How do you assess that? How do you decide in the case of a minor who might come to you wanting some kind of gender-affirming medical care or seeing themselves as transgender individual? How much probing do you do? You obviously want to be supportive of these kids who really are transgender. How much probing do you do to decide if they're really in that category, and how do you do it?

Dr. Turban: Yes, it's a long process. If people are interested, we published a paper in the Journal of the American Academy of Child and Adolescent Psychiatry that goes in much more detail. We first have a set of sessions with a young person. We get a history of how they've thought about gender, any steps they've taken towards a new name or pronouns, how people have reacted to them.

If they have any trauma history, make sure they know all the physical effects of hormones, both positive and negative. When they start, when they reach their peak, make sure they know the difference between sexual orientation and gender identity and gender expression. Really think through what is their future life going to be like if they are to transition and have these physical changes. That's maybe a quarter of the list of things that we go through.

Then we go through a similar set of sessions with the parents, giving them education about all of the same things. A lot of what we're telling both the parents and the kids are important things that people have told us about hormones as adults that they wish they had known or would have been important to know as young people. There are some of these theories that people feel their initial trans identity was from trauma or was from internalized misogyny.

We don't have evidence whether that's true. It certainly harkens back to the ex-gay movements of the past where people were gaslit into thinking that was true and later found it wasn't true for themselves. We don't shy away from that. We talk about those theories with young people and their families to see if they feel like that might relate to them. It really is this in-depth, comprehensive education, information-gathering process. First, with just the kids, then with just the parents.

Then, usually, there are a set of topics that between the kids and the parents might be getting a slightly different answer. We bring everyone together to have open, respectful conversations about it, to get everyone on the same page. It is very rare for a parent to not have some concerns about their kids starting gender-affirming medical interventions, right? It is a huge decision. We're really taking our time to speak with everyone and try to get to what the best answer is for their child.

Brian Lehrer: Let me sneak one more caller in here because Ali in Brooklyn, from, I think, personal experience, wants to reply to the caller earlier who said, "How could a kid aged three to five know any of this about themselves?" Ali, you're on WNYC. Hello.

Ali: Hi, Brian. I just wanted to call. My niece, she's transgender. She started affirming that she was female around age three. When I was younger, my younger sister had cancer. She ended up losing all of her hair through chemotherapy. We were at the grocery store, and she was misgendered as a boy. It was very upsetting to her. At the time, she was young. Obviously, three. She knew she was being misgendered. It really goes to the point that no matter if you're straight, gay, trans, kids know. Kids know at a very early age whether they're male or female. It just is.

Brian Lehrer: Thank you very much. I want to get your quick take, Dr. Turban, as we run out of time on another story. The New York Times reported yesterday that the Trump administration will end some specific LGBTQ suicide preventions service or prevention services through the National Suicide Hotline. Specifically, they're ending their work with The Trevor Project, which the Times describes as a nonprofit that has provided specialized support to LGBTQ callers to the 988 suicide prevention hotline.

They say they've received a stop-work order effective next month. It says they've instructed the National Suicide Prevention Hotline, the Trump administration has, to stop offering specialized support to LGBTQ callers, saying those callers can rely on the hotline's general services. I wonder if you've seen that or if you have a thought about the actual implications for LGBTQ people who call 988 as a practicing psychiatrist.

Dr. Turban: Yes, I saw the headline and was shocked. I think the timing's particularly egregious, to be frank.

Brian Lehrer: Like Happy Pride Month.

Dr. Turban: Well, it's Pride Month. Just a few weeks ago, under threat from the Trump administration, the largest pediatric gender clinic in the country closed at Children's Hospital LA. This decision upholding bans on medical care that every major medical organization endorses for trans kids. That Supreme Court decision went to an effect yesterday. This really seems like adding insult to injury.

I went through psychiatry training myself. Throughout my formal psychiatry training, I received little, if any, training on how to take care of LGBT kids in particular, maybe a little bit on lesbian, gay, bisexual kids, almost nothing for transgender kids who really have to seek out specialized training to know how to support those kids and their families. I can't imagine the general crisis hotline. People are very happy with this since they're going to be getting calls from, again, suicidal children who are at very high risk. They may not know how to handle the situation. This is relatively breaking news to me from yesterday. We'll have to see how it evolves, but it's hard to see any way in which that's a good idea.

Brian Lehrer: Dr. Jack Turban, a psychiatrist who treats transgender adults, adolescents, and children. He's back after his appearance last year where he talked about his book, Free to Be: Understanding Kids & Gender Identity. Back today after the Supreme Court ruling on this yesterday. Thank you so much for your time.

Dr. Turban: Thank you again.

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