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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. It's Pride Month, so we will take this time now to learn more about a group whose existence has been made into a polarizing culture war issue, transgender children, for our latest Pride Month segment. In previous years, Pride Month has been a time of more simply perhaps celebrating diverse expressions of gender and sexuality.

This year, for a lot of LGBTQ people, things feel particularly tense, where in a national election year, the existence of the most vulnerable members of the LGBTQ community has been weaponized for political gain, just the existence of trans people and trans children. Last month, Donald Trump promised to roll back Title IX protections for transgender children on day one of his presidency, a move that would "prohibit federally funded schools from preventing transgender students from using bathrooms, locker rooms, and pronouns that align with their gender identities."

While intense transphobic rhetoric comes from the top of the Republican Party, we've seen states put forth bills that seek to stigmatize and in some cases outlaw crucial aspects of transgender life and care. The news isn't all bad though from that perspective. Yesterday, a federal district judge in Florida, maybe you heard this, struck down that state's law banning gender-affirming care for trans youth. In a 105-page decision, the judge ruled that "gender identity is real." Florida had unlawfully banned puberty blockers and hormone treatments ignoring "widely accepted standards of care."

Now, there is seemingly endless debate about how to care for transgender children, what kinds of care are performed in the best interest of children, and ultimately, whether they should exist at all. Rather than further politicizing this issue, though, in making children the center of our red versus blue battles, let's discuss what life is like for transgender children and their families.

Joining me now to shine a light on this experience is Dr. Jack Turban, director of the Gender Psychiatry Program and assistant professor of child and adolescent psychiatry at the University of California at San Francisco. He's recently published a book called Free to Be: Understanding Kids & Gender Identity. Dr. Turban, thanks so much for joining us today. Welcome to WNYC.

Dr. Jack Turban: Good morning. Thanks for having me.

Brian Lehrer: Your book follows multiple transgender children throughout their early years of life, I'll tell our listeners. Why don't we start as close to the beginning of childhood as we can because I think people are often surprised by how young some transgender children are or at what a young age an expression of questioning the identity versus the gender they were tagged with at birth seems to occur. Talk about how early your book addresses children's experiences.

Dr. Jack Turban: Yes, one point I try and make in the book is that gender experiences are really diverse and different for different young people, but there certainly are kids who in their pre-pubertal years, so elementary school, sometimes even preschool years, have a really strong sense of their gender identity being different from what was on their birth certificate. It's really important to note that for these very young kids, we don't consider any medical interventions despite what you might hear in a lot of the political conversation.

It's really making sure that they have a space where they feel safe and supported and can talk about those experiences and make sure basic things like bullying and harassment aren't happening in schools. Certainly, some kids have a very strong sense of this very young, similar to how a lot of cisgender kids have a sense of their gender identity in their preschool years.

Brian Lehrer: What is gender exploration? I'm going to ask our listeners this too. If you are the parents of a transgender child or if you are a transgender person yourself, think about your earliest experiences of this and talk about what that felt like, what it made you think about as early in your life as you can reach back to, and socially what that was like, meaning in your interactions even with your parents and then with other peers as you were just a kid trying to figure out who you were.

212-433-WNYC, 212-433-9692 on what gender exploration and expression looked like for you or for your kids so other people can understand it, not so much from a political standpoint, but from a personal experiential standpoint here in Pride Month. How would you begin to answer that question, Dr. Turban?

Dr. Jack Turban: Gender identity is really complex and it's how we think about ourselves in relationship to masculinity and femininity. I have a whole chapter in the book that suggests exactly what you're saying of giving people prompts to think about their own gender identity. I think of there being three parts. We know from some of the scientific research, including these twin studies, where you can look at identical twins and fraternal twins and see how likely if one is trans is the other to be trans and separate how much of this is genetics, innate, biology versus how much of it is from the environment.

Those studies suggest that 70% of your gender identity seems to be this biologically determined thing. I hear a lot of people talk about this transcendent sense of their gender, so just a feeling of their gender that's really hard to put into words. Some kids might draw themselves as a certain gender and have a, "Wow, this is me," feeling. Or they might use a new name and pronouns and it feels really in line with who they are, or they might feel that their birth name and pronouns really create distress for them, but just this feeling that's hard to put into words.

Then there's your relationship to gender roles and expectations. This is really complex and also very fraught for a lot of people since gender roles have been used to disenfranchise people often and they vary culture by culture. You can't deny the fact that the way you relate to different gender roles and expectations impacts the way you think about yourself also. Then the third part I talk about is your relationship to your physical body and its gendered aspects.

As you can imagine, those three parts can combine in a lot of different ways, and there's a lot of ways to be trans also. I have trans kids who maybe have a really strong sense of that transcendent sense of gender identity but feel pretty okay with their physical bodies. I have other kids who really have distress around their bodies not aligning with their gender identity, and those are the kids that we sometimes talk about medical interventions.

Brian Lehrer: What about the kids who are more gender fluid, that is, let's say, assigned male at birth who does not firmly identify as a girl but more a non-binary kind of identity?

Dr. Jack Turban: There are a lot of kids like that. One of the main characters in my book, I follow from their childhood into early adulthood, and that is very much their experience. The thing that was most important for that person was just having a safe space to talk about this and explore and understand themselves, and also making sure that we worked with their schools to make sure that they weren't bullied, that they could use bathrooms safely, that their family understood them and could support them.

As much as we talk about these medical interventions, I think it's often the focus of politics. One of the best predictors of good mental health outcomes for trans kids is just having a loving, supportive family that understands them. We do a lot of work with families just making sure that everyone can communicate.

Brian Lehrer: In your book, you define a phenomenon that many people may experience regardless of how we relate to our sex assigned at birth, gender threat. What is gender threat and what happens to trans children who experienced gender threat early in life even from their parents?

Dr. Jack Turban: Gender threat is really common. It is an experience where usually early in your life you do something that doesn't align with societal expectations based on your sex assigned at birth. Maybe you are assigned male at birth and you play with dolls and you get bullied, or maybe you were assigned female at birth and you want to play rugby and someone tells you women shouldn't do that, you can't do that. Then a lot of people will force themselves into these rigid gender boxes to prevent more of that bullying and harassment.

For trans kids, this is particularly intense because they often get a message very young that their gender-diverse expression is bad or not acceptable or shameful, and then they hide it for a really long time. We published a study recently where we found that the median amount of time between realizing your trans identity and telling anyone is a decade. Really, these kids are hiding this and suffering with it for a really long time.

My hope is that we can open up these conversations so that kids feel like they can talk about it more, but definitely, for parents, it's often difficult because they have their own experiences of gender threat. They want to save their kids from that same kind of gender threat. That is often what makes this hard to talk about.

Brian Lehrer: Aaron in Brooklyn, you're on WNYC. Hi, Aaron.

Aaron: Hi, Brian. Great show. I'm really glad you're doing it. I am the father of a trans, almost eight-year-old, girl who before their fourth birthday, basically came to us and said, "I'm a girl. Why are you calling me a boy? Why are you using these pronouns?" We didn't really know that that was really a thing at that age. It took us a little bit of time. I remember when they even said, "I was a girl in your belly."

From their point of view, their innate association with a gender that was different from what we had said just based on their hardware, based on them having a penis, was just so natural that, for us, it was almost easy where all we had to do was listen to them. I know that that's an outlier case in that there's a huge spectrum, but this was something I was not aware happened at such a young age and was just a totally normal thing.

They don't even really see themselves as trans, they just see themselves as themselves. How they pee has nothing to do with really how they see themselves. We haven't done any medical interventions or anything like that. Now, people don't really know, in our lives, just because they're so used to them being themselves. It's our job to create just a space for our kids to just be who they are, regardless of their gender identity. That's the big goal, and this is one way that you can just support them and just listen and say, "Hey, you're you, and I'm here to make you be the best you."

Brian Lehrer: It sounds like you're a wonderful, supportive parent, Aaron. Thank you for telling your story. Dr. Turban, I'll tell you that I have a personal friend whose child questioned their gender that early, aged like three or four, and is only a few years older than that now, but it has solidified in what the child said they felt they really were in terms of how they've continued to identify. Definitely, it did not come from the parents. Definitely, it did not come from social pressure by political groups for this three or four-year-old. Same thing with Aaron. Is it unusual for it to happen that young?

Dr. Jack Turban: No, I wouldn't say it's unusual. Really, I appreciate that you made that point that nobody forced this young person to be trans. I think that's been the strangest misinformation out there is this idea that parents are forcing their kids to be trans or society is pushing kids to be trans. The reality is that these kids are facing extraordinary stigma. No parent wants their kid to have a difficult life or be exposed to that stigma. Usually, parents are scared. They're definitely not forcing their kids to be trans. They're scared of their kids being trans.

To the caller's point, there's so little information out there, so I'm really hopeful that this book will help parents who are in the situation of just trying to find true science-based, evidence-based information, because what's out there, sadly, has just been wrong and stigmatizing.

Brian Lehrer: I think a lot of parents who have a child who's presenting as if they're somewhere in the middle of the gender spectrum might worry that if they encourage gender exploration, their child may then feel pressured to transition. Is this a valid concern?

Dr. Jack Turban: That's a great question. People used to think that if you allowed a prepubertal child, in particular, to pursue a social transition, so use a new name, pronouns, et cetera, that would increase their likelihood of continuing to be trans. There's a great researcher at Princeton, Dr. Kristina Olson, who studied this question and found that wasn't the case.

It doesn't seem that social transition or supporting a young person in expressing themselves in a gendered way increases their gender incongruence or the degree to which they identify as trans, but rather, the kids that go on to pursue a social transition are the ones who have very intense gender incongruence, to begin with. No, the research doesn't really support that idea.

Really, what we know is the dangerous thing is instilling kids with shame, so if they're getting a message that stepping outside of a gender box is bad or dangerous or shameful, that is certainly going to impact their mental health and cause more anxiety.

Brian Lehrer: Well, we were just talking about the three and four-year-olds. I think Laura in Mineola is going to tell us a story about a very different phase of life. Laura, you're on WNYC. Hello.

Laura: Hi, Brian. This is Laura, a long-time listener, a first-time caller. I knew that I was trans since I was five. I transitioned late in life. I transitioned in my 60s. I knew I was trans because-- but I didn't have a word for it. That was the thing. I knew something was off, that I was meant to be a girl, but I wasn't. For many, many years, I dealt with it by not dealing with it like telling myself, "You're crazy. You like women, but you think you're a girl. There's something bizarre about that." Then later on, I found out that gender identity and sexual preference are two different variables. Now, they tell me.

I wasn't terribly dysphoric. In other words, I didn't want to scream every time I looked in the mirror. It was more like a general wistful sadness that I wasn't who I was meant to be. Many, many years later, when I'm in my 60s and I'm living alone for the first time in 40-some-odd years, I said, "Look, own it. See what happens. Nothing ventured, nothing gained." That was one of the best decisions I ever made. People always used to say, "You don't smile that much," and now, I smile constantly.

Brian Lehrer: Oh, that's a wonderful story. Laura, I imagine you feel affirmed, or was the changing nature of the public conversation, where it's so much more in the center of the public conversation, even though there's a lot of cultural war conflict around it, is that part of what allowed you to actually fully embrace your identity and transition in your 60s, which was recently?

Laura: It certainly helped. If I had had that opportunity, I might have done it in the past. I often thought that if I had known what I know now about being trans, I might have transitioned a lot earlier, but life got in the way. I had other priorities. I had had two marriages. I was committed to them. It was just like the dam broke, and I decided to own it. That said, I think that the conversation has been very helpful in getting me to where I am now.

Brian Lehrer: Thank you for your call. I really appreciate it. Gio in Queens, you're on WNYC. Hello, Gio.

Gio: Yes, hi. What I'm trying to figure out is, at such an early age, how do they know? How does a child know without being exposed to any social construct or any social interaction as to what male or female is? I don't want to deny the experiences that people are having and that it's an actual situation, but how does a child know?

Brian Lehrer: Well, that's a great question.

Gio: Why would a child say--

Brian Lehrer: Yes. Dr. Turban, since we would probably all accept, the caller and you and me, that gender is in many ways socially constructed, how do they know at that young an age? You hear the question that Gio is asking.

Dr. Jack Turban: Yes, absolutely. I can tell you the way I think about it is, again, from those twin studies and the biological studies, it seems that we're born with what I think of as a scaffolding. You don't have language when you're born, but it does seem there's something wired into the brain that gives you this general feeling of masculinity and femininity. However, you build on that scaffolding throughout life as you're exposed to culture and language. Then you start to add language and expression and understanding to that feeling. That's how I think about it.

You have that scaffolding and that feeling, but of course, you need to be exposed to language and culture to contextualize and build on and decorate that scaffolding to understand yourself.

Brian Lehrer: Before we run out of time, I want to jump ahead a little bit in childhood without getting into the politics of when gender-affirming care, medical interventions like puberty blockers, and other things are the best way to go but more still at the experiential level. I think puberty seems to be a crucial time for transgender children obviously. You write about heightened levels of anxiety and depression for trans kids on the cusp of or in the early stages of puberty. What's the significance of this period of development in your experience?

Dr. Jack Turban: I go back to highlighting that they're really diverse experiences. Some trans kids reach puberty and are not distressed by their puberty and are fine and go through it. Others, leading up to the puberty, certainly when it starts, they become extremely anxious and horrified because their body's starting to develop in a way that doesn't align with who they are.

Julia Serano often talks to audiences and says, "If I gave you a million dollars but you had to go through a puberty different than the one you went through, would you do it?" I think a lot of cisgender people, that helps them realize how scary that is and what these kids are experiencing. It is really, really diverse. One thing that I want to highlight that's often missed is it's never a small decision for a young person to pursue a gender-affirming medical intervention.

Under current guidelines from the Endocrine Society and what's called the World Professional Association for Transgender Health or WPATH, a young person needs to have a comprehensive mental health evaluation to really have a broad understanding of their gender and their mental health, make sure they understand all these treatments, what they do, what they don't do, risks, benefits, side effects, parents also fully understand those things and be on board. For some of these kids, it's certainly the right decision to save them from that intense distress from puberty but it's not a small decision.

Brian Lehrer: As the last question, in the intro, I mentioned Donald Trump's promise to reverse Title IX protections for transgender children and Florida's ban on gender-affirming care that was ruled unconstitutional in court yesterday. What effect in your experience does all of this negative political and media attention-- and of course, there's supportive attention too, but there's all this negative stuff being hurled at them. What effect does it have on transgender children and their families in your care?

Dr. Jack Turban: These bills I talk about is having both direct and indirect effects. Bans on medical treatment, for instance, when young people lose their access to medical treatment, their mental health worsens. Bathroom bills are really interesting. Constantly, people are saying the reason we need to force people to use the bathroom of their sex assigned at birth is because if we have trans-inclusive bathroom policies there will be more sexual assaults. No one ever talks about the research showing the opposite is true.

There is research showing that if you have trans-inclusive bathroom policies there are lower rates of sexual assault against trans young people and no increase in sexual assaults against the general cisgender population. I have a whole chapter in my book that goes through the science and the research that I wish people would bring to these political debates. I really hope people will pick up the book so those can enter the conversation more.

There's also indirect effects of these different bills. My patients are in California, they don't have direct impacts of these laws, but they're still hearing politicians and powerful people say things like, "Your identity is a mental illness and you shouldn't be allowed to use the bathroom that you identify with because you're going to sexually assault people," or, "You shouldn't be allowed to play your elementary school sports because you're going to hurt your peers because you're physically dangerous."

They might know those things aren't true, but if you're hearing that constantly, constantly, constantly, you start to slip into your mind like, "What if I am dangerous? What if I am mentally ill?" That just really takes a toll. Unfortunately, that's something that my patients are dealing with that is really hard for us to undo. I'm hopeful that the national conversation will shift in coming years to be more evidence-based and supportive and reflective of these kids' actual lived experiences.

Brian Lehrer: Dr. Jack Turban, M.D., director of the Gender Psychiatry Program and professor of child and adolescent psychiatry at the University of California, San Francisco, and the author now of Free to Be: Understanding Kids & Gender Identity. Thank you so much for sharing your understandings with us.

Dr. Jack Turban: Yes, thank you so much again for having me.

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