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Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning again, everyone. Now we'll continue our observance of Pride Month with a second segment this month, focusing on the medical care offered to transgender children. As it happens, there is breaking news on this front just in the last few minutes.

Washington Post headline here, Supreme Court agrees to review Tennessee ban on gender transition care. It says 23 states have passed bans or restrictions on gender transition care for minors since 2021, and at least one of those bans, the one in Tennessee, which I think is pretty sweeping, is going to go to the Supreme Court in the next term. Now, a few weeks ago, some of you may remember we had Dr. Jack Turban on the show.

He's director of the Gender Psychiatry Program and assistant professor of child and adolescent psychiatry at the University of California at San Francisco. He was talking about his new book, Free to Be: Understanding Kids & Gender Identity. During that segment, we got deep into the weeds about what the inner lives are like for gender-diverse children, including how they become aware of their gender and at what early ages, and how they internalize the politics surrounding their identity.

It was such a great conversation that time ran out before we got on to a whole second half of it, which would have been about gender-affirming care itself. Dr. Turban is back with us. We decided to invite him back for round two, and it comes just as this news is breaking, which I'm now told Dr. Turban has a personal professional relationship to. Dr. Turban, welcome back to WNYC.

Dr. Jack Turban: Hi. Thanks for having me back.

Brian Lehrer: Are you an expert witness of some kind in this Supreme Court case?

Dr. Jack Turban: Yes, for this case.

Brian Lehrer: What can you tell us?

Dr. Jack Turban: I can tell you the same thing that I told the trial court, for this case, which is that all major medical organizations oppose these state-level bans, gender-affirming medical care, that we know that for patients where it's indicated that they see improvements in mental health and in studies where we've looked. Comparing kids who receive this treatment to those who it would have been indicated, but they didn't receive the treatment, that those who get the treatment have better mental health, less anxiety, depression, suicidality, et cetera.

These laws have really been scary for doctors, that it was one of the few times that lawmakers have tried to outlaw what is the standard of care that most doctors are treating. It's created this crisis where families are needing to move out of state or need to go to other states to get their medical care, and really just an unprecedented situation.

Brian Lehrer: It looks like the Tennessee ban is on the sweeping end of the restrictions that more than 20 states have passed that it bans gender transition care of any kind for people younger than 18. Is that your understanding?

Dr. Jack Turban: Yes, I would say some of the laws go even further of trying to restrict care for adults on public insurance, but definitely, it is one of the more restrictive ones.

Brian Lehrer: For people who hear these terms and are not personally involved, they are not people who have transitioned or have even known anybody who has transitioned or considered it, do a little one-on-one. What do we mean when we say, "transition care or gender-affirming care for somebody under 18?"

Dr. Jack Turban: There's a lot of nuance that's lost in the media. I think one helpful way to think about it is to understand that we support young people in different ways at different stages of development. For very young children, like pre-pubertal children that we were talking about last time, doctors wouldn't consider any medical interventions. These young people might decide to use a new name or new clothes or pronouns.

A psychiatrist like me or a therapist might work with that kid to talk through that, make sure they're not being bullied, figuring out how to talk to their family about that, but no medical interventions before puberty. For some of these young people, they'll enter puberty, and as their body starts to develop in a way that doesn't align with their gender identity, they'll become very psychologically distressed, more anxious, more depressed.

At that stage, you might consider starting what's called a puberty blocker, which are these medications that have been around for decades. They're FDA-approved in pediatrics for a condition called precocious puberty, which is when kids just go into puberty very young. The nice thing about them is they're reversible.

If you start that medication and then later decide you want to proceed with puberty and you stop the medicine, the puberty you were going through will proceed. That can be a huge relief for some of these kids who are horrified about their body developing in a way that can't later be undone. [unintelligible 00:05:12]

Brian Lehrer: What do your few sessions with children look like? How do you assess them? Before you would prescribe a puberty blocker, what do you need to know?

Dr. Jack Turban: There's this myth conception out there that doctors are forcing these medications on patients, or that patients can come in and get a prescription right away, but the reality is that this is a very conservative area of medicine. The current guidelines require that you have what's called a comprehensive biopsychosocial mental health evaluation.

Before you can get a puberty blocker or gender-affirming hormones as a minor, you need to go see a therapist who does a full general psychiatric intake to see if you have any other mental health conditions that need support, understanding your social support, hearing the history of how your gender identity has developed, and then you discuss the risks, benefits, and side effects of those treatments, along with a whole host of other factors that we really go into depth with before we'll sit down and the full family has to agree on the treatment.

Brian Lehrer: One of the arguments for banning medical intervention for trans children is that they can wait until they're adults and make a decision that they're less likely to regret. What do you make of that argument?

Dr. Jack Turban: The research on this is interesting. We actually see that people who transition under the pediatric model of care, where we have this comprehensive mental health evaluation, they're less likely to stop hormones in the future. If anything, it seems that they're making better decisions when they're younger because it is such a comprehensive process, but also you need to recognize that for some of these kids to wait until adulthood, will just be devastating to their mental health.

If you let puberty progress all the way through, a lot of those things can't be undone later without invasive surgeries that they can be undone at all. You'll often hear in this field, people will say, doing nothing is not a neutral decision, that choosing to allow a young person to go through the puberty that's causing them distress can be just as weighty of a decision as deciding to start one of these medications. You really need to weigh the risks and the benefits on each individual case.

Brian Lehrer: What are the risks? If you have a child in your care who seems clearly trans, maybe they've been presenting as a gender different from what's on their birth certificate for years and years. I have a friend with a pretty little kid who is pretty sure that this kid themselves is pretty sure that they are the other gender from what was on their birth certificate.

By the time that kid is 11 or 12 or 13 or whenever you would prescribe puberty blockers, they feel like they know. They are likely to feel like they know this particular child. What are the risks? When you evaluate risks, what are the risks?

Dr. Jack Turban: It depends on the intervention, but all medications have their unique side effects. Puberty blockers, for instance. While you're on a puberty blocker, you fall behind on bone density compared to your peers because you need sex hormones to mineralize your bones. For those young people, it's important that they exercise and take calcium and vitamin D, and that their doctors track their bone health to make sure that they don't become at risk for something like a fracture.

Hormones also have their own side effects. Estrogen, for instance, can increase your blood clotting risk. It's really important to make sure that people aren't smoking, which can increase your risk, screening to make sure they don't have an underlying blood clotting disorder. It's just like any area of medicine, where we sit down with people and weigh those potential side effects and risks against the potential benefits.

Brian Lehrer: Listeners, if you have a question for Dr. Jack Turban, we can take a few or an experience. Have you taken in gender affirming puberty blockers at all in your life? Since we're talking about gender identity for kids, let's limit this conversation to the experience of people under 18 by and large.

Currently, if you've ever been in the experience of identifying as a gender other than what you were identified as at birth, and considered doing something that you would call a medical intervention about it, or if you're a parent of anyone, you can call Dr. Turban with a question, 212-433-WNYC, 212-433-9692 call or text. What about hormone replacement therapy? What are the different drugs offered to families that fall under that category?

Dr. Jack Turban: Those are considered later in adolescence. The older Endocrine Society guidelines said not to consider things like estrogen or testosterone until age 16, but some doctors have, again, because of that bone health issue of if you're on a puberty blocker for too long, your bone density falls behind, the latest guidelines note that you could consider starting earlier depending on the case.

For trans girls, it's usually estrogen that they take because estrogen is not very good at shutting down your testosterone production, they'll often take a second medication to block their testosterone, something like spironolactone, or medication similar to the puberty blocker. Then for trans boys, it's usually testosterone. That medication causes things like voice deepening, hair growth, all the things that you expect from what you think of as "male puberty".

Brian Lehrer: One of the questions that often comes up is, how reversible are these things, and how common is detransition when people at some point in adulthood decide that either they made a mistake, or they don't want to stay in their transitioned gender?

Dr. Jack Turban: Puberty blockers do seem to be fully reversible, and that if you stop them, the puberty that you were otherwise going to go through will precede. Hormones are not fully reversible. The longer that you're on estrogen or testosterone, the less reversible some of those effects will be. Voice changes, in particular, are really hard to undo later. If you've had a lot of hair growth on your face, for instance, that could require something like electrolysis to undo.

Some of the effects on body fat distribution and muscle mass might revert a little bit but those can also be potentially permanent. With all families, we talk about the potential risk of your gender identity evolving, or detransitioning, or wanting to stop hormones, so that is one thing that you need to consider. What I will say is this topic of detransition, when we look at the numbers, it doesn't seem to be very common for people to start hormones in adolescence and then later identify as cisgender, and when it does happen, it's really complex.

Sometimes it's because they were in really unaccepting social environments. They transition and then people treated them poorly. We published a study where we looked at 27,000 trans adults, and of them, 13% had detransition at some point in their life just because of external pressure, pressure from family, or stigma, or fear they couldn't get a job.

Then also, you can imagine, if you're in a place that's telling you that being trans is a mental illness or is invalid, that you might start to internalize some of those ideas. It's not a very common occurrence, and when it does happen, it's really important to unpack exactly what's going on to figure out how to best support someone.

Brian Lehrer: When it comes to putting children on medications, there's vast concern in the United Kingdom, apparently, which is going in a different direction than the United States at this point. Doctors like Hilary Cass, who some people may have heard of have claimed that "US doctors are out of date" on youth gender medicine, and reported the "evidence supporting the use of puberty-blocking drugs and other hormone medications in adolescence was remarkably weak."

The National Health Service in the UK no longer prescribes puberty blockers to children. I don't think they have the same anti-trans Christian nationalism if you want to call it that political strength in that country as we do here. What's your response to this assertion, and the apparently divergent paths of doctors in the US and in Europe right now?

Dr. Jack Turban: The Cass report is interesting. There's certainly parts of it that I don't agree with. I'm not sure where this idea that the American doctors are out of date comes from since American doctors had published some of the highest-impact research in this area over the past few years. What I think is also interesting, though, is that there are a lot of areas where the Cass report agrees with doctors in the United States. I would say that's what's probably most important to emphasize.

The Cass report actually doesn't say, to ban the use of puberty blockers or hormones, and explicitly acknowledges that there are patients who as minors benefit from puberty blockers or hormones. What the Cass reports suggested was that that only be conducted within a clinical trial so that you can continue to collect more data because as you said, they felt in a very technical sense, that's a term of art, how they grade the evidence, but they want more evidence, so they want to study this really rigorously.

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Brian Lehrer: Go ahead.

Dr. Jack Turban: It is pretty politicized in the UK, perhaps not in the same religious way that it is in the US, but certainly, there is a lot of anti-trans sentiment that's prominent in the UK. I do think that's driving part of this because the government didn't actually follow the recommendations of the Cass report. The Cass report said, "Make sure they're still accessing the clinical trial", but the government chose to ban puberty blockers without setting up the clinical trial.

That is the area of divergence where I think we're all in agreement, both the Cass report and doctors in the US that some patients benefit from care, but they should have a comprehensive evaluation before starting, you should make sure you're treating them with medical and non-medical interventions. We recognize that not all trans kids need these medical interventions, but unfortunately, in terms of care delivery, it was stopped, essentially, in the UK, even though the Cass report said to set up this clinical trial.

Sorry, so much saying on this because most American doctors don't necessarily think it would be ethical to coerce these families to do clinical trials. That's another area of disagreement.

Brian Lehrer: You have a chapter in your book dedicated to the parents of transgender children, what kind of care do you provide for them?

Dr. Jack Turban: I'm glad you asked that because often missed from this conversation. This is really difficult for parents in the same way that it is for kids. All in a different way, but still really difficult, but if you're a parent, you're naturally afraid of your kid being part of a group that's going to face a lot of stigma, you might understandably be worried about these different medical interventions, or worried that your kids can change their mind.

Sometimes we even hear things that you wouldn't necessarily think of, like parents maybe have a Christmas ornament for when their kid was very young that has their child's birth name, and it's really hard for them to let go of that. In my practice, I always make sure that parents are given just as much support as the kids. I want them to have their own private place to talk through things and feel supported.

It's also important that it's really easy to say something in passing that you don't mean in front of your child that the child feels it's stigmatizing and sticks in their mind for a long time. I recommend that parents have a therapeutic space where they can really talk through things, so what they bring to their child is their final thought, rather than thinking out loud, if that makes sense.

Brian Lehrer: Yes. Listener writes, "I have a non-binary 11-year-old. We're in a Bronx school that's been terrible, but we haven't yet explored anything medically, but I would love to know what is often offered for non-binary young people." There's a spectrum of gender, we know that. Is non-binary a category that would wind up with some kind of gender-affirming intervention, like puberty blockers, or do you have to be at a clearly trans end of the spectrum if that's the way you describe it?

Dr. Jack Turban: Potentially, I guess I would highlight that both binary trans kids and non-binary kids, for some of them, they want hormones and medical interventions, and some of them are okay with their physical bodies and feel they don't need them, but there certainly are non-binary youth who pursue puberty blockers, and might also potentially take estrogen or testosterone later.

Brian Lehrer: Listener writes, "There are many people who have very reasonable and logical concerns about whether or not transitioning young children is a good idea. These people should not be automatically deemed anti-trans. That is not necessarily the case." What do you say to that listener?

Dr. Jack Turban: Yes, I think that maybe it goes back to my earlier point that parents are understandably going through a lot whenever their kids come out as trans. I think it's important that I have a place where they can express all of their concerns, and talk through things, and really be validated and understood.

Brian Lehrer: What do you make of the idea perpetuated by some that being transgender and/or non-binary is a new phenomenon that's trending that it's a matter of style more than biology because you didn't see very much of this in the past compared to now?

Dr. Jack Turban: Yes, that's a complicated topic. I guess one thing I would point people to is the work of Jules Gill-Peterson, who's a historian, she wrote a great book called Histories of the Transgender Child, really documenting that this isn't new and that there have been transgender children all throughout history, going back way further than the past few decades.

I think people are on to something that there is a phenomenon where kids are thinking about gender, was more nuanced today than maybe my generation or generations before did, where there's not one way to be transgender. There are some of these kids who are trans in a binary way and have intense physical gender dysphoria. There are other kids who maybe are adopting a non-binary identity that still falls under the transgender umbrella, but for them, it's really about rejecting gender norms or societal expectations based on gender, and it's not so much about their physical bodies. It's really important to remember that being trans doesn't immediately mean medical interventions. I think it is true that more young people are identifying as trans because they're thinking about transness under a broader umbrella that people may have in the past.

Brian Lehrer: There we will leave it with Jack Turban, M.D., director of the Gender Psychiatry Program and assistant professor of child and adolescent psychiatry at the University of California, San Francisco, and the author of the new book Free to Be: Understanding Kids & Gender Identity. Dr. Turban, I really appreciate that you came on with us twice this month. One more to talk about the inner lives of trans kids in part one, and today to go into the medicine and the psychiatry of gender-affirming care, which is where the political controversy tends to lie.

Coincidentally, we had the breaking news this morning, that the Supreme Court will take up in its next term, this ban on gender-affirming care for anybody under 18 by the state of Tennessee, a case in which you're an expert witness. Thank you for lending your expertise on multiple levels to our show this Pride Month.

Dr. Jack Turban: Of course. Thanks so much, again, for having me.

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