How Many People Detransition? Exploring Detransition

How many people detransition? Dr Jack Turban, child and adolescent psychiatry fellow at Stanford University School of Medicine, joins the GenderGP podcast for an episode exploring the notion of detransition.

Together Jack, Helen and Marianne discuss the notion that a person's gender expression and gender identity can change throughout their life. They asked "How many people detransition"? They acknowledge the use of detransition as an argument against affirming transgender people and the damage that this does, as well as covering how we need to broaden our understanding of what detransition really means, what is driving it and how we can work to support someone through the process.

If you have been affected by any of the topics discussed in our podcast, and would like to get in touch, please contact us via the Help Centre. You can also contact us on social media where you will find us at @GenderGP on Twitter, Facebook and Instagram.

We are always happy to accept ideas for future shows, so if there is something in particular you would like us to discuss, or a specific guest you would love to hear from, let us know. If you've enjoyed "How Many People Detransition? Exploring Detransition with Jack Turban", let us know. Your feedback is really important to us. If you could take a minute or two to leave us a rating and a review for the podcast on your favourite podcast app, it will help others to discover us.

 
Links:
Website: www.jackturban.com
Twitter: @jack_turban
 

Get the facts about detransition and how many people detransition

 
The GenderGP Podcast
How Many People Detransition? Exploring Detransition with Dr Jack Turban: 
 
Hello, this is Dr Helen Webberley. Welcome to our GenderGP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.
 

Dr Helen Webberley:

Hi everyone. Dr Helen Webberley, Marianne Oakes, and we've got a lovely guest all the way from California today. I'm going to let him introduce himself.

Dr Jack Turban:

I'm Jack Turban. I'm a child and adolescent psychiatry fellow at Stanford, and I researched the determinants of mental health among transgender youth in particular. And one topic that I've been particularly interested in recently and writing more about is this idea of kind of non-linear gender transition trajectories, which is a fancy way of saying that somebody's gender expression and sometimes their gender identity is not necessarily always the same for their whole life. And this has been creeping up more and more in the media as like an argument against affirming transgender people, which I think is a hundred percent wrong. So I've been trying to kind of broaden people's conceptualization of what quote "detransition" means and setting up more of a formal framework, particularly for mental health professionals or physicians who are working with people who say they want to detransition to understand exactly what that means and what are the different things that could be driving it and how do you work to really understand someone through that process and support them the best that you can.

Dr Helen Webberley:

Briliant. Thank you. Lovely. Well, that makes me very excited. There's lots of things I'd like to talk to you about. So detransition is, it's become a kind of a painful word, I would say. For me, and certainly for me in my career and my work, and when I read about it and when people when (unclear 1:54) detransitioning are brought up as the other side, via example. So it's not a happy word in my vocabulary. So just to expand on it, what does it mean? Where did it come from? Is that a real word? And what does it encompass?

Dr Jack Turban:

It's become this really awful word, right? Cause it's,

How many people detransition? Dr Jack Turban, child and adolescent psychiatry fellow at Stanford University School of Medicine, joins the GenderGP podcast for an episode exploring the notion of detransition.

Together Jack, Helen and Marianne discuss the notion that a person’s gender expression and gender identity can change throughout their life. They asked “How many people detransition”? They acknowledge the use of detransition as an argument against affirming transgender people and the damage that this does, as well as covering how we need to broaden our understanding of what detransition really means, what is driving it and how we can work to support someone through the process.

If you have been affected by any of the topics discussed in our podcast, and would like to get in touch, please contact us via the Help Centre. You can also contact us on social media where you will find us at @GenderGP on Twitter, Facebook and Instagram.

We are always happy to accept ideas for future shows, so if there is something in particular you would like us to discuss, or a specific guest you would love to hear from, let us know. If you’ve enjoyed “How Many People Detransition? Exploring Detransition with Jack Turban”, let us know. Your feedback is really important to us. If you could take a minute or two to leave us a rating and a review for the podcast on your favourite podcast app, it will help others to discover us.

 

Links:

Website: www.jackturban.com

Twitter: @jack_turban

 

Get the facts about detransition and how many people detransition

 

The GenderGP Podcast
How Many People Detransition? Exploring Detransition with Dr Jack Turban: 

 

Hello, this is Dr Helen Webberley. Welcome to our GenderGP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.

 

Dr Helen Webberley:

Hi everyone. Dr Helen Webberley, Marianne Oakes, and we’ve got a lovely guest all the way from California today. I’m going to let him introduce himself.

Dr Jack Turban:

I’m Jack Turban. I’m a child and adolescent psychiatry fellow at Stanford, and I researched the determinants of mental health among transgender youth in particular. And one topic that I’ve been particularly interested in recently and writing more about is this idea of kind of non-linear gender transition trajectories, which is a fancy way of saying that somebody’s gender expression and sometimes their gender identity is not necessarily always the same for their whole life. And this has been creeping up more and more in the media as like an argument against affirming transgender people, which I think is a hundred percent wrong. So I’ve been trying to kind of broaden people’s conceptualization of what quote “detransition” means and setting up more of a formal framework, particularly for mental health professionals or physicians who are working with people who say they want to detransition to understand exactly what that means and what are the different things that could be driving it and how do you work to really understand someone through that process and support them the best that you can.

Dr Helen Webberley:

Briliant. Thank you. Lovely. Well, that makes me very excited. There’s lots of things I’d like to talk to you about. So detransition is, it’s become a kind of a painful word, I would say. For me, and certainly for me in my career and my work, and when I read about it and when people when (unclear 1:54) detransitioning are brought up as the other side, via example. So it’s not a happy word in my vocabulary. So just to expand on it, what does it mean? Where did it come from? Is that a real word? And what does it encompass?

Dr Jack Turban:

It’s become this really awful word, right? Cause it’s, I feel like 90% of the time when you read it, it’s really being weaponized. It’s also a really vague word, which is something that we’ve been trying to explain a little bit more. Right? So when you say detransition people usually think that means like transition regret. It brings up this idea that somebody transitioned, then then realize like, oh my god, that was a huge mistake. I’m actually cisgender, I regret every domain of gender affirmation I’ve ever had. And as I’m sure you know, that’s not the reality of the situation, that detransition is not synonymous with regret and it’s most of the time probably doesn’t mean that somebody, all of a sudden identifies as cisgender and regrets their having transitioned. So we talk about kind of breaking it down into first of all, what you mean by detransition? So, is it somebody who is stopping hormones, right? That’s a more precise definition. Is it someone who is changing their gender expression permanently? So are they going to start using different pronouns? Are they going to go back to a different name? Are they just like legally detransitioning? So are they changing their gender markers on official documents for some reason or another? Right. So it could be surgical, it could be medical, it could be social, it could be legal, it could be expression. Detransition does not mean one thing. So that’s the first thing: kind of what domain of detransition are you talking about? And then the second question is, is this detransition associated with regret? So there certainly could be people, it’s not very common, I don’t think most of us have seen a lot of us in our practices, but there are occasionally people who start hormones and then later detransition from the hormones or some other domain and do wish they hadn’t done that. Right. That’s very uncommon, but that is one possibility to think about. But it’s important to remember that not everybody who detransitions in one of those domains, regrets having transitioned. We wrote a case study in Journal of Pediatrics, for example, a kid who identified a hundred percent as transgender in a really binary fashion, identified as a female and then started estrogen for a period of about six months and then decided actually, I’m gender nonbinary. I’m kind of comfortable with my body the way it is. I don’t think I need estrogen anymore. So I’m going to stop it, but I don’t regret the estrogen at all. And I feel that it was really important. And actually for me to understand my gender identity and come to this solidified stance. So in that sense, you could say that person detransitioned, right? They stopped the hormones, but they didn’t regret the hormones. And then I know I’m bringing up so many things.

Dr Helen Webberley:

Okay, go for it.

Dr Jack Turban:

So what domain it is, whether or not it’s associated with regret. And then the last question is on whether it’s driven by internal or external factors. So external factors we refer to as things like harassment from your family, did you transition and then all of a sudden you weren’t able to find a job because of stigma? Did your spouse pressure you to detransition? Were you being bullied at school, right? All of these different external factors, did you lose your health insurance? You know, there’s so many different things that could kind of force someone to transition from an external factor. And then there could be internal factors, where maybe your gender identity evolves into a different identity, like that patient I was just talking about who identified as female and then identified as non-binary. And that is not pathological. There’s another thing that we’re trying to highlight, right? Like your gender identity can be dynamic in that that is not necessarily a problem. In fact, I would argue it really rarely is a problem in and of itself. So that’s the basic framework. We have a paper that hopefully is coming out soon, where we took the data from the 2015 US Transgender Survey. So this was a survey of over 27,000 transgender adults in the United States. And we found that of those who had transitioned in some way, don’t quote me on that exact number, but it’s something like 13% of them said that at some point in their life, they had detransitioned. And when we looked at why they did that, the vast majority of them, like close to 90%, I think, had detransitioned due to some external factor. And a lot of them were really horrible, right? Like their families were awful to them. They got fired from their job. They were physically harassed, all of these things. And then a very, very small number of them had cited at least one internal factor, so that their gender identity changed. And usually it was something along the lines of going from a really binary gender identity to something less binary and feeling that they didn’t want hormones or wanted to have a different type of gender expression. And so obviously that’s not like following people from time, 0.1 forward, like these are people who currently identify as transgender or gender diverse, but I think it’s important for us to know and think about the fact that that’s a lot of people, right? Like a lot of currently identified transgender people have like, quote, detransitioned in some way in their life. And so if you’re working with someone who says they want to do that, you really would be doing them a disservice if you didn’t look into all those potential internal, external factors to understand why this is happening for them and to support them through it, especially if it’s something like family rejection or legal discrimination where you could try to help them.

Dr Helen Webberley:

Yeah, okay. That last sentence there really struck home with me actually, because all the time you’ve been talking, I’ve been thinking of this is really valuable so that we can tell people who don’t believe us, that the reasons for detransition are not because the gender identity wasn’t there in the first place, if this is any different. And all the time you were talking, I was thinking like that, so this is how we explain it to those that get worried to the healthcare regulators, the policy makers, the anti-trans people, the people that don’t like to understand what it might mean to be transgender. And then your last statement was if you’re working with someone and I’m like, we almost forget, don’t we, that the, the work that we do is actually supposed to not be defending or arguing against people who don’t get it, but to actually support patients, clients, people in their gender journey and what it means for them. And I think sometimes we forget that, don’t we? We’re so busy trying to justify the work that we do as, as doctors and research scientists and counselors like you, Marianne. And we forget that actually, what we’re trying to do is provide the best care for our workload of patients. It’s really interesting.

Dr Jack Turban:

Yeah. And awful, right? Like it’s really awful that these, that people have decided to take this phenomenon and politicize it to the point that now it’s hard for patients to want to talk to their doctors about it. Right? And to talk to their communities about it. Yeah. So it’s kind of the stress if you are detransitioning for one of these reasons to want to go tell your friends, your doctors, that, that you’re going through this, because all of a sudden you’re associated with these really vicious attacks on transgender people at large. Right? And it’s just unfortunate that it’s become that. Another thing that I haven’t published on, but I think we should, is right, so we talked about these internal and external factors, and it’s really similar to the minority stress model in that–so in the minority stress model, it’s kind of for LGBT people broadly, there are these distal factors that are described. So things like legislative discrimination, rejection from family, harassment in your community, and those things make you more anxious and depressed, right? But then there are these proximal factors, which are things like internalized transphobia or internalized homophobia, and expecting that you’re going to be rejected based on your LGBT identity. And right in that model, they’re really explicit about explaining that those distal factors drive internal factors. So if you’re constantly told that being transgender is wrong, at a certain point, you’re going to maybe start to think being transgender is wrong and then feel really horrible about yourself. Cause you can’t change it. Same thing as sexual orientation and what we’ve started seeing some reports of, are people who have gotten caught up in these really intensely political movements like trans exclusionary radical feminism. So groups that will, you know, kind of go tell transgender people like your identity is wrong. It’s misogyny, it’s homophobia and kind of link their identity to all these really negative things, similar to what society does at large, for any stigmatized population. And then they start to believe it. So that external factor of being told being transgender is wrong. They might start to internalize. And then that might drive their detransition also, and right. Yeah. That happened back when people were doing gay conversion therapy, sadly people still are, when it was more common, there were plenty of people who said they were ex-gay right. So they entered these communities. They were told that being gay was wrong. And then they internalize that. And then they were like, you know, like I’m not gay anymore. And presented to the world saying that. All of a sudden psychiatrists in the world was saying like, you can do conversion therapy. Like you can’t make people straight. And then it wasn’t until decades later that these people came out and said, actually, no, we were just like really forced into saying that, believing it. Right, we were upset about it, concealing our identities for all these years. And I worry that similar things are happening now for transgender and gender diverse folks.

Dr Helen Webberley:

Marianne, I know this is a topic, very close to your heart.

Marianne Oakes:

Yeah. And you, you obviously know more about the model than I do, but I just kind of, there was a few things coming to my mind you were talking. So I come from a very simplistic place. What the first thing is when we talk about the detransition and transition that this notion that we become transgender. And then we start being transgender is just a complete fallacy. I don’t believe anybody becomes (unclear 12:26). It’s what we do with it that we’re really talking about. How do we deal with this information that I have about myself and how do I function in the world? So I think when he was doing the, when he was talking about the research that you’ve done, the question that came to my mind was what kind of treatment that they get while they were transitioning, you know, were they gatekept? Did that internalized transphobia get reinforced, you know? How does the model of care to help them to transition, influence how they deal with the transition? So I think it’s, you know, this simplistic idea of we’re just making a series of decisions, and you know, it means we’re either trans or we’re not. I just think it’s far more complex and it will be really good to see which models of care have better outcomes and has a less detransition rates. It really makes us ask, how many people detransition? I don’t, I don’t even know if he counts to that, but that is what I was going through with my mind.

Dr Jack Turban:

Yeah, I think that’s a huge question that especially in pediatrics, people are grappling with–I think people have had an easier time in adult medicine kind of recognizing that these like assessment, gatekeeping models were a little bit ridiculous and damaging. And it’s interesting that not all of the lessons from that have made it into pediatrics yet because people don’t trust kids to make decisions in the same way, obviously, but like things people are familiar with, right? Like if you’re, if you set up this assessment, gatekeeping protocol, people are just going to figure out the answers and then tell you what you want to hear. And you’ve set up this really kind of like argumentative relationship with your patient or client. (unclear 14:07) And you’re like, why, why even bother? You know? And so more and more there’s discussion in pediatrics, where there are some folks who do believe that kind of, we need this assessment model to understand if there are other things going on, because I think it’s going to make it less likely that these kids have that very specific type of detransition that doesn’t appear to be very common, right? Where somebody transitions and regrets a medical intervention, right? How Many People Detransition. That’s really what people are afraid of is starting a medical intervention and regretting it and not being able to take it back. And finally, people are starting to broaden that conceptualization a little bit and realize like there’s not data that, that any of these assessments make that less likely. And so people are trying to do research to figure out just like you’re saying, which of these models truly based on the data, best support people? Then there’s more and more, I think a bit of a shift towards realizing that when you have this like really, the model that’s really focused on like assessment and gatekeeping, that you lose the other things that are really important about counseling and psychiatry, which is like having the person be open with you and supporting them where they are, and like facilitating their understanding of gender and what kind of domains of affirmation they want or don’t want. And it’s really hard to do that if the person feels like they have to prove themselves to you. And so we’ll see there’s a shift, right? So most of the models in the US still do use a model based on the Amsterdam model where somebody has to be in therapy for six months and come with a letter. And the letter says that like, they really are transgender, have gender dysphoria and meet the WPATH guidelines. And then psychiatry, I would say, that’s still, where are most of the US is, but there are a few clinics, and mostly pediatrics, adolescent medicine specialists who are moving away from that and doing more of an informed consent model, like what people do and adults where they’ll sit down, they’ll tell the person, listen, these are what these medical interventions do. This is what they don’t do. These are all the potential implications for your health, you and your family go discuss them, like, come back, we’ll make sure that you really understand all the intricacies of this. And then if you have all the information and you know, all the risks and benefits, then, then you don’t need to be in therapy for six months, but it’d be great if you have a therapist, like kind of support you through this process, because it’s really hard to, because most of society is awful. And sometimes people need help navigating that. So there’s definitely a tension between those two approaches right now. And I think it’s just going to take a little bit more time to see how it all evolves. (On how many people detransition)

Marianne Oakes:

I don’t know if I can say, I think I agree with you entirely. And I, there’s a little part of me sometimes with the work that I do is it becomes clear that this isn’t about challenging somebody’s gender identity. It’s about helping them to cope with it, you know, actually help prepare, you know, one of the things I can say is I have no idea how it was to lose male privilege (unclear 17:08) female in the world until I did it, and nobody ever spoke to me about that. That was never part of my treatment plan. All they kept saying to me was, are you sure with all the questioning was, are you sure? Well, I was sure of who I was, wasn’t prepared for what was going to be ahead of me. And there’s just a little part of me thinks we concentrate on the medical aspects, which did the challenge that I had as a trans woman was who are they looking after here? Are they looking after their own interests and their own expert status, or do they really care about my outcome? What’s best for me? Does that make sense?

Dr Jack Turban:

I think it makes a lot of sense and right, I think to be realistic about assessing the situation, I think it’s hard to ignore the fact that the people who are implementing these medical interventions for the first time, it was very new in the US to provide these interventions for adolescents. And I think you’re right, there was this fear of like malpractice litigation concerns. So that I think it was certainly at play as much as what people will be more open about and saying that they’re worried that, that a patient is gonna have a bad outcome, but it’s really hard to disentangle that from the provider being worried that if there is something that they perceive as a bad outcome, that it would impact them. So I think you’re a hundred percent. Is that what you were alluding to?

Marianne Oakes:

It is, really. Yeah. And even as I’m saying it, there’s a little part of me understands why, if that makes sense, I don’t want to be over empathic, but you know, there are times I sit in front of somebody and I’m thinking, God, you know, they’re not fitting the model that I think would, or you know, they’re not answering the question in the way and it can be a challenge. But sometimes we just have to be brave. Well, how would somebody that’s never experienced gender dysphoria, disentangle that, so, you know, I’m not pretending it’s not complex.

Dr Helen Webberley:

It strikes me, Jack, that research policy, it all seems to be, you know, you were talking earlier about the, you know, the assessment, what kind and how long assessment should it be? Should there be gatekeeping or no gatekeeping should there be informed consent or informed consent? And how does then that impact on detransition rates? And it’s like, we spend, we spend so much time on that kind of research rather than the kind of research that Marianne would like to see, which is how are you best going to support me when my male privilege is taken away from me because I’m actually female and how my experience as I’m transitioning is going to be impacted by all those external factors you were talking about earlier? And yet we’re stuck, aren’t we, making all this research to convince everybody on how to make it better for our patients (unclear 20:00) the same topic, aren’t we?

Dr Jack Turban:

A hundred percent. And I get yelled at for this all the time. Right. And I recognize the problem, right? People who actually like live in like transgender people and transgender youth are like, why are you studying like conversion therapy? And it’s like we know conversion therapy is bad. I’m like, I know, but I’m just so afraid. But if we don’t have like this concrete data that we’re going to lose some of these political fights and be like thrown back, but a hundred percent, I recognize that it is like living in the Twilight Zone that we’re doing research on some things that should be self-evident. Unfortunately they’re just really strong political forces that are like here, right? Like having the fight here when, where the research and the work should be here. So I apologize for a lot of (unclear 20:53).

Dr Helen Webberley:

Well, tell you what, you’re younger than I am. So use your career to get that bit of research first and then spend the next half of your career, you know, doing the research that’s really, really going to help people. I’m interested in your trajectory because I was reading a chapter in a book the other day written by an expert in gender identity, a cis-gender doctor writing about aspects of gender identity. And one of the views put forward was that if you have a transgender adolescent and you allow them a binary path of medical transition, so puberty blockers followed by gender-affirming hormones, which puts them to the other end of the binary and the other end of the pole. Then in some ways, his argument was, that that would prevent any exploration of nonbinary identity. And perhaps it would be better, the inference was that if you didn’t allow them to have such an early age (unclear 21:48) at the other end of it, that they might go through the middle a little bit and see what it’s a little bit like to be a little bit of both kind of thing. And not even that really, because basically just saying, hold off in case they are nonbinary. And if you make them too polar, too binary, you exclude that chance. I want to get your thoughts about that and how many people detransition?

Dr Jack Turban:

First of all, that it’s a bizarre argument, right? Like, I’m sorry, you’re going to say, you’re going to tell all kids that they can’t have any solution to their physical body dysphoria, because you think that will prevent them from being able to later identify as non-binary. So, first of all, that’s not just not true. Right? You can start medical interventions and then later identify as non-binary that happens all the time. And I think it maybe kind of what they were getting towards was this right? So I feel like periodically there’s this argument, not in real life, but in politics where people will say that, like they have it in their mind that whenever you offer an adolescent, any form of gender affirmation. So like, if you let them change their pronouns, if you let them start puberty blockers, if you let them start hormones, if you let them have a legal name change that, like you’re forcing them into a binary, transgender identity that right. That you’re like forcing them. And then it’s funny because now all the conversion therapy policy statements from major medical organizations say like, you don’t push a kid in either direction, right? You don’t push a kid to be transgender in a binary fashion. You don’t push a kid to be cis-gender like any of that is wrong. Like it is not our job to force someone into one gender identity. And really what our job is, is to sit with someone and let them explore how their life and identity is evolving and support them through it. And taking a medication doesn’t make you suddenly unable to speak. You know, it doesn’t make you unable to explore if your identity is non-binary, you know, there’s nothing about medical interventions that prevent you from being able to have that exploration. So I just don’t agree with that at all. (On how many people detransition)

Marianne Oakes:

I was just going to say where nonbinary is concerned, as well. I was working with somebody recently and I think for, let’s just say for somebody who is assigned male at birth to be non binary, the most difficult thing they are going to have through their lives, as they grow older is for their feminine attributes to be recognized in the wider world and the older they get, the harder it will get. So gender affirming hormones, isn’t about making them binary. It’s about accentuating a part of them that people don’t see. I think it’s vice versa for the assigned female at birth that, you know, you’ve got all these feminine attributes. How do I express this masculine part of me? And it doesn’t put me into a binary. I think sometimes we get too hung up on on what the medical process is. And you know, what we’re trying to, what the medical people are trying to do and achieve by offering this medication. And sometimes we forget to understand why is the person trying to achieve, and this notion of, you know, hormones would make somebody binary. I think I’ve just started saying recently, you know, I’ve, I’ve probably overshot the m ark to be able to comeback because if I hadn’t overshot the mark, I could never have found where I needed to be. Does that make sense? That, you know, that’s the risk that I’ve had to take to find my comfort zone and a concept on it without pushing and pushing and pushing and just say, Oh, actually it’s probably going a little far. I’ll just come back a little bit now. So non binary, binary, it just doesn’t, it just doesn’t compute with me.

Dr Jack Turban:

Yeah. I feel like it goes back. Like you’re saying that most cis-gender people really think like you are male or female, right? Like you, and like, if you have estrogen in your body you’re female, if you have testosterone in your body, you’re a male. And I think that like notion is so ingrained that it’s hard for folks to understand, like somebody can be taking estrogen and being non binary. You know, like those things are not, not in conflict, even though many would kind of presume that they are.

Dr Helen Webberley:

In the beginning, Jack, you were talking about, you know, whether you’re gay or you’re not gay. And that, you know, some people said that they were gay and then they’re like, well, no, sorry, I’m not gay after all. And then they’re like, well, I am gay. And it’s just yes or no, isn’t it. It’s fine to me. But that just is a problem. Why do we have to classify it? Why do you have to be one or the other, or even as a non binary, are you male or female? Are you nonbinary? Are you gay? Are you straight? And it’s like, because it’s just a massive, massive spectrum. And, you know, you’ve been talking about this recently, this going further along the gender spectrum. And then just because you felt it, and then it was a good thing, but you actually a little bit too far, and you want to come back a little bit and that that’s definitely not a kind of binary fashion, is it? It’s a much more of a spectrum type place to be.

Marianne Oakes:

Don’t cis people do this as well, though. When you look at a teenage girl, you know, working out her own sexuality, a little looking at her own gender expression and dressing ridiculously put in way too much makeup on, you know, maybe sexualizing herself and learning that actually, where can she be comfortable? So they’ll go too far and then start bringing it back. And you know, why will trans people be any different, I suppose, and gender can be fluid. And, you know, we all get up some mornings and feel a little bit different than we did yesterday. And maybe express ourselves slightly differently. So I don’t, I don’t think we should be excluded from that party, shall we say?

Dr Helen Webberley:

I that’s, that’s, that’s definitely the gender expression that coming in as well, which is so important reason as you’re finding your comfort place to live. Isn’t it? Absolutely. Another thing I want to challenge you, we will not challenge you on, another thing I want to talk to you about is the model of psychiatry in gender care. Once again, I was reading Norman Spack’s, I think it was 2009, and he wrote a really beautiful piece on what his experiences of being a gender specialist, what he learned from his patients, from the adolescents that he talked to. And he was saying, the trouble is right. If you a young person or older person, whatever, if you wanna refer to a psychiatrist who doesn’t have a great deal of experience with gender, gender identity management, shall we call it that, then you’re gonna come out with a psychiatric diagnosis, and then you’re going to come out with psychiatric medication when it actually, what you needed was a gender identity diagnosis. If we use that word, and gender affirming medication. So I was really interested that even back that long ago, he was talking about the role of psychiatry. And clearly we need psychiatry because of, because of any coexisting, you know, mental health conditions. But do we need psychiatrists at all? I know that you are one. What about the role of psychology counseling? If that’s not too much of a challenge for your profession.

Dr Jack Turban:

It is certainly not. Actually in medical school, I was at Yale, and I would jump on the Amtrak every month to go see Norm and his clinics. He’s one of my favorite people. And he used to always say like, gender dysphoria is not a psychiatric illness. Like this is an endocrine condition. And like I, as an endocrinologist happen to help people with medical interventions that they need, which I thought was very wise. Obviously I’m a psychiatrist. So I have like a slightly different view. I think more just psychiatry needs to be better. And psychiatry is historically not good at supporting LGBT people. Right. We spent many, many years saying that being gay was a psychopathology. We should fix. We spent many, many years saying that gender diversity is a pathology. And like still kind of do sometimes, right? Like our profession does not have a good history with these things. However, I would say there are good people. And to your point, they’re often in psychology, not psychiatry, that are kind of pushing psychiatry forward so that it can be useful for LGBT people. I think it’s gotten better and better at being good for LGB people. I think it’s working on being better for transgender and gender diverse folks. Right. But when you go through medical school and you go through psychiatry training, you can go through all of that and never learn the minority stress model. Right. You could go through all of that and never know what pubertal suppression that’s. And in fact, most psychiatrists don’t learn anything about any of this, but I do think there’s a role like you were saying. Or I think like what Marianne was saying of sitting with somebody and providing support for when and not all transgender folks. Right? So especially I work with a lot of kids who are in affirming environments and get affirming medical care, and they don’t have mental health problems. To be honest, they’re doing fine. They probably don’t need a psychiatrist very much, but in most of the country, there are most kids are dealing with some sort of transphobia people in the media. They’re maybe dealing with being bullied at school. Maybe their families rejecting them, maybe their extended family is rejecting them. And we do have these models in psychology and psychiatry to help people understand the ways in which that experience of being in society impacts you in, in negative ways. People understand the ways in which that happens and how to build resilience and kind of move forward through it and deal with really common experiences of having anxiety symptoms or depression symptoms or trauma related symptoms. So I’m hopeful. And I’ve been trying to do a lot of work, just putting more in medical education, putting more in psychiatry residency education, more in child, adolescent psychiatry, training of learning, how to do that kind of support in a way that’s going to be useful to the community. Was that a long answer? (On how many people detransition)

Dr Helen Webberley:

Okay. Yeah, no. So, so the way to put you out of the job is to not allow you to do any research on the medical models and you know, what assessments and stuff we should do, but only let you do more research on the how we can help better. And then also to stop the external factors that cause mental illness within gender diverse people, and then we won’t need psychiatry. So that, that would be a good. Marianne, does that put him out of a job?

Dr Jack Turban:

It just may be true.

Marianne Oakes:

I’m going to be really, really diplomatic here, because I think, I don’t deal with diagnosis, when we talk about gender dysphoria, I think there’s this notion that it’s the same thing for all people. And yeah, I just see it as two words that describe something that’s motivated me to self-actualize and move forward and try to make sense of it. And I do think that some people, I think a visit to a psychiatrist, might help them to better understand what their gender, you know, is this gender dysphoria that needs diagnosis and, oh, is this somebody that’s trans and actually your bet accounts then about support on how to deal with that? You know, that not everybody needs psychoanalyzing, but some people definitely do. And you know, I think there’s a place for it without question, cause I’ve come across people where I’m out of my depth because actually I think they need, they need more than I can give them. They need somebody that, that they need a medical authoritarian figure who can actually, you know, help them to understand. And then there’s those that, that are just getting on with it and you know, the right support. And that’s where counseling comes in. I don’t know, was that diplomatic?

Dr Jack Turban:

Yeah. And I agree with you. I think kind of what you’re also maybe highlighting is that psychiatrists don’t treat gender dysphoria, right? There’s no psychiatric intervention for gender dysphoria. There are medical interventions for gender dysphoria, if you will. And it’s not the rule like right, how the psychiatrist’s going to treat gender dysphoria, they’re not like they’re not going to make that go away. That’s kind of going back to right. The only way that it’s ever been proposed that psychiatry can do that was through conversion therapy, which obviously doesn’t work. It can make people much, much worse. But really I think right, psychiatrists are here to kind of help with all the other mental things like mental health things that may come up that are not gender dysphoria, but maybe anxiety and depression that come up from being in world where one is transgender or gender diverse. And right, the only argument for the diagnosis existing is insurance coverage. It’s not like where, we’re like writing in our notes, our treatment plan for gender dysphoria, right. Never once have I had a treatment plan for someone’s like gender dysphoria, but I’ve had treatment plans to help them with their anxiety or their depression or trauma related symptoms. It’s a different thing. (On how many people detranstion)

Dr Helen Webberley:

Absolutely. And the other thing that I wanted to, I know that we haven’t gotten all day. I’d love to talk to you all day, but we haven’t got all day, but is Marianne and Abby and I went over to Los Angeles to listen to Johanna Olson-Kennedy, and Aiden and Darlene Tando to talk. And just I’ve said it before I say it again. So inspirational, you know? Absolutely. And so you said a couple of things, but if I was wanting to, if I was rewriting the rule book for transgender care, I think, you know, they’ve coined it and you’ve added to it today. And basically Johanna has just said, look, if your kid, if your kid tells you that they’re trans, they most likely are. Just believe it. And Darlene, about detransition. She said, look, she said that there are some kids who just need to try out their birth gender again, once or twice, just before they carry on and that’s absolutely fine. And then you and Jack have been talking about the fact that just, let me change their pronoun, change their hair, give them the blocker. (unclear 36:02) you know, with, with their peers, you know, how is it until we’ve got that model of care going on?

Dr Jack Turban:

Yeah. I was really talking around it and not naming names, but that model does exist in the US, right? So Dr Olson, that’s her model. Brown University’s clinic has a similar model. And I think we’re now starting to have the conversations like great, those models have now been around for a little while, where they don’t have a lot of mental health involvement. They don’t have a gatekeeping model. They have this informed consent model. And so far it seems to be going fine. So, and now we have some rigorous research coming. So Johanna has this RO 1, right? This multi-site NIH funded study where they’re following these kids longitudinally. And some of them are in this informed consent model. And over time we might see that that’s fine. And then hopefully if there’s more data, the field will move in whichever direction the data agrees with. But timeline, to be honest, I kind of suspect it might be a few decades until the data comes out. I don’t know. And in the meantime, bright people are going to have more of these theoretical conversations around which one makes sense. And I think more and more people are being convinced, theoretically, that Jo’s model is a better model. But there’s by no means any consensus. And so I think, until the data comes out, there’s just going to continue to be kind of these two approaches and people fighting about it.

Marianne Oakes:

Cause you obviously I saw the tweets about detransition and we were talking about it earlier, the general consensus in the circles (unclear 37:42), it’s about 1% of people that detransition. That’s how many people detransition. I haven’t got a clue how true or how accurate that is, what, even if I was to be frivolous and say, let’s just say it was 10%. There’s an argument to say that any doctor, anybody working in this field has got a 90% chance of getting it right. And I’d like to see the research informing that because I genuinely believe if you went into this, knowing that there was a 90% chance you were going to get it right, you’d be less likely to be guarded. And it would ease the decision-making process. You can tell me I’m completely wrong there, by the way, I don’t know what the figures are. It’s confusing.

Dr Jack Turban:

(On how many people detransition) The figures are confusing. And I would say if the figure were 10%, then I think a very small fraction of that 10% are people who truly regretted anything, then maybe they detransitioned and did not regret it. That’s how many people detransition. That’s right. If you look at like the papers that are out there, the Dutch model, they have their paper on surgical regret where it’s like, 0.6% is their higher number, but when they actually go and look at those, even just that 0.6% of people, a large number of them, didn’t, it’s not like they identified as cisgender and were upset, they had surgery. They were mad that people were awful to them after their surgery, you know, like they still had the gender identity they had, they still wanted their surgery, but like life got harder after. And so for that reason, like they started taking exogenous hormones of their sex assigned at birth and kind of like changing their gender expression through that. So kind of, I think the big thing that I’m really trying to like drill into people’s minds is that we need to stop using this phrase detransition, and like citing statistics on it because that’s not a bad outcome. We know how many people detransition. The bad outcome is regret, and they’re not always the same thing, but also like, to your point, right? So if 90% of people that start estrogen are later happy with their decision, that means that if you stop giving estrogen to people, 90% of people are going to be really upset and regret having gone through their puberty that is making them horribly dysphoric. And that’s like always lost, right? That people like, think of taking exogenous testosterone or estrogen as like a horrible thing. If you later wish you hadn’t done that, but they never pay attention to this, like obvious elephant in the room that if you go through puberty, that’s the same thing, right? You were having estrogen or testosterone going through your system and you may later regret that. So it just logically doesn’t, there’s so many problems with the way people are interpreting the data.

Dr Helen Webberley:

I think what you’re both saying is it’s the same thing, isn’t it? Which is if we use those surgical regrets figures, the 99.4% are happy, the nought point six per cent weren’t so happy. And why are we so focused on protecting that nought point 6%? Why are we not using the 99.4% who are really, really happy. You know, why are we so focused on the tiny proportion of people who might not be happy and actually, why weren’t they happy about it or what caused it? But it’s really interesting. (On how many people detransition)

Dr Jack Turban:

The general public doesn’t realize how medicine works sometimes, I think, and they don’t realize that this is not horribly different. So right. Anytime we prescribe the medication, there are risks and benefits. So no one would ever get upset. If I prescribed someone, a statin for their high cholesterol, right? Like Lipitor. However, there is a very small chance that I could prescribe that medication and then the person could have muscle breakdown and go into kidney failure. Right. Does that mean that I don’t prescribe that medication at time point one where I don’t know if that’s going to happen? No. Cause like most likely that’s going to lower the cholesterol and they might not have a stroke, some benefits. And that’s what the informed consent models is telling people like, this is what this medication will do. And these are the potential things that could do that would not be good. And then people make their decision based on that. But I think because hormones are so politicized, that notion is really lost.

Dr Helen Webberley:

Definitely. And that’s certainly how I see the role of a doctor in gender identity healthcare, is about that medical laying out the risks and benefits that we know about medicine and shaping that up with how the person knows about their gender. Definitely think that’s the doctor’s role. Jack, thank you so much for being willing to thank you for the education that you do and the education that you’re bringing into medical schools and post-graduate curriculae. And also for the research you do. And please take all that I’ve said as a pinch of salt because the research that you do and produce really, really helps us over here to shape and feel confident in the health care that we provide over here. So thank you so much for all you do. It’s very, very far reaching and thanks for being with us today.

 

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