While transgender people have experienced growing visibility and acceptance in recent years, there’s still considerable confusion about even the most basic facts about trans people, gender identity and gender expression. What does it mean to be transgender versus transsexual? Are kids too young to know the difference? Are kids just “confused” or are they just suffering from psychological issues? The implications of such myths can further deny equitable opportunities to children who identify as transgender—from discrimination from health care providers, a reluctance to seek preventive care, and future employment discrimination, resulting in disproportionate unemployment rates and a consequent lack of any health insurance coverage.
Christopher Lewis, MD, pediatric endocrinologist and medical director of the Washington University and St. Louis Children’s Transgender Center, joins the show to debunk myths associated with transkids.
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Debunking the Myths About Transkids
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Learn more about Christopher Lewis, MD
Christopher Lewis, MD
Christopher Lewis, MD is a Washington University pediatric endocrinologist and director of the Transgender Center at St. Louis Children's Hospital.Learn more about Christopher Lewis, MD
Transcription:
Melanie Cole, MS (Host): While transgender youth have experienced growing visibility and acceptance in recent years, there's still considerable confusion about even the most basic facts when it comes to trans youth. This is Radio Rounds with St. Louis Children’s Hospital. I'm Melanie Cole and today we’re debunking the myths about transgender youths. Joining me is Dr. Christopher Lewis. He’s a Washington University pediatric endocrinologist and the codirector of the transgender center at St. Louis Children’s Hospital. Dr. Lewis, it’s a pleasure to have you back on with us again today. Please explain a little bit about transgender care in this country. As we’re debunking these myths, how is it evolving right now as you're seeing it right there on the front lines?
Christopher Lewis, MD (Guest): So I would say over time—the past 10 to 20 years—it has become obvious that this kind of care is something that was needed for not just adults but for adolescents and youth as well in order to help them achieve their goals and health needs not just from a medical setting but mental health support as well. It was noted that the kind of care that it needed is typically multidisciplinary meaning it’s a combination of working together with adolescent medicine providers, endocrinology, psychiatry, psychology, and a variety of other disciplines within medicine to provide the care. Currently we’re probably in the mid-40s in terms of number of clinics that across the U.S. provide multidisciplinary transgender youth care.
Host: Well, thank you for that. It is such an interesting topic. So tell us about some of the challenges as we’re talking about myths and things that even other providers might not know about working with transgender youth specifically. What are some of the challenges when you are dealing with youth and dealing with adolescents as they're going through this and figuring everything out for themselves. I mean adolescents is a tough time anyways. Tell us what are some of the challenges that you see every day.
Dr. Lewis: One of the challenges that we run into is that people both within the community and medical providers. So transgender providers are pushing an agenda or some sort of ideology. What I say to all of my patients and their families is my job is not to tell them what path they need to go down. It is to educate them and provide them the resources that they can make the decision themselves. If the individual is an adult then they are able to make those decisions autonomously. If that individual is a minor then those decisions are made in conjunction with their mental health provider and their guardians who really are the ones that can provide consent which are their parents.
Host: Well, that’s very important information. So give us some common myths that you hear. Some people thing that transition related care or that insurers don’t have to cover transition related care. You're the co-director of the transgender center at St. Louis Children’s Hospital. Break up some of those myths for us, Dr. Lewis, about things that people come in and ask you and that other providers might not even know.
Dr. Lewis: So when you're asking about whether or not transgender care is optional or not, it is a decision that is made by the individual and/or their family in conjunction. The timing of when someone should or should not transition is ultimately up to them. Not every transgender person that comes to see us elects to undergo hormonal or surgical transitioning. Some are fine with just undergoing various aspects of social or legal transitioning, and that’s also services that we will help them with if they're not interested in hormonal or surgical interventions. So the first myth is that every transgender person wants hormones. That’s just not accurate. Also that every transgender person wants to undergo surgery, and that’s also not accurate as well. We try to, like I said earlier, education every patient and their family about the pros and cons of every decision that we make. That highlights that the choice to not pursue hormonal or surgical intervention at some point in the future is an act of decision. A lot of times people perceive that not making decision, waiting until someone is a certain age or certain other characteristic that the family feels more comfortable pushing the decision out further is an act of decision that does have both benefits and consequences that have to be discussed.
Host: So when you're discussing them and as you cover more of these—it is so interesting how people view this. What about things like gender identity and sexual orientation? Are they linked? I think that’s a source of confusion for so many people.
Dr. Lewis: You have to think about four concepts. Biological sex, which is anatomic genotypic chromosomal variations of sex. Then you have gender identity, which is how someone identifies internally on a spectrum of male or female or even agender meaning they do not identify as only male or only female or some other degree along that spectrum. When we’re then thinking about sexual orientation, that is how someone’s gender identity correlates to what they find themselves romantically or sexually attracted to. Then finally gender expression. How we chose to portray our gender to the outside world, which may be something that correlates to our gender identity or may not. All four of those variables—biological sex, gender identity, sexual orientation, and gender expression—while they are all associated with one another and related with one another can be completely dependent of one another.
Just to talk about a different type of population that I take care of. I am also the medical director of our difference of sex development clinic. Those are individuals who’s biological sex are not 100% male or 100% female. They are intersex. That have degrees of biological sex that falls somewhere in between that spectrum of male or female in a medical standpoint. We have to have the same discussions about gender identity and gender identity development with that patient population as we do with the transgender population that we take care of as well. When we’re exploring those concepts, if we think about someone who is assigned male at birth but identifies as female but in terms of their play and preferences they still like stereotypical male things, a lot of people will doubt that individual’s identity as female. But if you have someone who is assigned female at birth, identifies as female, but has male preferences in terms of play, activities, dress, etcetera, society would call that individual a tomboy but still never invalidate that person’s identity as a female. Those sort of topics and definitions and constructs that we make are all societal in terms of how we define them and orchestrate them and how they impact the development of a child in their identity.
There are many civilizations both current and in the past that have existed that have recognized more than two genders. I think as we continue to move forward in our society we are recognizing that allowing people to explore this aspect of their humanity is just as important as any other characteristic of their personality that we encourage children and youth and adolescents to explore and express throughout their lifetime.
Host: Well said. 100% agreed. So what resources can St. Louis Children’s Hospital provide to referring physicians to help guide these conversations in their clinical practice? What would you like other providers to know about that?
Dr. Lewis: Well, the transgender clinic is always an option for people to refer their patients to for us to have that discussion if the pediatrician isn’t comfortable. We have support staff that go to medical facilities and provide education and training for those that want to be more well equipped to have these conversations. Also our family resource center. While it’s typically the resources are made for families I think can also be utilized by medical facilities and general practitioners to help bolster their resources not just for themselves but for their patients as well. Then if someone is really wanting to go in-depth into these conversations and topics, there’s a slew of online tutorials, modules, and resources that we could provide them access to. They would just need to get in contact with our support staff at the transgender clinic and we’d be able to provide them with whatever resources or services that they’d need sort of managed towards the specific question that they have.
Host: To learn more about the center for families at St. Louis Children’s Hospital, please call 314-454-2350. Or to consult with a specialist at St. Louis Children’s Hospital you can also call the children’s direct physician access line at 1-800-678-HELP. Thank you so much Dr. Lewis for coming on and giving us such great information about the center and about what other providers can expect from referral. Please also visit our website at stlouischildrens.org for more information and to get connected with one of our providers. This has been Radio Rounds with St. Louis Children’s Hospital. Please remember to subscribe, rate, and review this podcast and all the other St. Louis Children’s Hospital podcasts. I'm Melanie Cole.
Melanie Cole, MS (Host): While transgender youth have experienced growing visibility and acceptance in recent years, there's still considerable confusion about even the most basic facts when it comes to trans youth. This is Radio Rounds with St. Louis Children’s Hospital. I'm Melanie Cole and today we’re debunking the myths about transgender youths. Joining me is Dr. Christopher Lewis. He’s a Washington University pediatric endocrinologist and the codirector of the transgender center at St. Louis Children’s Hospital. Dr. Lewis, it’s a pleasure to have you back on with us again today. Please explain a little bit about transgender care in this country. As we’re debunking these myths, how is it evolving right now as you're seeing it right there on the front lines?
Christopher Lewis, MD (Guest): So I would say over time—the past 10 to 20 years—it has become obvious that this kind of care is something that was needed for not just adults but for adolescents and youth as well in order to help them achieve their goals and health needs not just from a medical setting but mental health support as well. It was noted that the kind of care that it needed is typically multidisciplinary meaning it’s a combination of working together with adolescent medicine providers, endocrinology, psychiatry, psychology, and a variety of other disciplines within medicine to provide the care. Currently we’re probably in the mid-40s in terms of number of clinics that across the U.S. provide multidisciplinary transgender youth care.
Host: Well, thank you for that. It is such an interesting topic. So tell us about some of the challenges as we’re talking about myths and things that even other providers might not know about working with transgender youth specifically. What are some of the challenges when you are dealing with youth and dealing with adolescents as they're going through this and figuring everything out for themselves. I mean adolescents is a tough time anyways. Tell us what are some of the challenges that you see every day.
Dr. Lewis: One of the challenges that we run into is that people both within the community and medical providers. So transgender providers are pushing an agenda or some sort of ideology. What I say to all of my patients and their families is my job is not to tell them what path they need to go down. It is to educate them and provide them the resources that they can make the decision themselves. If the individual is an adult then they are able to make those decisions autonomously. If that individual is a minor then those decisions are made in conjunction with their mental health provider and their guardians who really are the ones that can provide consent which are their parents.
Host: Well, that’s very important information. So give us some common myths that you hear. Some people thing that transition related care or that insurers don’t have to cover transition related care. You're the co-director of the transgender center at St. Louis Children’s Hospital. Break up some of those myths for us, Dr. Lewis, about things that people come in and ask you and that other providers might not even know.
Dr. Lewis: So when you're asking about whether or not transgender care is optional or not, it is a decision that is made by the individual and/or their family in conjunction. The timing of when someone should or should not transition is ultimately up to them. Not every transgender person that comes to see us elects to undergo hormonal or surgical transitioning. Some are fine with just undergoing various aspects of social or legal transitioning, and that’s also services that we will help them with if they're not interested in hormonal or surgical interventions. So the first myth is that every transgender person wants hormones. That’s just not accurate. Also that every transgender person wants to undergo surgery, and that’s also not accurate as well. We try to, like I said earlier, education every patient and their family about the pros and cons of every decision that we make. That highlights that the choice to not pursue hormonal or surgical intervention at some point in the future is an act of decision. A lot of times people perceive that not making decision, waiting until someone is a certain age or certain other characteristic that the family feels more comfortable pushing the decision out further is an act of decision that does have both benefits and consequences that have to be discussed.
Host: So when you're discussing them and as you cover more of these—it is so interesting how people view this. What about things like gender identity and sexual orientation? Are they linked? I think that’s a source of confusion for so many people.
Dr. Lewis: You have to think about four concepts. Biological sex, which is anatomic genotypic chromosomal variations of sex. Then you have gender identity, which is how someone identifies internally on a spectrum of male or female or even agender meaning they do not identify as only male or only female or some other degree along that spectrum. When we’re then thinking about sexual orientation, that is how someone’s gender identity correlates to what they find themselves romantically or sexually attracted to. Then finally gender expression. How we chose to portray our gender to the outside world, which may be something that correlates to our gender identity or may not. All four of those variables—biological sex, gender identity, sexual orientation, and gender expression—while they are all associated with one another and related with one another can be completely dependent of one another.
Just to talk about a different type of population that I take care of. I am also the medical director of our difference of sex development clinic. Those are individuals who’s biological sex are not 100% male or 100% female. They are intersex. That have degrees of biological sex that falls somewhere in between that spectrum of male or female in a medical standpoint. We have to have the same discussions about gender identity and gender identity development with that patient population as we do with the transgender population that we take care of as well. When we’re exploring those concepts, if we think about someone who is assigned male at birth but identifies as female but in terms of their play and preferences they still like stereotypical male things, a lot of people will doubt that individual’s identity as female. But if you have someone who is assigned female at birth, identifies as female, but has male preferences in terms of play, activities, dress, etcetera, society would call that individual a tomboy but still never invalidate that person’s identity as a female. Those sort of topics and definitions and constructs that we make are all societal in terms of how we define them and orchestrate them and how they impact the development of a child in their identity.
There are many civilizations both current and in the past that have existed that have recognized more than two genders. I think as we continue to move forward in our society we are recognizing that allowing people to explore this aspect of their humanity is just as important as any other characteristic of their personality that we encourage children and youth and adolescents to explore and express throughout their lifetime.
Host: Well said. 100% agreed. So what resources can St. Louis Children’s Hospital provide to referring physicians to help guide these conversations in their clinical practice? What would you like other providers to know about that?
Dr. Lewis: Well, the transgender clinic is always an option for people to refer their patients to for us to have that discussion if the pediatrician isn’t comfortable. We have support staff that go to medical facilities and provide education and training for those that want to be more well equipped to have these conversations. Also our family resource center. While it’s typically the resources are made for families I think can also be utilized by medical facilities and general practitioners to help bolster their resources not just for themselves but for their patients as well. Then if someone is really wanting to go in-depth into these conversations and topics, there’s a slew of online tutorials, modules, and resources that we could provide them access to. They would just need to get in contact with our support staff at the transgender clinic and we’d be able to provide them with whatever resources or services that they’d need sort of managed towards the specific question that they have.
Host: To learn more about the center for families at St. Louis Children’s Hospital, please call 314-454-2350. Or to consult with a specialist at St. Louis Children’s Hospital you can also call the children’s direct physician access line at 1-800-678-HELP. Thank you so much Dr. Lewis for coming on and giving us such great information about the center and about what other providers can expect from referral. Please also visit our website at stlouischildrens.org for more information and to get connected with one of our providers. This has been Radio Rounds with St. Louis Children’s Hospital. Please remember to subscribe, rate, and review this podcast and all the other St. Louis Children’s Hospital podcasts. I'm Melanie Cole.