 Our technical, but thank you for coming and for being patient with our technical difficulties. We are really excited to have Paula Martin here with us today. She, and I'm going to go ahead and introduce her. As you know, we are at the tail end of our gender equity and ethics series. We have this week and then next week we have some external speakers coming and then I'll be closing out on May 23. But let me give Paula enough time to because of the technical delays. Paula Martin is a postdoctoral teaching fellow in the Department of Comparative Human Development and also with the Center for the Study of Gender and Sexuality. Martin works across the fields of medical anthropology, science and technology studies, gender studies and youth studies investigating how gendered medical practices shape the way that young people's futures are imagined and enacted. Her current book project called Practicing Gender. This is kind of disciplinary in anthropology, my home discipline, we tend to script our full talks so just to say that that's what I'll be doing but please feel free to like make it known if you need clarification or need me to take a pause at any moment. And I hope that there'll still be some time for questions at the end. And the other comment is that I want to make upfront is that the work that I'm sharing today is in kind of the early stages of attempting to theorize ethical stances anthropologically. So that when I'm saying ethics or ethically in this talk I'm not necessarily using those terms in the same ways that correspond exactly with traditional or expected bioethical models that you might be a little more familiar with. I'm interested in using the language and the concepts of ethics as a way of highlighting how care is modeled and developed, how as care is modeled and developed, we're doing more than simply looking for better scientific evidence or working to provide a universally assumed good. Instead, our individual and collective values and beliefs about what kinds of people youth are, and what gender is are impacting what comes to be seen as the right course of treatment. This also means that my work is several steps away from directly recommending practices but I'm nonetheless very invested in starting conversations with providers about how to use what I find to address inequities in gender care and to improve the care that's offered to gender diverse youth. So, with that said, I'm going to dive right in and I'll look forward to our conversation at the end. What should we do when a young person, a child or a teenager makes a claim to see if I can hide this for a second. What should we do when a young person a child or a teenager makes a claim to a gender identity which is different from the one they were assigned at birth. This is the question that my talk today takes up, drawing on research with providers of gender affirming care and the patients and the clients they serve. That claim might come as it did in my research in the form of a child delivering a recorded video to her parents informing them she is a girl, not a boy, or when someone experiencing their first period finds as loop did that it was just completely, completely wrong. Parents may find this unsurprising based on their children's hobbies or habits, or it may feel abrupt sudden, as some parents put it, just like another obsessive interest, they thought their child would soon forget about. For some youth, it may be impossible to articulate until something just breaks. Gender affirming care refers to practices both social and medical that aim to help a young person align their felt sense of gender with the gender they are perceived as part of what sets my work apart from others researching gender diversity is that it largely takes place among those who already agree that to answer the question. What should we do when a young person claims a gender identity other than the one they were assigned is that for many youth we likely should do something, and that something should be supportive. My interlocutors and I share a set of foundational commitments that young people can be trans and that they are entitled to access care on that basis. But this leaves out the perspectives of those who would argue against the possibility of trans youth at all, or hope to invalidate trans identity itself. Yet even within the world of affirmative care, the question of what it is that should be done and when remains a problem, a problem I argue that is rooted in both the uncertainty of gender and the uncertainty of the future. Drawing on my fieldwork at one of the most prominent pediatric and adolescent gender clinics in the United States. I argue that within the field are two grounding logics which structure how care is provided and understood that of prevention and that of potential. I use these terms to highlight the different epistemic and ethical orientations which characterize how providers, families and young people themselves relate current desires for gendered intervention to an unknown future. My talk is going to progress in four parts today. In the first part I'll describe what current practices of gender affirming care look like provide evidence for my fieldwork about that care and practice, and give a brief overview of the sites and methods of my project. In the second part I'll turn toward a discussion of prevention and describe how to oppositional anticipated futures have come to dominate rhetoric around the risks and benefits of affirmative care. Part three will discuss the the ethic of potential and share how some clinicians and youth justify care by directly orienting towards the possibilities of a good future, even as it remains uncertain. I'm going to end with a brief discussion of what we might take away from my research in terms of implications for gender equity in the practice of medicine. By the end of the talk I'll have provided some insight into how the practices of gender affirming medical practices and the processes of justice. Let me end my talk. In late January the Republican governor of Utah signed the first but not the only bill of the year. As an increasingly politicized issue in the United States, gender affirming care has seemingly moved from a niche field, rarely discussed outside of daytime talk shows. Not notions of bodily autonomy and the meaning of gender itself is being fought. In a similar feeling that this is a recent phenomena, scholars such as Jules Gil Peterson have argued that trans young people played a central role in the historical development of the clinical notion of gender itself combating narratives which position trans youth as new. Yet it is also true that transgender youth were not publicly identified as a specific population who needed a specific clinical protocol in the United States until the 1990s. Medical practice in the United States draws most heavily from what is usually referred to as the Dutch model. This model originated in the Netherlands in the 1980s and soon became the standard approach to affirmative intervention before adulthood. In their original model, the first steps towards accessing medical intervention was psychological assessment, which at the time was unsurprisingly linked to highly normative understandings of binary gender. The goal of the assessment process was to distinguish between youth who would persist in their proclaimed gender identity from those who would desist or ultimately come to identify with the sex they were assigned at birth. Now early studies of persistence and desistence have been vigorously contested on a number of grounds which I'm not going to dig too deeply into at the moment. The most important thing to take away which I've sort of represented here in the image is that there is this idea that some gender expansive youth will grow up to be trans adults and some will not. And that the distinction between those groups is foundational to how the how the field of youth focused affirmative care has developed. My argue is that the desire to continue separating youth along those lines and the difficulty in doing so is a large part of what shapes how the ethics of potential and prevention show up in the clinic. But before we get more into that let's meet a patient. Riley walked down the hallway to Dr. M's office accompanied by both of her parents like many other four year olds. Unlike many four year olds, however, when offered the opportunity to ask her question first to her new doctor, she turned to Dr. M and directly inquired, how do you make a vagina. Dr. M kindly told her that she didn't actually make vaginas to which Riley promptly turn her attention to me vigorously note taking off to the side and asked, how does he do it. At that precise moment, I was too busy writing down what was happening to actually understand what was happening. So I kept scribbling as Dr. M laughed and Riley said that he doesn't make vaginas either and it's not a vagina that makes you a girl. Riley's question in her desire is in many cases exactly what so many detractors of care find threatening the possibility of irreversible intervention onto the body of a child based upon nothing but a child's expressed desire and eventually a clinical opinion. But as Dr. M explained to Riley's parents, as Riley and I played on the floor with a new set of toys kept precisely for this purpose. There were no medical interventions offered at this stage. The only changes that one might pursue were things these parents had already done shifts in hairstyle name and clothing, these important but malleable signals of gender, the ones which Riley had used to mark me incorrectly as a boy. So in this case, the answer to the question, what should we do with a child who's making a claim to a gender they were not assigned at birth. From the affirmative perspective is to allow her to make these changes, which for four year olds often means very binary choices and clothing and activities and strong desires to keep things categorized as boy things or girl things. But even for supportive parents and children with clearly verbalized desires decisions often start to feel more complex once medical interventions enter the picture. Medical intervention for Riley, should she continue to ask for it wouldn't come until she began puberty when she would be eligible for treatment with gonadotropin releasing hormone analogues, commonly called puberty blockers. So here's one possible timeline of intervention the one that's most commonly invoked in standards and kind of clinical discussion about care it is certainly not the only trajectory of intervention. But you can see here how social changes come before puberty suppression come before exogenous hormones and come before surgery right and so this is the most typical for young people like like Riley. So an early medical intervention this idea of the puberty suppression in particular is considered one of the trademarks of the Dutch approach and it remains a cornerstone of what youth focus care often offers. The Dutch were the first to introduce the notion of an embodied pause, a halt in physical development which would in theory do two things. It would give youth more time to consider how they felt about gender and their body before embarking on any further transplant. And it would prevent the development of unwanted sex characteristics. Now Riley was one of the youngest patients that I met during my time at the trans youth clinic which is a pseudonym. As a major hub for affirmative care located in California, the TYC had over 1000 patients in active care ranging from ages four to 25. When I concentrated in the greater metro area around the clinic, some like Riley flew from states away drawn by the reputation of the clinic and the reputation of Dr. M, the clinic director. During my field work. I attended approximately 60 clinical appointments, as well as weekly case conferences with the interdisciplinary team of doctors nurse practitioners social workers psychologists and community outreach workers. I also spent time in meetings with the affiliated clinical research team running a longitudinal study on the impact of early intervention. A part of my research that I won't talk a ton about but we can talk about in the discussion. When I wasn't at the clinic I was conducting interviews with youth and their families as well as with professionals and advocates both locally and remote and attending multidisciplinary conferences on gender and health. For the new patients who arrived in 2019, which was the year of most of my field work. The majority were white trans masculine and between the ages of 12 and 17. The skewing towards a more privileged youth undoubtedly shapes the way that care practices are developed in utilized. I'm interested in understanding how care is provided to those who receive it and how those practices make evidence and foundational truths about how youth and gender are conceptualized within the United States. It's certainly true that many youth never make it to the clinic at all. And this is a critical problem that some other scholars like the sociologist traverse have taken up in recent years. For patients who do end up at the clinic. What often drew them in was the experience or anticipation of a body whose gendered attributes were unwanted. It was an early stop as it was for Riley but more often it was only after lengthy negotiations between youth and their families that the topic of medical intervention itself was broached. Yet once intervention was being considered, either in the form of puberty suppression or gender affirming hormones, the clinic became a central place from which I could observe how different versions of a future were imagined and invoked in order to guide a course of treatment. It was through these observations that I came to articulate the ethics of prevention and potential and to see how these concepts identified different relationships drawn between the experiences of youth in the present and their anticipated futures. The first relationship and the most prominent of these two ethical stances is the one I glossed as prevention, which I will turn to now. Once more return to the question that I began with the question, what should we do with a young when a young person claims a gender identity other than the one they were assigned at birth. For many, a response is correct when it brings about a future that is desired. But in the specific case of affirmative gender care, the futures that are most often invoked are the ones which providers and parents have an ethical imperative to prevent. These are the desirable futures which dominate discourse around the risks and benefits of early affirmative intervention. The first is the future where youth who change their gendered embodiment come to regret those changes, particularly if they eventually identify with the gender they were assigned at birth. The future of regret is a focal point in highly publicized cases of D or re-transitioners. One example is the case of Kira Bell, a young person in the United Kingdom who upon again identifying with the gender she was assigned at birth, brought a suit against the clinic which provided her care. This rarely halted all early gender affirming intervention in the United Kingdom. Though it was eventually overturned, this series of events only sharpened existing anxieties that any patient could become an adult like Miss Bell, who looks towards the state, the clinic or their families as the ones who should have prevented what they now regret. In my fieldwork, regret emerged as a threat which had to be guarded against, primarily through techniques of expertise and knowledge gathering, which could transform the uncertain future into something predictable. As Harley, a social worker at the TYC told me, parents come in here wanting a lot of times, wanting an assessment, right? They want to know, is my kid trans? So this is a really big question. Harley, is my kid trans? By the end of this visit, are you going to be able to tell us if in fact my kid is trans? To which I will have to break it to them. There is no assessment for your kid being trans or not. In this instance, asking if the kid is trans is a way of asking if they will continue to desire any changes that they make and how their gender is embodied. Will they persist? As Harley says, this is a difficult, maybe even an impossible assurance to give. In his view, there is no checklist or test which can provide it. Dr. M would often sigh over new practices or providers telling me how they do what I think they would endorse as cautious, which she scare quotes, but which is really fearful. People are just paralyzed, she says. What if they regret it? The future translates caution into fear, frustrated by the way much conventional practice prioritizes the avoidance of regret above any other need. In many cases, future regret is rendered so catastrophic that the only other future outcome powerful enough to counter it is an even more disastrous one. One where youth who are prevented from accessing affirming care find their lives to be no longer bearable and die by suicide. In the future, the one shaped by the fear and reality of suicide among trans youth is the one that is occasionally delivered as a blunt ultimatum to hesitant or unaffirming parents. What's worse that you have a trans kid or a dead one. Highlighting the suicide rate among queer and trans youth, which according to some researchers is as high as four times the rate as a non LGBTQ youth has undeniable political and pragmatic significance. Nonetheless, what I suggest is that relying on suicide prevention as the primary justification for providing gender affirming care only reproduces the same logic of prevention which results on the fixation on regret. In other words, when care provides becomes primarily about these two polarized outcomes, the future shaped by unbearable regret in the future shaped by a young person's death, then determining who can access intervention becomes about developing assurances that these futures will not come to pass assurances which are in many cases impossible to deliver gender care itself then becomes about predictive capacity and epistemic authority, neither of which are often held by young people themselves. Another way to understand the difficulty of grounding the ethics of intervention in prevention is to contextualize it within the scholarship on risk, particularly risk as it is theorized in the social sciences. In a broad sense risk has been conceptualized as a primary characteristic of social life. Attending by an attended by an ever proliferating set of predictive technologies that simultaneously provide increasing amounts of data and heighten our awareness of that which we do not know, or even worse, might not know that we do not know. For example, Joe Dumit has described health in the United States as defined by this double insecurity, never being sure enough about the future, always being at risk, and never knowing enough about what you could and should do. In this way, gender affirming care is not exceptional, but rather a case which profoundly illustrates the ways that contemporary medical practices must account for that which is never quite knowable. But what sets gender affirming care apart from many other medical practices is the uniqueness of gender identity itself, the difficulty in operationalizing gender within the clinic, particularly in the era when diagnoses no longer directly attempt to reinforce a normative or binary, but instead to treat the feelings of distress that can emerge from inhabiting a gendered body in a gendered world. Harley was not the only one to talk with me about how parents look towards clinical experts to validate their children's experiences. Young people also described how their parents hoped clinicians could assuage any of their fears about future regret. Jonathan was 13 when we first spoke at length in a private room of a public library in his suburban hometown. He sighed when he told me about his father who didn't want me to start anything. According to Jonathan, his father had remained skeptical about his identity until his dad talked to Jonathan's own therapist. Although Jonathan found this upsetting, he also sympathized with what he imagined his father going through. I mean, I understand it. Honestly, he told me, you're worried about your kid. You think you think you don't want them to make like the wrong decision. You don't want them to be affected later in life. Other parents focused less on the testimony or evaluation of experts and more on the power of time, asking youth to wait until certain markers were passed until they learn to drive or got their grades up or were just older. Yet asking youth to wait, whether for the validation of an expert opinion or until some future time, Canon often does result in increasing distress for youth who feel their bodies developing in unwanted ways. The lady who described herself as a late bloomer, thank God, found herself confronting the limits of her patience when she came out after she came out to her parents. They told her she needed to wait two years before pursuing transition. I asked her how serious her parents were about the two years and how often she thought about it. I was like, we're one day closer, one day closer, and then eventually I just couldn't take it anymore. And I was like, oh, you know what, like I have to do this now. Otherwise, I'm not going to be able to live with myself. Zoe imagines a future that is unlivable, which even when posited against future regret is almost always a powerful motivator for action. But the question remains if this appeal to the unlivable life is the only way of combating the deep seated fear of future regret, even if that fear is often located in the adults around a youth rather than in a young person themselves. Much of what I have described so far has been about how the need to prevent bad futures, both regret and suicide emerge from an inability to trust in youth themselves. The idea that youth, particularly teenagers cannot be no trusted to know something like gender in the absence of verifying measures like the brain MRIs or blood tests, some parents came into the clinic hoping that they would receive. Prevention is not the only way to manage the uncertainty of the future or the uncertainty of gender. Other logic also exists. One switch more radically orient towards the capacity of youth to determine their own futures, and which consider not just the future to be prevented, but the ones which should be cultivated. To understand that I now turn towards one of these alternative framings, the one that I call potential. In 2011, what we're asking is, do you want to go through endogenous puberty. Dr. Why another TYC physician says to two parents. He says this to help these parents sift through the temporalities expectations and meanings layered into clinical decision making, and importantly, to separate out the question of identity itself from the embodied changes that interventions can both stop and facilitate. Prevention still logically structures how providers like Dr. Why describe the utility of gender affirming care, especially in terms of avoiding unwanted bodily development. Dr. Why doesn't see his role as determining if a youth will always identify with the gender they enter the clinic with. I do obviously ask questions about gender, he would tell a family, but I'm not keeping score. Dr. Why's attempt to move away from being a scorekeeper is also a move which reflects the desire to shift the conversation about the ethics of intervention away from the perpetual battle between regret and suicide. As I began to see it in my fieldwork. This is also a shift towards seeing within the practices of medical care, a way to foster the potential of a good future, instead of only ways to prevent bad ones. But this is also about articulating a future where trans people belong, not simply because a trans life was the only way to stay alive, not only as a last resort, but because trans lives are also good and desirable lives to live. Aiden and Darlene, both clinical social workers often speak about their work to packed ballrooms at conferences drawing professionals as well as families. I attended a number of such conferences between 2015 and 2019, taking advantage of them as sites which provide insight into how models of care are articulated and circulated outside of the clinic. This meant that I saw Darlene and Aiden give several versions of their most popular presentation over the years. In an especially well attended summer session, Darlene was explaining that what is usually used to distinguish between youth who should receive intervention, and those who might not need it. Sometimes this is described as the difference between youth who are transgender and those who are gender expansive is the experience of distress. In fact, the current clinical diagnosis governing governing most gender affirming care is gender dysphoria or clinically significant distress associated with gendered embodiment. The feelings that made Zoe say I have to do this now. In the workshop, Darlene challenges this diagnostic necessity by asking the assembled crowd. Why would we want distress from anyone. We aren't waiting for distress when or should intervention be offered. Darlene once again puts the question to the crowd, this time asking if we aren't waiting for distress. How do we know when the right time is from somewhere in the back a person calls out when they ask for it. Both the presenters laugh, replying, we keep planting you in our audiences. As Darlene goes on to say in this same workshop. It's true that if you offer options your kid might take you up on it. That's because it's right for them. In other words, rather than only providing supportive intervention, if it's felt to be the last step in preserving a life intervention can be something which facilitates a life which is good and desirable, even when the alternative may also have been bearable. So in my view what brings together Dr. Why, Aiden and Darlene here is how they shift from relying on prevention as the ethic which grounds care to imagining the potential future they could help young people reach. Instead of demanding certainty or attempting to calculate an amount of correct distress, they change both the temporality of engagement in the location of authority, effectively recentering the importance of what young people are asking for in the present moment. In the clinic, turning away from prevention and towards potential also meant that I would occasionally see patients whose future desires were somewhat unclear to their providers. Dr. M described one such patient to me as someone who had initially identified as a feminine boy. When we met in the clinic, Ryan had only recently started taking feminizing hormones after some time on puberty blockers. When Ryan and I met up again a few weeks after I first met her with Dr. M, I asked her what she thought the blockers offered her. She told me, I just really didn't want to go through male puberty, because then I couldn't decide later. She knew that she didn't want a beard. I didn't want to shave and stuff. I just knew that like, I don't really know what I want, but I didn't, I knew that I didn't want to be a man. Ryan says that she identified as male until I was like 12. Part of this she attributed to being homeschooled and allowed to wear the clothes she wanted and grow her hair as she liked without much social pressure to fit into normative gender categories. As Ryan described it, her gender was something that she wanted to let stay small until something happens and then she would have to change it. For her, the something was both social as she started going to group classes in the fifth grade where she mostly used feminine pronouns and embodied as she had to address the changes of puberty. When Ryan started high school, she was generally undisclosed, a possibility enabled in part because of her early access to care. Her ability to determine when and how she might share her trans identity is a power granted to her in part by a treatment logic that both recognized and valued her potential, even in the absence of a strong claim on a specific gender identity. In other words, Ryan wasn't prevented from accessing intervention until she either performed a level of certainty which would assuage the concerns about regret and the adults around her, or until she was so distressed she didn't think that life was bearable if she couldn't begin to transition. Now it might seem that potential here is linked to what proponents of puberty blocking in particular have named as its reversible nature, the fact that as an intervention, it offers primarily impermanent effects in the body. But this is not exactly my claim for a few reasons. First, because irreversibility itself fails to encompass what actually happens when pubertal development is forestalled, because as with any other aspect of life, you can't ever go backwards. Every experience, every embodied action contributes to a young person's capacity to both envision and reach a future that they desire. Second, potential itself as I see it is useful as a logic and as an ethic because it can help facilitate ways of seeing future outcomes outside of the mutually exclusive options of regret, suicide or permanent trans identity. That is, it provides a conceptual frame for understanding the value of providing care now, even absent a guarantee of future outcomes, which is not limited to the fantasy of reversibility. For example, as Amy, a clinical psychologist working outside of the TYC put it, why would you hold somebody back when they could live a full life right now in their gender. Amy references here the way that access to gender affirming care is chronopolitical to borrow from the queer theorist Elizabeth Freeman, a term that Freeman uses to reference how some groups have their needs and freedoms deferred or snatched away, and some don't. Here, Amy points to how asking youth to defer the process of transition is in some ways to ask them to defer their processes of living. Amy nonetheless acknowledges the power of regret saying, I know the refrain is but what if they change their mind. That is the refrain, I reply. So what I say, first of all, is that we can't predict that won't happen. We should be very careful that this is a long term decision. That is, that there is a vision into the future, and a real understanding of the present, but we cannot guarantee it. If they were to change it, change our mind then we would help them in the next gender iteration. There is nothing tragic that will have happened, as long as they have the social supports to do it and the understanding that gender pathways are lifelong, and they can change. So by saying this, Amy reframes the way that gender transition is understood as a singular event and transforms regret into something which even should it occur, might not be something tragic, but just additional information which someone can then adapt to. As another young person Caleb discussed it with me, the possibility of regret in his future, the regret his parents were extremely attentive to didn't feel like the right framing. And no, he told me I'm not going to look at it as more of a regret. Instead, as he imagines looking back on his life from 20 years into the future, he says, he's going to look at it like at 18. I at least did something that I thought was going to make me happy, and I did it. And if I love it in 20 years and I'm still doing it, then it's my happiness that I live with. Caleb refuses the chrono political imperative to defer his happiness out of fear, and instead reasserts what he sees as the potential of a good life, both in the future, and in the present. And what I want to draw attention to is the way that by doing so Caleb inevitably shapes his future towards the one he desires while remaining open to the fact that some of his desires may change. The future may be uncertain, but it is also his, his future, and his happiness. So the medical anthropologist in remole has argued that the essential question of medicine is no longer the one that Foucault identified as where does it hurt, but instead the question what is your problem. Within the context of the adolescent gender clinic, the question of what about the experience of gender is or could be a problem is tied up with the way that youth are imagined to move towards the unknown future. What Caleb described today are two distinguishable ethical orientations towards that unknown future, that of prevention, and that of potential. While prevention logics determine the actions of now based upon the future which is anticipated as harmful, logics of potential acknowledge the radical uncertainty of the future and attempt to provide support which can enable youth to meet their futures, whatever they look like. Despite the very real needs to attend to the ways that future harms can be prevented, such a perspective can also limit the ways that young people are able to advocate for their own present needs. So to conclude I want to pose three major concerns from kind of the broader gender equity standpoint that we should have especially given the current wave of legislation attempting to prevent youth and families from accessing affirming care happening in states all across the US. The first is just to under simply underscore that denying affirmative care creates and contributes to massive inequities between transgender and cisgender youth. I haven't spent much time today dwelling on the existing research that shows how affirmative care, which is supported by every major medical body in the United States goes a long way in reducing the differences in rates of negative health outcomes between cisgender and transgender youth, but I do want to be explicit that denying access to this care is undeniably harmful. Gender identity and expression has long been considered a human right and denying youth access to interventions that enable their gender identity and expression is without a doubt an infringement upon those rights. Considering this truth though, there are many who still hesitate to feel that they are able to provide the kind of care that youth are looking for. I will end with two open ended questions that I hope help to illustrate the ways that simply going about care as usual, generally supports cisgender youth differently than transgender youth, and this can be inequitable. So these questions are first our expectations for trans youth matched by expectations for their cisgender counterparts, considering interventions around puberty in particular. And when is non intervention actually cisgender affirming rather than neutral. And I think that both of these questions help to get at the ways that bias against trans lives and trans youth can show up in the process of making clinical decisions and are places that I suggest that providers might begin to extend or deepen their own thinking about what it means to provide care in a way that responds to the needs of gender diverse youth, and which actively values their existence. So I'll end there. I'll put the slide back up with the CME code for you all and I think that really just a little bit of time for questions. We do have some time for questions. Thank you so much for that. I'm all sort of soft and I'll let our audience ask questions you've obviously worked in a very big organized strong clinic. Yes, a lot of resources for transgender care. And, you know, as we are starting our journey at University of Chicago, you have obviously seen a very strong clinic can you just tell us what that looks like the structure of it and what tips from watching that you to be developed, being in that clinic Yeah, I can. Well, I don't know how how right on the nose is but but here's something interesting that I have noticed about doing this work in a while is that in a lot of adolescent clinics they seem to be oriented around one of two dominant models. One is the endocrine model where there's a lot of relationships with people doing disorders of sex development or intersex research and training right that's really sees affirmative care as about the endocrine system. The other is the public health model that comes from the fact that there are a number of experts doing this care who are doing HIV prevention work first, and then in their work doing HIV and AIDS care. They met more trans youth and they they realized that there was no reason to limit people from accessing that care especially when they were towards the end of their life. And I think that there is, you know, one of the differences between those kinds of clinics who grow who emerge from those models is that the folks who fall more into the public health model tend to be in my experience, tend to be fellow providers who can who really focus on seeing young people as complete patients who don't need to sort of isolate gender care to endocrinology or to psychology right but instead say that as a pediatrician or as an adolescent medicine doctor, I deal with young people in their real kind of complete identity all the time. And so as instead of developing expertise that involves outsourcing care, we're going to develop our capacity internally to see gender just as one more component of a young person that we're actually already treating because we're already providing sexual and reproductive health and sexuality right has to do with gender identity of the person as well and who they're relating to. So I think one thing that makes those programs, you know, I think they can be a bit more aligned with some what I would say is the more radical sort of forward thinking models is that they want to just see gender identity as one more part of a young person and not something that sort of they're going to offshoot to somebody else that makes sense. Yeah, more primitive primary care. But for primary care. Absolutely. Yeah. So I think it's really important for an Americanologist to deal with this gender. Yeah, right, especially because the actual medical need tends to be something which is for most patients is going to be really easily managed by primary care is actually not going to be very complicated and it's going to fit right into what you would expect to see from any other sort of adolescent right you're not going to. There's very little specialized medical knowledge I would say or that's how a lot of these providers would say it's much more about for in a capacity to see gender diverse people as people who are just like coming to you asking for their needs to be met and you're going to try to work with them on what that means. Yeah, wonderful. Yeah. Yeah. Yeah. Yeah. So people on zoom can hear the question. Yes, yes. Sorry, what I'll repeat the question. Oh, yes, basically, Dr asked, you know, there've been attacks on the healthcare workers and any expertise or advice about those situations from your work. Yeah, I will say that, you know, because I was at this really dominant clinic with the very famous director, you know, she had a ton of experience of horrible things happening to her right people finding out her phone number because it was posted on grant funding like funding websites and through, you know, public calls for information they were getting the grant she had applied for and finding her contact information and she was getting somebody maybe once got out of billboard and put horrible things about her like in the city that we were at. One time someone did someone did try to come to the clinic. It's unclear what their intentions were they tried to sign in as her which was a mistake. But so there was, you know, it's, and the thing that I learned a lot from her is that of course it felt very threatening to do this work, but the work itself is threatened. And she sort of had the perspective that if providers aren't willing to sort of be advocates in this moment, like you like you sort of have to sort of buy in that if you're going to provide this care you also have to take on some of the risk of that advocacy work in the same way that these young people are at risk right in the world. And there's not, you know, it's terrible. I wish that people didn't have to sort of put themselves on the line, but, but they do to some extent, and that I think instead of just trying to skirt around and trying to meet that head on was more successful for them right to feel like they were collectively behind the fact that they were doing this work right to feel like there was a shared commitment within the clinic right to participate in conferences to have networks with other providers right across the US who are doing advocacy work, and to be recognized for your work by the community itself to right went a long way. But it certainly is difficult right and I think it's difficult in the same way that it's difficult for abortion providers in the same way that it's difficult for people you know during again people who are providing HIV and AIDS care at some point in time right. Yeah. Yes, exactly. So one was, can you expand on the issues around fertility preservation in GM, GM ST, the expense and the challenge for the team to anticipate their 30s, their 30 year old self interest in having kids. Yeah, I have a lot of thoughts on this. One is that this idea. One I think there's that there's a bit of a mistaken premise that you can also promise anybody that they will have fertility in 30 years. First of all, so this kind of gets back to this question are the expectations that we're having for cisgender youth and trans youth the same right, like the idea that we wouldn't sort of be able to tell a cisgender youth that they will definitely be able to have biological children you know I'm in my 30s I have plenty of friends who desperately want to be parents and are simply uncoupled and don't have children right or have had infertility struggles or have become queer later in life right. So this is like, people are really marking it as a unique problem for trans youth and I think that that needs to be deconstructed a little bit. And then the other thing is to simply say that you know, there are many decisions that young people make that have forever lifelong impacts right consider we're at the University of Chicago right. It is going to change young person's life they get an education at the University of Chicago versus somewhere else in many ways because of the institution because of the amount of that you might have to take on right, and yet we allow young people to make these kinds of decisions, despite the fact that we cannot say that in 30 years you won't regret that you didn't go to a different college right, or that your parents didn't move somewhere with a better education system for you to go to a better high school so you could get into that college right. So I think that this kind of my is a bit myopic the focus on fertility as the ultimate good that needs to be preserved and I think there's a lot that people doing gender affirming care can also learn from people doing reproductive health care right and preserving again access to abortion and things like that where we can say, who are we trying to treat are we trying to treat sort of the you as a person who is a potential producer of other generations or you as the person who exists here with me today. Right. And I think asking young people to sort of put their lives on hold on hold based on this idea is is problematic. Yeah. At the same time I would love to see them develop. I mean there's really interesting science going on right right now and my next product is actually going to be largely about fertility. So this is like I'm very I'm very interested both in the conversations and in the technologies that they're developing which are coming out of, you know, pediatric treatment of pediatric cancers right where they have to deal with fertility and also kind of a developmentally disrupted age. So they're trying to figure out what of those interventions can be adapted for the use among trans kids and there's some evidence that if that young people can go on a course of hormones to really have kind of a short short puberty of their natal puberty in order to potentially bank gametes but you know it's a little dice about how how we're going to end. This one right. Yeah, so this is a big this so this persistence distance distinction is a historical one and it's very contested because at some point. There was a bunch of research most of this came from Kenneth suckers clinic in Canada which was actually shut down a few years ago from largely community pushback because of the kind of care he was offering. And there was research that was coming out of psychology in his clinic that said that you know 80% of young people who have a diverse gender identity before puberty will not have that after puberty right. And this is the thing that's been cited a ton and current legislative efforts to eliminate care where they just said no they don't need that any present of these kids won't need this care, why should we you know bother giving it or it's dangerous. Some of the big pushback against how that statistic was constructed has to do with the fact that because of the time period that it was being developed. Many people were bringing to their, the idea is that many people were bringing their kids to the clinic that you would not bring to the clinic today right because they had a little bit of gender diversity, maybe they had a little bit of a typical gender play right, or they didn't have to play with their brothers outside in mean ways and so they thought this is so concerning right, and that now because there's more acceptance in some senses of gender diverse behaviors, people who actually come to the clinic asking for medical care are much more likely to be aligned with this group that is actually going to persist right. And the other thing is this question about whether or not that I'm sort of interested in is whether or not we should be always motivated to say that if it's possible for you to live a younger life than you should, rather than saying, actually a trans life is also a good and valuable life, and if you're on the fence, if you could go either way as a young person. Why are we always pushing you away from being trans right that actually that comes from a more transphobic view of the world that says that that life is always going to be worse right. And so if we move away from that question so much, and instead, you know, allow young people more options, the other thing that I learned that like maybe we also see things a little bit differently right but that this kind of always trying to predict outcomes is really challenging, also because like right now the research, you know there is a ton of research happening right now that's more focused on this question is like predictive capacity to say how many people are going to stay in this identity but that kind of like people like the person, the psychologist that I call Amy here right, who really wants to build this idea that even if you offer supportive intervention and some things change that doesn't have to be a failure right, instead what you did was you met that young person where they were at at that time and they may have needed that in order to get to where they're going next and there are increasingly more stories of adults who might talk about their own experience like that right who even if they don't stay with the gender they are in a position to be, they may have said you know it was really necessary for me to have that experience like I learned a lot about myself, and I also like got to have this kind of this way this way of being in the world that was different and that desire was not going to go away until I experienced it right this idea that we can't always abstract ourselves right into the future we have to live our way to it. I just want to tell you what's going to say about that and now I have fun. Yeah, this one last question from the zoom. It's a little bit of a comment but I think it reflects one of these slides is great presentation it seems to me that healthcare providers might want to avoid the future regret to regretting having provided care, for example surgery that they provided before. I think basically saying like you're getting not engaging with the patient perhaps. Well if there's any such thing as like, future regret for providers not. Yeah, parents and certainly I mean I think we're providers and again rightfully so right providers have immense amount of responsibility for the care that they offer right and so there's a bunch of concern about whether or not you're going to contribute to whether you are going to regret something right. I think it's really interesting to think about the, you know, I can't remember exactly what this is and maybe someone here would know right but there are common regret rates for all kinds of surgeries that we do all the time right like knee surgery and hip surgery I think in particular, and yet we do not have great swaths of doctors saying I cannot I will not operate on your knee because I know it's still going to hurt afterwards and you're going to be pretty mad about it. And instead actually we do those surgeries quite a lot. So again it would just the question is to continue to say what in what ways are the expectations that we hold gender affirming care and young gender and gender diversity young people do very different than other sorts of situations that actually have a lot of similarity. Yeah. Yeah, that's the one takeaway I took from your talk. Yes, like how different we're treating it than any other thing. Yeah, right. Yeah, which takes a lot of work. Well thank you. Just to remind you we have two weeks left we have next week with some colleagues talking about salary equity and promotion equity and then I will close it out on May 23 for the end of our session. And for now we'll stop the recording and then ask the ethics fellows to come down and have a more intimate discussion with Paula Martin so thank you again for great talk.