Scott Webb (Host): Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. I'm Scott Webb. It's really nice to have you both here today. We're essentially going to talk about transgender health, but we're also going to define some important terms for folks, and I'm really looking forward to this conversation. So Ralph, I'm going to start with you. What is gender dysphoria?

Dr. Ralph Bernardo: That's a great question. And I think before we talk about gender dysphoria, we actually need to define gender. It's important to remember that we all have a gender identity. It's our internal sense of being male, female, both, neither, or something else. For many people, their gender identity aligns with the sex they were assigned at birth, and this is called being cisgender. But for others, there's a mismatch between their inner sense of self and that assigned sex. And that's where we start talking about transgender identities.

For many cisgender people, it's just a part of who they are, and they don't have to give it much thought. But for transgender individuals, that disconnect between their inner experience and the way the world sees them can be very significant. I think it's also important to understand that gender is a social construct, and this means that societies create ideas about what it means to be a man or a woman or something else, and these ideas can vary widely across different cultures and different time periods. And this shows us that the expectations and roles that are assigned with gender are not fixed, they're not universal, but rather shaped by social norms.

And gender dysphoria is the term that we use to describe this distress or discomfort that someone experiences when their gender identity, again, that internal sense of being male, female, or something else, doesn't align with the sex that they were assigned at birth. And it's important to renote that gender dysphoria can present in different ways and to varying degrees. For some, it can be quite mild, while for others it can be pretty severe and significantly impact their daily lives.

Host: Yeah. Yeah, this is really interesting. I knew it would be. And that's, Ralph, a good baseline is just to get us into the conversation today. So then, what does it mean to be a transgender person?

Dr. Ralph Bernardo: So, a transgender person is someone who, again, their gender identity is different from the sex they were assigned at birth. It's their internal sense of being a man, a woman, both, neither, or something else along the gender spectrum. It's a deeply personal and fundamental aspect of who a person is. It's important to remember that being transgender is not a choice, and it's not a mental illness. It's simply a natural variation in the human experience, and transgender people have existed throughout history and across cultures.

Host: Yeah. You know, I have two children. They're a little bit older, 17 and 21 now, but I had conversations with them when they were younger, and they would ask me these, you know, hard questions to answer for parents. And I would try to explain to them as best I could that, as you're saying, with cisgender people like myself, I was born a male, I feel like a male, and I just never really gave it much thought for other people. You know, they may have been born one thing, male, female, whatever, but they identify, they feel like they're something else. And so, I fumbled my way through explaining it to my kids, oh, and they were younger, but you didn't fumble, you were great. And, Paul, I think there's this sense that maybe kids are too young to know if they're transgender. What are your thoughts on that?

Dr. Paul Pelavin: I think a child is only too young to know if they're transgender if they're not able to verbalize it or express it. So, probably any child old enough to verbalize or express who they are, even some preschoolers or even young preschoolers can express their gender identity, so as children go through phases of exploring different gender expressions. But for some children, these feelings are persistent, consistent, and really insistent over time. And that can be a transgender identity, potentially, at a very young age. I've taken care of kids as a pediatrician who are in preschool who feel that they may have been assigned a male gender at birth, but they feel female and potentially vice versa. But just so it's important to listen to your child, take their feelings seriously.

And I think some parents might worry, "Oh my gosh, if my kid is saying they're transgender and they're 3, I have to give them hormone therapy." There's no hormone therapy their kids need. There's no medical therapy. It would just be helping them if they want, to say, if they're a little boy, to do things that are more feminine or potentially maybe wear a dress. There's no danger in that. There's no permanence in that. Although, in many cases, it may be permanent, but that's not dangerous. It's just helping your child. Along that line, dismissing or minimizing a child's gender identity can be harmful to their mental health and well-being. Because if they feel they're a female and you say, "No, you're a little boy," you know, they're constantly being told something that's giving them cognitive dissonance and make them upset.

 And there's research that shows that transgender children who are supported in their gender identity have better mental health outcomes than those who are not. So, it's just important to create a safe and supportive environment where a child, your child, can explore their gender identity without fear of judgment or rejection.

Host: Yeah. In hosting a lot of these podcasts, the term or the concept of supportive care comes up a lot and that's where exactly what I was thinking there, was just really supporting our kids the best we can, even if it's confusing for mom and dad, you know, that we wouldn do our best along with pediatricians and other medical and mental health experts to try to just support them in whatever they're feeling and wherever this journey is going to go. I did want to ask though about transitioning, you know, and at what age can, should a child transition? And really, Paul, what does that mean? Like, what does that look like?

Dr. Paul Pelavin: So for a child, that varies upon the age, and there's no one-size-fits-all answer to this question. So, the appropriate age for a child to transition will vary depending on the individual child and their circumstances. So for younger children, say a child in preschool or elementary school who's not yet in puberty, it's just a social transition. So, that would include things like changing their name, pronouns, and clothing, which sounds easy on paper, but it can be hard for a parent who's used to saying, "Oh, this is my little princess," "This is my little boy," and all of a sudden start using different pronouns. It's not easy, but there's nothing permanent about it. It's probably a lot easier for the kid and other kids and for the parents.

But once the children approach puberty, that's when there'd be a medical, not really a transition, but sort of a freezing of puberty to give a child more time. And children at this age can start experiencing increased gender dysphoria, sort of a being upset with how their body is changing in a way that's not consistent with their internal gender identity. For example, a transgender boy starting to grow breasts, or especially when a transgender boy starts getting a period. And the ideal is you don't wait until someone's most of the way through puberty. But with the guidance of medical professionals, usually almost exclusively pediatric endocrinologists and therapists, families would consider a puberty blocker as a first step, which is an entirely reversible option that suppresses the development of secondary sex characteristics.

So, the secondary sex characteristics, so for a cisgender girl, or for a transgender boy, development of breasts, eventually development of having a period, or for a transgender girl, growth of their penis, the growth of their testicles, deepening of the voice, and that allows the child more time to explore their gender identity. This is something that's not generally done just with a general pediatrician. But it'd be something with a pediatric endocrinologist. So, you have to find a pediatric endocrinologist who can do this. But you can't do this in all states. So, this is going across the entire United States. And some states, it's not legal to do this, unfortunately.

Fortunately, in many states, it still is legal, and I think it is absolutely the right thing to do for children. And I feel very strongly that it is the right thing to do for children because One thing that, going back to a previous question about gender dysphoria, if a child isn't treated, or an adult isn't treated, it doesn't just make them upset, but it can lead to anxiety, depression, or even self harm, or even suicide.

And I believe, Ralph has mentioned before, not in this talk, but I know at a talk I heard Ralph give, about the rates of suicide for transgender and LGBTQ children, especially those who aren't supported. So, a lot of politicians and certain doctors talk about the risks of transgender therapy and what are we doing to our children, but if we don't treat these children, they're going to be very upset, at a minimum, probably clinically depressed, and have an increased risk of suicide. So, it's dangerous for these children not to get therapy and life-saving to get therapy.

Host: Yeah. I'm wondering, we think about the hormones and once a patient, let's say, or a child in this case, begins taking hormones, can they stop? Can folks sort of pause this transition, if you will?

Dr. Paul Pelavin: Yeah, at any point. So, children can stop taking hormones if they choose to. The puberty blockers are completely reversible. Once you stop a puberty blocker in a child, they will go through puberty. However, some of the effects of gender-affirming hormone therapy, which is either giving testosterone to a transgender boy or estrogen to a transgender girl or usually older transgender male teen, transgender female teen.

Some of those effects can be essentially permanent, like deepening of the voice for a transgender boy or perhaps breast development for a transgender girl. So, it's just important to have open and honest conversations with your doctor before starting hormone therapy to understand those effects. It's just known, like, for example, for puberty blockers, those are very well studied for kids who have early puberty, and we know that those effects are reversible. And those children can grow up to be fertile adults.

Host: Okay. Yeah, it's good to know. I mean, just in general, the nature of being a child or adolescent and thinking one thing, believing one thing, or even at the time knowing one thing, and then changing one's mind or life happens or however that works. Good to know that these things sort of can be paused, can be reversed if necessary.

Dr. Paul Pelavin: Right. And it's not usually a willy-nilly And it shouldn't be a willy-nilly by an endocrinologist like myself, like a kid comes in for their first visit and say, "Oh, I'm transgender." And I would ask, "Okay, how long have you lived like this?" For example, "Have you socially transitioned? How much does this upset you? Have you spoken to a therapist?" Because I think it is the right thing to always respect what a child tells you, but to make sure they've thought this through, they've talked this through. But in most cases, people aren't going to come and ask for something like this. It's not easy. And I think if they go to the step of reaching out and asking for help, they probably need that help. But I think there's some cases where, at a minimum, it's always reasonable, I think, for a child to meet with a therapist, talk these ideas through before starting any type of therapy. But that doesn't mean there shouldn't be therapy for these children. What do you think, Ralph? Do you agree? Like, you wouldn't start therapy immediately just when someone comes in who hasn't ever really thought this through or lived the opposite gender socially.

Dr. Ralph Bernardo: Absolutely. I absolutely agree with that, Paul. And, like you were mentioning, I think that this is something that requires a multidisciplinary approach, obviously involving the individual, their family, parent, guardians, behavioral health providers, and medical specialists, absolutely.

Host: Yeah, it makes me wonder, Ralph, Paul mentioned there about socially transitioning is maybe the first step for many. Is that one of the ways in which someone can transition without the use of hormones? Does that sort of fall under that category?

Dr. Ralph Bernardo: Yes, there are many ways to transition without the use of hormones. And Paul started to have this conversation a little bit, and this may include things like social transitioning. And what this entails is changing one's name, for example, using a chosen name or using someone's preferred pronouns, changing the way they look by what they wear, how they style their hair to align with their gender identity. For many, this can be a very powerful first step.

Some individuals may also choose to have surgeries, such as top surgery, for example, breast augmentation or removal, or even bottom surgery, which involves the creation of genitals that are in line with someone's gender identity. These surgical interventions can significantly help to alleviate someone's gender dysphoria and improve the quality of life. There's also something called legal transitioning, which refers to the process of legally changing one's legal gender markers and documents, like someone's driver's license, their birth certificate and even their passport to align with one's gender identity.

I think what's important here is that we have to remember that each individual's journey is different. It's a personal journey and there's no right or wrong way to do it. Some people choose to transition in one or more ways, for example, and each individual should explore their options and choose a path that feels more authentic to them, more comfortable for them. Often what I'll tell my patients is that they are the authors of their books and we as medical providers are their editors to make sure that their book is being written safely. But we can't tell somebody what words to write on their page. And I think it puts things into perspective and to remember that each journey, each individual transitions in their own unique way on their own time.

Host: It's so interesting that you said that. I stole this, so full disclosure. But I used to tell my kids that the future is unwritten. they will be the authors of that story, you know, of that journey. So, I'm totally with you here. And I just wonder though, Ralph, about, you know, once you start hormones, like the future, right? So, future decisions, like starting a family, something like that. How do those pieces fit?

Dr. Ralph Bernardo: It's important to remember that transgender people can have the same desires for family planning as a cisgender person. And the options for family planning are the same for transgender people as they are for cisgender people. This can include things like assisted reproductive technology, adoption, surrogacy, among other things.

And hormones can affect fertility, and this is an important conversation to have with a healthcare provider before starting gender-affirming hormone therapy. And perhaps Paul can talk a little bit more about the nuances with younger transgender individuals that come to the office. Some hormones may reduce or eliminate fertility, while others may have minimal impact. And there are ways to preserve fertility, such as cryopreservation, looking at things like freezing eggs or sperm before beginning hormone therapy. Conversations with healthcare providers and fertility specialists can help individuals make the right choices, for them and their unique situations.

Host: Paul, I'm wondering, from a sort of a physical standpoint, a physical medical standpoint, are there any dangers here, going through this process? Will this affect health and growth and bones and all of that stuff?

Dr. Paul Pelavin: So, I think for any therapy, any drug has risks. Any drug or any medication has a risk. Any surgery has a risk, like, for anything, regardless of transgender, any type of healthcare. So, we have to look at the balance of risks and benefits. So, of course, there's some risks because that's just the way the world works.

However, the benefits can be so great for these kids because having untreated, unsupported gender dysphoria can be lethal if a child ends up committing suicide or, at a minimum, cause a lot of lifelong chronic severe depression and anxiety. So, I think you have to look at the risks in the context of those benefits. So, hormone therapy is generally safe when supervised by a knowledgeable healthcare provider. Especially important to remember that the hormones that are used for delaying puberty.

And also, the hormones for gender-affirming hormone therapy are not new medications, like the puberty blocking hormones like Lupron and Supprelin. Lupron is an injectable drug. Supprelin is an implantable drug that blocks puberty. They've been used for decades treatment of children with early puberty. And hormones like estrogen and testosterone have been used safely and effectively for decades In various medical treatments ranging from in adolescence, you know, giving estrogen as part of a birth control pill, giving estrogen for kids, usually cisgender girls who are not going through puberty normally, or testosterone for speeding up puberty and then later on in life for menopause management and adult hormone deficiencies.

To minimize these side effects, just regular monitoring and checkups are important. And some potential effects include changes in cardiovascular risk factors and bone density, but these can be monitored before and during therapy. And it's important just to discuss any concerns you have with your doctor, usually a pediatric endocrinologist for puberty blockers, sometimes a pediatric endocrinologist or an LGBTQ healthcare specialist or another endocrinologist, LGBTQ specialist like Dr. Bernardo, and having a comprehensive understanding of your risk and benefits.

I just want to go back to one question that was asked before about fertility. So typically, most people who are transgender, who are treated don't necessarily come at the very beginning of puberty. Like they come as little kids and then have puberty blocked and then immediately start gender-affirming hormone therapy. And Ralph is saying, if someone It was about to start gender-affirming hormone therapy, and they've gone through a cisgender typical puberty, you can collect sperm, say, from a transgender female or collect eggs from a transgender male. However, if someone had their puberty blocked from day one, like say a kid comes to me, a transgender boy, and they're starting to grow breasts, and I block their puberty, and they don't go through puberty to grow breast and menstruate. And then. They decide, look, I want to start testosterone, which is usually around age 16. And incidentally, I want to also bring up that surgery usually is almost never done in adolescence. So, there's a lot of fear out there saying, "Oh my God, my child's going to be mutilated" or some ridiculousness like that. But no, first of all, this is a choice of a surgery. And number two, it's not done in children.

Gender-affirming surgeries, it's never, ever, ever done in children. It's usually done in adults who can give consent. But it is possible to collect potentially collect eggs or sperm from somebody who hasn't gone through puberty, but that's going to require much more work and isn't as guaranteed for fertility if someone hasn't gone through puberty. Because like normally girls, cisgender girls don't become fertile women until they've had a period, and cisgender guys don't become fertile until they're able to produce sperm, and that doesn't happen until later in puberty. So if you haven't gone through that puberty, it might not be possible easily to have fertility. There are options, but it's not as easy, just to be aware of that.

But that doesn't mean you can't have a family. Like, having a family, you know, if you just think about family as a biologic family cisgender woman who have babies through intercourse and then have kids, you know, that's a traditional nuclear family. But you know, there's adoption, there's your partner having kids. Just the child who you adopt and who you love is your child. I just want to stress that. It doesn't mean like if someone says, "Oh, well, my child will have a family," like anyone can have a family.

Host: Right. There is sort of the traditional ways, if you will. And then, as you're saying, it could be adoption and otherwise. I wanted to stay with you, Paul, and just talk maybe just a little bit more about the mental health side of the journey. You know, we talked about physical. Let's go flip the coin and talk about, you know, how we can protect and support our children's mental health.

Dr. Paul Pelavin: I would say the number one way to protect and support your child, it starts at home, and with the parents loving and supporting your child unconditionally. Children whose parents are supportive do so much better because sometimes, and it's really sad if I have kids whose parents don't support them, usually they get to my office because, usually, if they're young enough to come to a pediatric endocrinologist, they're not thriving. So at least one parent supports them, but it's still very hard to have one parent who supports them will use their preferred pronouns and another parent who doesn't. So, loving and supporting your child unconditionally is number one.

So listening to them, respecting their feelings, creating a safe and accepting environment where they can express themselves without a fear of judgment or rejection is essential. Finding therapists and also other support groups who are knowledgeable about transgender issues. So, there's ways to find therapists. You want to find people who are experienced dealing with transgender care and not people who are either going to be clueless or, maybe at best or at worst, even being negative and being mean.

So, it's important to educate yourself about gender identity and the challenges transgender youth can face so you can be an advocate for them both in school, in the community, say at their church or their synagogue, or at other youth groups. And then, going back to what I said before, showing your child you love and accept them for who they are with their gender identity helps them to navigate that journey with confidence and resilience.

Host: Yeah. And you mentioned education there, and I think that's such a big piece of this. And so, I'm sure to, to that end, this podcast today, it's certainly been educational for me. I'm sure it has been for listeners as well. Yeah. Ralph, I just want to give you sort of last word, if you will, here. But Paul teased a little bit there. Give folks some ideas, maybe even some specifics about resources that are available for them, for parents, for children, for everybody, really.

Dr. Ralph Bernardo: So, yeah, there are definitely many resources that are available for both families and individuals who are transgender or who are simply questioning their gender identity. Organizations like PFLAG, GLAAD, and the Trevor Project are just a few that offer valuable information. There are also support groups and educational resources through these services as well. Individuals can also find support groups and therapists locally who specialize in working with transgender youth and their families.

And I think one of the more important things for both families and individuals who identify as transgender or gender-diverse is looking for local LGBTQ+ community centers or online forums where they individuals can actually connect with other families, other individuals who have had shared experiences. And I think that's one of the most important pieces here is really to connect with the community. Find out about other people's journeys, what challenges that they have so that you can help navigate yourself or your child through the process. And it's important to remember that reaching out for support and information can make a significant difference in the well-being of an individual and that individual family's journey. And it's important to remember that as medical providers, as a society, as a community, we all play a part in this journey and we need to be supportive when we are hoping to navigate or helping navigate an individual through this journey, that can be a lifetime for sure.

Host: Yeah, you know, some conversations that I have, I move right on after I'm done. And other ones like this one are going to cause me to think a lot, you know, and try to process this. And that's the great thing about podcasts is that listeners can listen, they can pause, they can start over, they can rewind, whatever they want to do, and I hope that they do because I feel like, such great information today. I really appreciate both of you. You're just compassionate expertise. Thank you for your time.

Dr. Ralph Bernardo: Thanks, Scott.

Dr. Paul Pelavin: Thank you.

Host: And if you found this podcast helpful, please share on your socials and check out our entire podcast library for topics of interest to you. And thanks for listening to Conversations Like No Other presented by Valley Health System in Ridgewood, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-291-6090 or email valleypodcast@valleyhealth.com. I'm Scott Webb. Stay well.