JoAnne Keatley: The next presenter, Dan Karasic, MD is an Associate Clinical Professor of Psychiatry at UCSF, and attending psychiatrist for AIDS care at San Francisco General Hospital (SFGH). He is the HIV specialist on the psychiatric consultation liaison service, a psychiatrist for the SFGH Positive Health Practice Ward 86, and for the UCSF AIDS Health Program. He is also psyciatric consultant to the St. Mary's care unit for the treatment of AIDS dementia. Dr. Karasic is chair of the Northern California Psychiatric Society's committee on lesbian/gay/lesbian/bisexual/transgender issues. He is a member of the LGBT advisory committee of the San Francisco Human Rights Commission, and the UCSF Chancellors Advisory Committee on LGBT issues. He has chaired workshops and symposia on transgender issues for the American Psychiatric Association, and the Northern California Psychiatric Society. He has given grand rounds on transgender issues at San Francisco General Hospital, and at UC Davis. It's my pleasure to introduce Dan Karasic.

Dan Karasic: Thank you, thank you (applause). You know, in all the talks I've given I don't think my job has ever been easier than it is today, especially with the Community Panel, which I think at the end of the day will have taught you far more than my lecture. I trained in Psychiatry in the 1980's at UCLA, where among the faculty there were two of the more famous people in transgender issues -- not necessarily entirely in a good way, Bob Stolar and Richard Green. And in hearing their lectures on transgender issues, and also hearing them talk about Gay and Lesbian issues and I identify as a Gay man, I even then had certainly a lot of questions about some of those formulations. And, in my work since 1991 as an HIV Psychiatrist at San Francisco General, the inadequacy of the models that we as mental health professionals are trained in really became apparent. (View the slide)

So, we're gonna start by talking about models for exploring one's patient's or client's gender identity, as a Primary Provider. And I'm gonna start by talking about the DSM Mental Disorder Model, and talk a little bit about why I don't think that that's particularly useful. Talk about transsexualism, the traditional transsexualism and the binary perspective of gender, and then about at anthropology and cross-cultural models for working with patients and clients generally. And looking at that as a framework for exploring your patient's gender identity. And then Laurie Kohler is gonna come and give the second part of this talk -- as Primary Care Clinician -- on exploring people's gender identity as Primary Medical Provider. (View the slide)

So, there are a lot of problems with the way psychiatry has viewed transgender folks, and the problems include belief in, in knowing what the etiology of what transgenderism is. In psychodynamic theories that have been long discarded in terms of understanding homosexuality, they're then applied to transgender folks. In labeling an identity as a mental disorder, as opposed to identifying symptoms in the same way we do for, say, major depression, or anxiety disorder, or other disorders in the DSM. And the consequence of this, which is pathologizing and really hurting our clients. (View the slide)

So this slide has a lot of text on it, and I don't expect you to be able read it. But the point of this text is that the APA has struggled with what a mental disorder is. And this comes from -- is in your DSM near the beginning -- their attempts to describe what a Mental Disorder is. It says that each Mental Disorder is contextualized as a syndrome that occurs in an individual associated with distress or disability impairment in distress, a painful symptom with disability impairment and functioning, or with significantly increased risks of suffering, death, pain, disability, or freedom. And so this syndrome or pattern must not merely be an expectable and culturally sanctioned response to a particular event such as death of a loved one. (View the slide)

So now the really operative part of the DSM's description of a mental disorder is in this last paragraph. Whatever its original cause, it must be considered a manifestation of the behavioral, psychological or biological dysfunction in the individual. Neither deviant behavior, ie., political, religious, or sexual; nor conflicts that are primarily between an individual and society are Mental Disorders. Now it would kind of be great if it just stopped there. But then it kind of has this little lost bit. Unless the deviance at conflict is a symptom of dysfunction in the individual as described above. And, which gives -- which not only confuses the whole picture -- but basically says that it's up to the clinician to determine whether it's the individual's fault or society's fault that the patient is miserable, in determining whether this is a mental disorder or not. And that really is what it comes down to.

So, the DSM lumps the gender identity disorders in the section of the book called Sexual and Gender Identity Disorders, and that includes include sexual dysfunction parafilias which are basically fetishes, and sexual disorder not otherwise specified, which is the diagnosis that, that can be given even to gay and lesbian people, if the provider really wants to bill for reparative therapy. (View the slide)

So Gender Identity Disorder results says that some persistent cross gender identification -- not merely desire for perceived cultural advantage of being the other sex. In adolexcents and adults the disturbance is manifested by symptoms such as a big desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex. So it certainly is a description that applies to a lot of transgender people. (View the slide)

Persistence of comfort with his or her sex or attempts of inappropriateness in the gender roles of that sex. And that the disturbances manifested by symptoms such as a preoccupation with getting rid of primary or secondary sex characteristics. Or a belief that he or she was born in the wrong sex. (View the slide)

Then it says that the person -- this doesn't apply to unisex people, and that if this little depart that it qualifies for some other disorder -- that the dysfunction is the responsibility of the individual as opposed to society, basically. Clinically significant distress or impairment in social and occupational areas of functioning -- because of dysfunction in the individual. (View the slide)

Now, what, of course, this description leaves out is the fact that social and occupational impairment and functioning is not something that you can separate between an individual and society; and certainly not when people have a disorder, or when people are diagnosed with a disorder because of psycho/social distress, and they're living in the society that is as oppressive as our society is to transgender people. And, we kind of thought that the American Psychiatric Association, and organized Mental Health had learned this lesson in 1973 in taking homosexuality out of the DSM. And a lot of the rationale for taking homosexuality out of the DSM was it was true that gay and lesbian people at the time by and large were a pretty distressed lot of people; but that their distress was mainly about not having civil rights and being thrown in jail and not being able to keep their jobs -- as opposed to some sort of inherent, you know, problem mentally. (View the slide)

So, I have a few slides from the Transgender Community Health Project to speak about, because I think it's such amazing work that they did. And, this is just showing even in San Francisco, tolerant city that we are, that most transgender people do suffer a pretty significant amount of oppression. (View the slide)

And this is a slide of a couple in Vallejo -- Jimmy and Sandy. Jimmy grew up in that Vallejo neighborhood, and you know, is an FTM man, a trans-man; and because he grew up in that neighborhood and he was known to be transgender, the neighbors have attempted to set his house on fire, have thrown heavy metal objects at him, have really harassed him and his fiancee -- at least his fiancee at the time and they're child or children, so much so that that the family was barricaded in their home. So, in this article that was in the Examiner about it Jimmy wasn't able to go to his Auto Mechanic Training School and was not able to go work. They had put off their wedding, and basically everything in their life was on hold. And one might say, if Jimmy came in, that he was somebody that was pretty distressed, and was having, because he was transgendered, pretty significant impairment in his social function -- he was not able to hold his wedding, and occupational function -- not able to go to auto mechanic school. But because of that impairment it's because he is afraid his house is gonna be burned down, and he is going to be hit over the head if he leaves the house -- it's hard to say that that the distress is related to internal conflict about his gender identity as opposed to a societal oppression. (View the slide)

The DSM also has a -- in the same gender identity sort of diagnosis it has the criteria for children. In which the child has to be four of the following: repeated stated desire to be or insistence that he or she is the other sex, in boys a preference for cross-dressing simulating female attire, in girls insistence on wearing only stereotypical masculine clothing; strong and persistent preferences for cross-sexual roles in make-believe play or persistent fantasies of being the other sex; intense desire to participate in the stereotypical games or pastimes of the other sex, and strong preferences for playmates of the other sex. (View the slide)

Well, these criteria which, I think came out of the feminine boys study in UCLA in the 1960's primarily, is really stuck in 1960's, and even previous gender role stereotypes. And only the first one even has to do with gender identity, and the rest just have to do with a range of gender expression even, you know, that may or may not be related to how the person identifies gender-wise. And certainly many of these things that are considered symptoms are really quite normal and healthy things for a child to not be bound by societal sexism in terms of choosing how to play.

And the Criteria B also includes the assertion of penis or testes are disgusting with will disapeear, you'd be better off not to have a penis. Or they -- or -- so it could also just be aversion to rough and tumble play and rejection of male stereotype toys, games, activities. And for girls it can be rejection of urinating in the sitting position assertion that she has or will have a penis, or the assertion that she doesn't want to grow breasts or menstruate -- because we all know that all girls want to menstruate [laughter]. Or a marked aversion toward normative feminine clothing. And I suppose it's up to the diagnosing, treating physician or really the parents who bring in their children to get this diagnosis as to what rough and tumble play, or normative feminine clothing is. And lo and behold, and even in following up the people from the feminine boys study and other studies, most people, most children given this diagnosis don't identify as transgender as adults. And it just shows that there's a range in -- in gender expression in childhood that doesn't upset children nearly as much as it upsets their parents. And, certainly those who saw "Ma Vie En Rose" really had a great display of that. (View the slide)

But psychiatry really had a real arrogance, I think, especially in the, in postwar Europe -- coming out of a kind of superhuman view of psychoanalysis. And this is from a comic book that I have from the 1950's. And it was -- the comic book series was called Psychoanalysis. And the Psychoanalyst is really -- he looks just like Clark Kent, doesn't he? [laughter] And sure enough, he almost morphs into a superman with x-ray vision as he gets to -- the very first patient he gets is a boy brought in by his parents because his father is very distressed that he prefers more feminine childhood activities as opposed to wanting to play football. And the analyst is very empathic, but ends up interpreting a dream where he's, the child is afraid he's gonna be killed by his father. And then on the way out the boy notices the Sports Section in the waiting room and says "Gee Doc, can I borrow that?" And there's really been a quite miraculous little cure there. (laughter)(View the slide)

So, the DSM also has this GIDNOS that includes intersex people. Number two is kind of interesting -- transient stress related cross-dressing behavior. So people who only cross-dress when they're stressed out [laughter]. Or a persistent preoccupation with castration or penectomy, without a desire to acquire the sex characteristics of the other sex. (View the slide)

So, and additionally there's -- in the paraphilias is this transvestic fetishism which applies only to heterosexual men and heterosexual men who cross-dress. And what I think those of us in practice have found is that the line between a cross-dressing, heterosexual man and a trans-woman lesbian is a much thinner line than this placement as a fetish portrays. That certainly people cross-dress for a lot of different reasons, and it's not just as an erotic tool for straight men. Certainly there are people who are diagnosed with transvestic fetishism who are later identified more broadly as transgender, or even transitioning. (View the slide)

So anyway, I hope I've gotten some of your sympathy of what I had to work with in coming as a Psychiatrist and having to take care of as many transgender people as I have over the years at San Francisco General. And an alternative model certainly in popular culture that is maybe more relevant, but has its limitations is the traditional transsexual story of Christine Jorgenson and Renee Richards -- probably the most famous folks in that model. And, I think that model has been limiting for me, too. It assumes a Western binary view of culture that I think doesn't apply to everyone. And it assumes a progression in transitioning that I think doesn't apply to everyone. Certainly with the Community Panel, you saw that there was certainly a range of ways in which people express their gender. But this traditional model was the man born in a woman's body, or the woman born in the man's body. And there's simply the medical solution of hormonal and surgical correction, and then everything is made right and the person can slip back into society as a man or woman of the, you know, the gender other than that of their original genitalia. And without really disturbing society's view of what gender is. And I think what's really in our popular culture, or particularly in terms of, actually more in terms of queer studies that kind of exploded some of this -- is anthropological views of gender in other cultures. And as well as looking at our own community, in that within the transgender community there are a lot of folks who don't necessarily fit that model. ( View the slide)

You've kind of seen this already, but just to see this with the lens that, you know, certainly here in San Francisco people are very split in terms of how they identify. (View the slide)

Whether it's primarilly as transgender -- this is for male to female folks -- as female, as transsexual, bi-gender, cross-dresser. (View the slide)

For female to male transgender male, transsexual quite evenly split. And in terms of sexual orientation that many MTF's are identified as bisexual and some as gay lesbian. (View the slide)

And particularly with female to male trans-people -- that just from the Transgender Community Health Project , 50% of the 122 people identified as gay bisexual men. (View the slide)

And, so we see where even in our culture with our own kind of cultural straightjackets of gender that transgender people are really kind of staking out frontiers in gender. But if we look in other cultures, such as Native American culture, the Mahu of Polynesia, and actually in every continent you can find transgender folks where in traditional societies there are quite set rituals for men and for women, and where if you study these rituals you can see that there are a third set of rituals for transgender folks that are apart from the other two. And in some societies it's a very respected position, in others less so. But that it really -- the way in which people whose gender expression is different from the extremes of male and female -- the way that expresses itself is very much a product of culture. (View the slide)

In our population we take care of in San Francisco, in addition, we do have certainly, and you probably saw one of the slides there from the Transgender Community Health Study that it is a very culturally diverse population. And what I'm going to postulate is that in the same way that you look at cultural competence in a culturally competent way, you look at the other aspects of the individual. But you look at their gender expression and their gender identity in that same way.

And I just have a little picture of Mahu from Hawaii here from "Tapestry." (View the slide)

And actually, the American Psychiatric Association, if you just look elsewhere other than in some of the DSM diagnoses, actually had some good things to say that we can apply to transgender folks. So this is from the APA's Practice Guideline on the treatment of adults. And it says, "Considerations for socio- cultural diversity: the process of psychiatric evaluation must take into consideration and respect the diversity of American subcultures and must be sensitive to the patient's ethnicity, place of birth, gender, age, social class, sexual orientation and religious/spiritual beliefs. Respective evaluation involves an impassive, nonjudgmental attitude towards to the patient's explanation of illness, concerns and backgrounds." (View the slide)

"An awareness of one's possible biases or prejudices about patients from different subcultures, and understanding of the limitations of one's knowledge of skills in working with such patients may lead to the identification of situations calling for consultations with a clinician that has expertise concerning a particular subculture. Further, the potential effect of the psychiatrist's socio-cultural identity on the attitude and behavior of the patient should be taken into account in forming a diagnostic opinion." (View the slide)

And in the DSM itself it has this outline for cultural formulation, cultural identity of the individual, including culture of origin, host culture and language, cultural explanations of an individual's illness, cultural factors related to the psycho-social environment and levels of functioning. (View the slide)

Cultural elements of the relationship between the individual and the clinician, e.g., differences in culture and social status between the individual and the clinician. Difficulty in determining why the behavior is pathological. And overall cultural assessment: how culture influences diagnosis and care. (View the slide)

And it's not much of a stretch, then, to really add gender expression into this. Cultural identity of the individual and conceptions of gender are including that of the cultural origin and the host culture -- that means here in the US. Relationships between culture gender issues and presenting mental health concerns or symptoms. (View the slide)

Culture gender and the relationship between the individual and clinician. The example given is differences in cultures, social status, and perceptions of gender identity or behavior, factors related to psycho-social environment and levels of functioning, and the overall assessment of how culture and gender identity or behavior influences diagnosis and care. (View the slide)

And I think if you're going from a cultural competence model, rather than a pathology model, it makes it much easier to level the playing field between the doctor and physician [patient]. And this is -- these are guiding principles of culturally competent care from the cultural competence standards in managed care mental health for under-served and under-represented racial ethnic groups. So it says that what's needed for culturally competent care includes culturally competent providers, consumer driven systems of care, community based systems of care, including familiar and valued community resources, natural support, collaboration and empowerment in determining the course of treatment, opportunities for feedback and responsiveness to feedback, access to care, and integrated care. And I think all of these that were written without thinking particularly about transgender folks apply to this population as well. (View the slide)

And then just lastly, this slide comes from another another talk, but the additional thing is -- I think with this model that care providers will question their role as a gatekeeper to care and not unduly focus necessarily on someone's gender identity when the patient comes to see you because they stubbed their toe, or they have an upper respiratory infection. (View the slide)

So, next I'm going to ask Laurie Kohler to come up, and Laurie's going give a description of a Primary Medical Clinician's assessment of gender.

JoAnne Keatley: Thank you, Dr. Karasic. Let's see, Laurie Kohler, MD, is the Medical Director of Family Health Center at San Francisco General Hospital. She's an Assistant Clinical Professor in the UCSF Department of Family and Community Medicine and works for the San Francisco General Hospital Family Practice Residency Program. Dr. Kohler has provided primary care for transgender patients since 1994. She worked at the Tom Waddell Health Center Transgender Clinic during its first four years, and continues to see transgender patients at the Family Health Center. Dr. Kohler also developed a Clinic for transgender inmates at the California Medical Facility in Vacaville and served as a consultant for the California State Prisons. She is committed to increasing access to Primary Care for transgender people through education and advocacy. It is my pleasure to introduce Laurie Kohler, MD [applause]

Lori Kohler: Hello. What I want to do will be somewhat repetitious of what Dan spoke about, but I want to offer a perspective that a Primary Care Provider, whether you are a physician or other type of care provider for transgender people, can -- something that you can use that would support a collaborative decision-making process. Because I think the reality is that for most of us in the room, when I looked at the participant list, that probably our patients or clients don't have access to therapists or access to psychiatrists; and whether we believe in that model or not, we really can't depend on it. And what that leaves for us to do is to help our patients in decision-making processes. And -- so we need some tools to do that. What I think is the nagging concern in the back of our minds is really that if we're gonna make a mistake. I think that's the worst thing. We don't want to sort of guide someone and misdirect them, possibly treat them when it's not appropriate, and then be stuck with some of the permanent consequences of say, providing hormone therapy.

And this is challenging because there are lots of complicating factors about being transgender and about gender itself. Obviously it's really the way we feel about gender that we bring to any encounter, that we bring to any visit with someone that we're working with. And so we have really a lot of work to do to explore that, because we have to understand how we feel, in order to be able to really understand what's going on for the people that we're working with.

Obviously, gender is really complex, and I don't claim to know that much about it myself. I think that a lot of academicians have tried. There are lots of Ph.D. dissertations that have been written, and there are probably just as many theories about gender as there are Ph.D. dissertations. I think also that, you know, of course, the popular press has capitalized on it -- journalists, talk shows. But the reality is that no matter no planet men are from, or what planet women are from, we just need to come down to earth and look at some of our own stereotypes, our own perceptions of gender, to be able to move forward and to begin to understand what it means to be transgender.

Most of us weren't really raised to think about transgender. We just think about boys and girls, and whatever the confusing adult life that comes after that. But I think that probably there was more time in our childhood that was spent reinforcing traditional concepts of male and female than probably was spent teaching us about any other subject in the world. And this was done either covertly, or overtly. I happen to come from a really liberal and permissive family, but when I graduated Junior High School, my graduation gift was a charm school course that lasted through the summer. And, what -- the reason I was told that I getting this lovely gift, was my sister said, "Well, I called and I told them my sister walks like John Wayne. Can you help her?" And it didn't turn me into a lady. It did make my summer somewhat more interesting because I had a big crush on the teacher, and so I had that to kind of fantasize through the summer.

Clearly, other people have had much more extreme intrusions into their development, and what they really represent are just feeble attempts to force us to adhere to society's strict and narrow gender boundaries. I think that from the perspective of someone that's transgender, even if you're very gender adherent -- meaning traditional -- and adhere to all of those boundaries, being transgender, that really the mere fact that the transgender person exists is difficult for most people to conceptualize. So you're challenging that very, very primal assumption, or understanding that we think we have about men and women.

So even I think today we all probably have good intentions. And Dan and I looked at the list and we said, "Oh, we're preaching to the converted." I think that if we even -- for those who think we might even begin to understand what it means to be transgender, or to understand about gender, we probably really don't. And, it's such a confounding issue that I think what we really have is a lot of unlearning to do. To go backwards to try to get back to some really basic ideas, and try to open our minds to new ones.

So what I want to try to do is figure out a way to sort of join what we understand intellectually in the kind of sort of academic viewpoints that Dan discussed, and then combine that with what we know politically about gender -- because obviously some of the ways that we behave are clouded by ways that we try to be politically in sync. And then to go on to our gut reaction, which really dominates most of our behavior and most of our responses. And I think we have to put all that together to make ourselves more accessible to the transgender people that we work with.

It's, I think, a long process, and it's not just gonna be magically changed today. But I think we have to recognize that our relationships with all people are structured around power dynamics between men and women. And so when the gender ambiguity exists, that exists for transgender people, the whole process of relating to other people has to be reorganized, because we can't fall back on those basic power structures that we rely on. And we all do rely on those. I think that if we really just spent a whole day trying to go through the day and look at all the ways that our gender affect the ways that we interact with people and the consequences of the interactions, it would be truly overwhelming, because you really, you can't escape it. It's everywhere. It's how you get treated when you go to buy a coke, and whether the guy behind the counter, you know, is gonna wait on you faster because he thinks you're a hot babe. Now that doesn't ever happen to me, and I noticed that I don't get as good a service. So I think about this all the time, every day. [laughter] So I think it's important.

And obviously some people want to dismiss anyone who disrupts this dynamic, because a lot of people have a lot of investment in maintaining the dynamic as we know. And that's also talked about a lot in politics. But it's not to say that we've actually made that much progress, I would contend. But we know better then to dismiss these people. And from listening to our panelists we also know that there are lots of ways to look at gender. And we have to be able to really cherish that diversity and to nourish that diversity. And I think it will make our lives a lot more interesting.

My personal challenges around this issue of thinking about what it means to be transgender started in 1993. And -- this is Sgt. Stephen Thorn, he's a sergeant on SFPD, and you probably know about him, maybe from reading the newspaper. And I think it was '93 when an article came out that he transitioning on the job. And so I read that article, and I said, "Oh, God." I was really kind of flipped out. And I thought you know, everyone's gonna think now that butch lesbians just want to be men, and now what am I gonna do? I mean, it's hard enough to go to the bathroom, and this just really screws up my life. [laughter] So obviously I wasn't really making the connection that in my struggle to try to define my identity and assert my identity I was offended by someone else trying to do the same thing. So, ironically it was, I don't know, weeks or a few months later that I was asked, "Oh, do you want to work at the Tom Waddell Health Center? We're starting a transgender clinic." I said, "Oh sure, I can do that." Well, obviously I knew that I had a lot to learn.

So, I think that -- thinking back on my process it really illustrates a couple of major problems that we have. Probably all of us have assumptions. One is that lesbians and gay men understand transgenderism and are supportive of transgender people, which I think is really probably not the case. We all have a lot of work to do around that. And the other is that gender and sexual orientation follow along the same continuum. If you are just really, really gay, then eventually you become a woman. And if you're just really, really butch eventually you're gonna become a man.

So that's not really true. But I am thoroughly confused by Martha Stewart, who seems to be a really, really gay man. [laughter, applause] But I don't know. I can say that, but I can't really prove it!

Okay, so probably in this room I don't have to argue much that gender and sexual orientation don't intersect. That while they may work to define one another, they're really quite different topics. I think it's almost confusing that we talk about what sex are you, because then it confuses sexual behavior and sexual activity with gender. And that's probably the basic place that we're kind of stuck. But I think that where we're really challenged is where gender expression intersects with gender or gender identity. Because it's those things that define -- the clues that we use to define gender -- either how somehow behaves sexually, how they look, how they conduct themselves socially, how they behave sexually. And I think that that's probably where we really get stuck. Because if we can accept that people can be lesbian or gay, or multiple genders, we still have these expectations about what gender means. And that if you're a man, you mow the lawn. And if you're a woman you are, hopefully straight, and your identity is female, and you're submissive and feminine, and you only sleep with one person. And that's, I think, we know, not the case.

So anyway that predictability is part of, I think, what really challenges us. And it does make life more interesting when we have that variety. And that fascination is, I think, what leads us to another trap that we can fall into. And that is that we translate our experience with transgender people into something that's fascinating and titillating. And, I mean, let's face it, I don't get asked that often "What's it like to work with a Diabetic?" I get asked, "Tell me about your transgender patients, and who did you see, what did they say, what do they look like, do they have a penis, and do they have breasts?" And all this stuff. That's what people ask me about. And so to try to maintain a respectful and serious attitude toward my work, I have to sort of translate those opportunities into a means to educate and inform people. And not just entertain them and titillate them. Because I think that I see that happen, and we really have to be careful not to behave that way.

The other thing is that we're really, like we say, there isn't a body of knowledge to fall back on. Either if you're a medical provider, if you're a therapist, if you're a psychiatrist a lot of what's presented we don't all believe in. There isn't any sort of cohesive information. There's not good information to help us understand all of this. So we really have to pay attention to the people that we're working with. I think the panelists said it the best. That it's especially challenging probably for physicians, because we want to be in control. We're used to dominating every encounter with our knowledge, we're the experts, and we want to maintain that. Because what the hell else did we spend all that time in medical school for? But the reality is that you really can't do that. And you have to give some of that up because it's just -- no one's ever gonna fit into any particular place that you put them. And so you spend all this time learning. The visits end up being more about learning and less directive.(View the slide)

Just to kind of go back to some of this -- really we can look at these parallel lines, and there are probably lots of other ones that we could add to it. But every person could, you know, falls on different places along those continuums there. It's not just transgender people who sort of sample from the smorgasboard of choices of how to behave, or how to express yourself. Every single person could fall anywhere along that line. But the reality is that it's mostly with our transgender patients that we end up talking about it. And so it creates this level of intimacy that we don't have or expect with other people. And so it's also more likely to sort of bring up your own person stuff, and bring your own emotion into it and challenge that in other basic ways. Because we don't generally -- we generally keep some of those things at a distance and keep them in a much more clinical context. So I think that's something else that we have to think about.

The other thing is that there are transgender people who live very traditional lives. And we have to keep that in mind, that's it's not just sort of this avant garde phenomenon that's only happening in San Francisco. You know, there's Phyllis Schlafley, there's George Bush, who really knows? And it's possible that they're transgender also. [laughter] So you really have to start with a blank slate and try to avoid assumptions that are gonna alienate people. And like I say, it's really challenging, because we don't know how to diagnose. We don't know what we're diagnosing. And we're kind of used to doing that. The thing to keep in mind -- I'm gonna take another two minutes, one minute, okay -- is that...? [applause] They're late with lunch. Okay. So the bottom line is that for patients who come in, I just want to say I'm not thinking about hormones -- for patients who come in to ask about hormones, they aren't making that decision in the ten minute visit that you have with them. They've thought about it for years. And even if you're trying to put it all together in your head in ten minutes, you have to respect that they've come there with a lot of knowledge, and a lot of insight, and a lot of soul searching before they get to that point of trying to even consider that decision.

So the first lesson is that we need adequate time to be able to inquire about that, to pursue it, to try to understand it. And to really hear someone's life story. I think it's also, there are certain levels of advice that we can have and some directed questions that we can ask. I mean, the first thing I think is it's really critical for someone not to be making that decision in isolation. I try to encourage people to go out and find support groups, to find social places where they can meet other transgender people, and try to get them connected. So they can see if that reflection really does mirror who -- come back and mirror them. And it's something that they're really working toward. I think it's important to try to help them identify who their role models were. And how did they identify in the past?

Dion talked about being raised in a lesbian community. And obviously those contexts will give you some clues about what people are responding to and sort of what got them to this point. And it's obviously important for people to find out if they've even explored living in the opposite gender. Have they talked to their family and friends? To bring those people that are important to visit. Because they have questions, too. And they're a really important part of the process. And they need to understand it. And they need to hear from you directly. Because there's obviously a lot of other issues going on for them. And you can't just rely on the person that you're working with to be able to translate that information in a good way for their partners.

So, I think there are also some questions that we have in the back of our minds. And some concerns that are probably, you know, sort of burning when we try to think about this decision making. And one is clearly we kind of go back to where I started. And we have to think, Is this person really gay, or are they really lesbian? And maybe they just haven't had a supportive environment that sort of helped to nurture that? And maybe they're responding to sexual behavior and confusing that themselves with gender. I mean, everyone isn't -- most people are well informed, but everyone isn't. And maybe they've come from, you know, the middle of Timbuktu, and this is all that they know. And I think that that's what worries a lot of people. I hear providers talk about that a lot. "Well, I think they're just gay." And you know, it's okay. I mean I think exists, I think that happens, but it's just something that will take a little more time to really pursue. And I think that it's not the majority of the people that we see.

Obviously some people also, you know, maybe they're just responding to a fad. And certainly in San Francisco I hear people say they're concerned about that. And it's -- the case that any of our patients may lie to us, they may have secondary gain; but we can't let those, you know, we can't let cloud our judgment about all of our patients. We can't make those generalizations about everyone just because they're transgender. I think we never sort of do that same sort of decision making with some one who is diabetic or hypertensive. We're still gonna treat them because they have the illness whether or not they're gonna take their medication appropriately. We'll check their blood sugar. We have to sort of apply those same non-judgmental terms to treatment for a transgender person.

I think, essentially, my overriding feeling is that really the consequences of hormone therapy are positive for those people who feel that they're benefiting from them. I think that basically that's an important part of it. But the most essential part of it is that someone has a person who will listen to them, who will be open to them. Because if you are just living your life in a way that you're being excluded from sort of the basic rules of society and the basic circles of our society, that the critical part is just having someone that will actually listen to you and not ask too many stupid questions. Because we all are gonna end up asking some stupid questions. But to be really just be respectful. And that part really just can't be taken for granted. So I really trust that we all will sort of take the opportunity to improve the way we provide our services to our transgender people and also continue to kind of think of all the different gender possibilities that exist, even for ourselves. Thank you. [applause]

JoAnne Keatley: So, are there any questions?

Audience Member: Thank you very much for your comments. I have a questions related to adolescents. I'm an adolescent Health Care Provider, and the guidelines say that people should not get hormone therapy until they're 18 years old. You know that people distress can last for a long time before they reach that age, and I was wondering what your comments and your colleagues comments were about medical treatment and access to those kinds of therapies for people before they're 18.

LK: It is true the Harry Benjamin Guidelines, I think they say "rarely" should hormones be given to someone under the age of 18. If you have, if you want to adhere to those strictly, it still allows for giving anti-antigens to male to female patients. But I think that it has to be taken in a broader context. I mean the Harry Benjamin Guidelines really aren't meant to be adhered to strictly. They're standards of care, but I think that when appropriate you have to make decisions that go outside of those standards of care. And I think that there are some of us around this city that are prescribing, carefully prescribing, treatments to adolescents. And I know that Castro Mission Health Center has a Dimensions Clinic, and they've actually developed some protocols for adolescents. I only have about two -- three patients in my clinic that are under 18. And those are actually patients that are very clear-cut, have actually had psychiatric evaluation, have been cross-dressing from a very young age, and sort of fit more of a classic model of being transsexual or transgender. Obviously, parental support is important, if the parents are in a relationship still with their children. But I think you have to be fairly -- a little more cautious with adolescents. I don't know, it's really so individual, I can't give a broad answer.

DK: And certainly there've been published reports out of the Netherlands of success with hormonal treatment of adolescents. And particularly cosmetically better results when people start younger. And so that's the -- the balance is for a, you know, truly transsexual person. The younger the person starts on hormonal therapy, certainly the better the results can be. The question comes in with children displaying gender variant behavior that most of them are not -- don't identify as transgender as adults. But when adolescents present very often they do. And so there's the question of, you know, at what age, in terms of protocols, would you make the determination that this is a consistent and long-lasting desire to be the other sex.

Audience Member: I just want to also comment on that. I have the latest information from the Harry Benjamin Association on adolescents. And these standards are not printed, but they are coming, and it's a clarification of the treatment of adolescents is: "With attention being paid to their emotional maturity and stage of puberty, rather than their age." So, I just wanted to say that.

LK: Safety is also another big consideration. Because I have a patient who is in school and she is male to female, and she is in school as a girl. And she's 15, and so she has girlfriends, and they have slumber parties. And she actually had to, you know, change schools so that she could sort of start fresh. And so I think it's important to think of treating as early as you think is really reasonable. Because she's at very high risk for, you know, for being beat up in school. And I mean it's very dangerous for her in many ways. So her family is actually really aggressively pursuing surgery, and she's only 15, so that's a big consideration. I mean for everyone, but especially for kids in school.

JoAnne Keatley: I think we have time for one more question.

Audience Member: Okay, I think the idea was you have to be very careful. But I think mostly it's better if they prescribe hormones. Because if they really are trannsexuals, they end up buying hormones on the black-market, so it's better for them to get a prescription.

LK: Thank you.