He later described what a social transition looks like, saying "this can be a variety of different things depending on the level where they are on their own pubertal process, but pre-pubertal kids are going to be growing the hair longer or growing it shorter, y'know, using different ways to express their gender via clothing." He then elucidates chest binding, where a woman who believes she is a man wears a suppressing garment over her chest. He also brought up "packers," which mimic the appearance of male genitals in women's clothing. This can be considering akin to stuffing a pair of gym socks in one's underpants.
Neff is board certified in internal medicine and pediatrics with Baptist Health in Louisville, Kentucky. In one slide, he linked "structural and systemic" issues, such as "organizational policies, healthcare education, provider availability, identity documentation laws and change processses," with individual reactions to those things, such as "suicidality, substance use, eating disorders, psychological distress, depression and anxiety, and PTSD." The idea behind this is that if society changes in order to accommodate trans-ness, then people who identify as trans will not be susceptible to these problems.
Neff said that when treating children with gender dysphoria, fertility options must be discussed. In Kentucky, where Neff practices, parental consent is required before medical gender transition is undertaken.
"You want to make sure that the gender identity you know, it's fairly stable and and what it is and that the gender dysphoria is persistent, especially the onset of puberty," he advised health care providers. "Of course, you need to meet diagnostic criteria for gender dysphoria. Need to understand the risk benefit, informed consent, all of that. If there are mental health concerns, make sure that they are being addressed, but that's not a clear contraindication to starting treatment." he added.
"And then again, thinking about fertility options again, it's harder to know if you're talking to a younger kid. They're 10 and 11, 12 what that might look like, but that should be kind of brought up. And then they have to be Tanner Stage 2 for puberty blocking agents. Same thing more or less for the hormonal treatments. Again, you want to talk about risk benefit, side effects, things like that," Neff explained.
For women who seek to transition to appear male, Neff said their first question is about removing their breasts and when they can do that. "When I talk to my trans male patients," Neff said, "typically the first question is 'When can I get top surgery?' And so I would say that by far the most common one that at least I've seen practiced and clearly from a certain survey as well. It's very affirming."
Neff stated his concerns about the "current climate" in which the concept of transition procedures for children is questioned and lambasted. In his view, children are not "having all these procedures." He said that "most people are not doing surgical procedures on folks less than 18 at least universally that I know of."
"For the most part," he said, "it's top surgery, maybe hair removal which is pretty low risk, in my opinion."
In his talk, he took aim at legislatures that seek to limit gender transition of minors, such as that of Kentucky. A law passed in Kentucky, and upheld by a federal appeals court, prevents minors from being given puberty blockers and hormone therapy for gender transition.
"What basically it says is that we can't provide care to folks under 18 in terms of either pubertal suppression or gender affirming hormone therapy, and surgical therapy as well, which again, most trans youth are not having any surgical treatments unless it's clearly indicated." Doctors who are providing those drugs to minors for the purpose of gender transition must wean their patients off of those drugs. Social transition is the only legal gender transition for minors in Kentucky at this time. Neff said that some of his patients' families have sought to move out of state so they can continue with their gender transition.
In his view, this ban is troubling because the drugs are "life saving." In terms of puberty blockers and cross-sex hormones, Neff said that giving kids these drugs is essential so that by the time they are adults, they better resemble the opposite sex they wish to be perceived as.
"I think this will certainly have impact into older adults too. We know that if we were able to do some of these things earlier on, we can prevent some of the other surgical procedures that are a bit more intensive. And also ultimately improve mental health and health outcomes for transgender folks," Neff said.
The idea is to prevent gender transition surgeries as adults, gender transition medication needs to be administered to minors. The concern here is that these permanent changes are made to a minor who may decide not to go through with transition. If a minor takes these drugs, then decides at 18 or older that they do not wish to appear as the opposite sex, the damage is done. The use of these drugs and implementation of these changes assumes that the childhood wish will be a lasting fixation even into adulthood.
This is a perspective held by many providers in the trans field. The idea is that if a child wants to be perceived of as the opposite sex, steps need to be undertaken to prevent them from developing the secondary sex characteristics of their natal sex as minors so that when they are adults, they look like what they wished to be as children.
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