Evan: 1:31

Imagine a 10 year old girl, the girliest girl you've ever met. I'm talking dresses, makeup, hair, all of it. Then, at 10 years old, she suffers traumatic sexual abuse and stews quietly over the next few years. She withdraws, she battles anxiety and depression. She stops shaving her legs, starts dressing more like a boy by 17. She wants she wants to be called Sam. This isn't a hypothetical. This is the kind of story therapists are seeing more and more. And here's the question Is this gender dysphoria or is it trauma manifesting as a fractured sense of self?

Evan: 2:08

Right now, youth gender identity is exploding. The Williams Institute at UCLA says 3.3% of American teenagers over 700,000 American kids now identify as transgender, while adults remain flat at about 0.5%. The New York Times admits it could be social acceptance, but also peer influence or political climate. At the same time, activist playbooks are out in the open. One major NGO report literally told campaigners to target youth politicians, to demedicalize the campaign, to get ahead of the media and to frame it as a human rights battle rather than a medical one. And it's working. Schools, politicians, even clinics are fast-tracking affirmation. Schools, politicians, even clinics are fast-tracking affirmation.

Evan: 2:53

But here's the problem. An independent review conducted by Dr Hilary Cass in the UK called the evidence for youth medical transition, quote remarkably weak and slammed clinicians for abandoning normal holistic assessment. Meanwhile, in America, a single phalloplasty can run $120,000. Vaginoplasties, top surgeries, hormone prescriptions for life all mostly covered by insurance, which means billions flowing to hospitals and drug companies. Compare that with therapy-first approaches, which cost a fraction.

Evan: 3:26

Which pathway do you think our healthcare system is incentivized to favor? This isn't about denying trans people exist. It's about asking are we doing right by children in distress or are we letting ideology, advocacy, money and profit drive life altering decisions before the root causes are even understood? Tonight, melissa and I are going to unpack the evidence, the trauma link and the ethics of how we care for kids caught in the storm of gender identity. Melissa, let me start with the big picture. We've got 3.3% of US teens now identifying as transgender, 770,000-ish, but the adult number has been flat at about a half a percent for decades. From your perspective as a clinician, does this look like organic growth or something else going on?

Melissa: 4:18

Evan, I definitely think that something else is going on here. We have a culture and society of kids that are struggling to figure out who they are in general, are struggling to figure out who they are in general and where you and I went through our middle school years and you know, really, from about 12 up through 17,. We tried to figure out who we were. We explored different sports, we maybe did some art or some music. You know, you listened to what kind of music as a middle school and high schooler.

Evan: 4:55

Gangsta rap.

Melissa: 4:57

Right and I went through a Christian music phase for a little while there.

Evan: 5:02

I had my Christian music phase too. Me and Casting Crowns were friends for a while.

Melissa: 5:05

That's right, but just trying to figure out who am I and what do I like and what are my interests. And today, because really we've this whole concept of gender didn't exist 100 years ago it was just male or female. What were you at birth? At birth, and when this whole concept or shift in vocabulary came about, it opened up this whole other area for people to explore in a socially acceptable way. And even as kids I played football with the boys. I had a stage where I dressed in oh, baggier jeans were in back then, but I dressed in baggier clothes and didn't wear makeup and just kind of figured out myself and struggled through that, sure, through that. Today, a lot of our kids, they don't have the ability to struggle through, they're emotionally sensitive, they're hurt over anything that's said, that doesn't feel safe and they collapse under any kind of pressure or any kind of challenge. And ultimately, it's my belief that identity, gender, which is something biological, is one of the last things in our society that can really be.

Evan: 6:55

It's a final absolute right. It's one of the few things that is a yes or a no, it's a black or a white. It's a binary code, absolutely, you know, you're a one or a zero right. So we talked a little bit about this earlier today and we were talking about the etymology of gender and sex because, you know, in our family conversations these kinds of topics come up because we're not afraid to talk about the unmentionables.

Melissa: 7:22

Which is funny when mom walks into the room into the middle of the conversation.

Evan: 7:28

What did I walk into? But so we talked about this and correct me if I'm wrong on this. I'm sure that you'll get to the details of it. But sex, in terms of biological sex, male and female, do you have a peepee or do you not have a peepee? That has been a binary question and answer for the entire human history. It's always been male or female. The concept of gender, I think, didn't even come around until what did we say? The late 1700s, maybe late 1600s?

Melissa: 8:08

So I looked up the etymology, and its ancient roots are in the Latin term genus, which is a kind, a type or a sort. You know genus and species, right Sure, and by the 14th century the English used gender to describe grammatical categories of nouns masculine, feminine and neuter.

Evan: 8:33

Which makes sense. If you've ever taken, if you're an American and you've ever taken a foreign language class like german, spanish, french, you might have heard terms given in two different genders, males and females.

Melissa: 8:48

Which has thoroughly and completely confused me ever since I started taking German in the seventh grade. So it was never extended. Gender was never extended to be used in regard to people until the late 14th and 15th century, and it was in part Shakespeare who used gender in the sense of sex. What sex was someone? And then up until the mid 20th century, gender and sex were used almost interchangeably in English.

Evan: 9:27

It wasn't until good old Dr John Money in the night of David Reimer fame, if I'm correct, right.

Melissa: 9:35

Yes, and for those of you who don't know who David Reimer is David Reimer, who we learned about actually in undergraduate social work in a human sexuality class way back in the early 2000s. David had a botched circumcision so they decided, courtesy of Dr John Money, that this is just a social construct. So we can just do surgery and turn David into a girl. And if you raise David as a girl, then this child won't know the difference, they'll socially adapt and we won't have a problem.

Evan: 10:17

So biology means nothing to Dr Money at this point. It's all social construct.

Melissa: 10:22

It's all a social construct.

Evan: 10:23

Okay, correct, how'd that work out?

Melissa: 10:25

It was a very poor outcome and unfortunately, David ended up committing suicide, and part of it was that they, the family was told don't tell David, keep David in the dark. And so David struggled with these feelings, and this was nothing new, honestly. The term intersexed used to be being a hermaphrodite, which was somebody who was born with either an enlarged clitoris or super small penis. And if we look at general anatomy, right, the clitoris is no different than the tip of the male penis. It all comes from the same place, and so it was easier to shrink something than to try to make it grow.

Melissa: 11:17

So when children were born and again, this is a very small percentage, but when they're born with ambiguous genitalia the professional term for it parents for a long time were told that they needed to decide, because the sooner you did the surgery, the better a child would be able to navigate life. And as more and more studies came out, they realized that this was such an epic failure on the part of the medical community and this is some of the people who are now adults that just felt like they didn't belong in their body, which is now why we frown upon doing these surgeries super early, but going back to that shift. So Dr John Money, who was a sexologist and a psychologist, started using this word gender in the 1950s and 60s to distinguish biological sex, male versus female anatomy, from a social or psychological role and identity. And it was there in the 50s and 60s that this term gender identity, gender role, launched and that was where we started to see some of these shifts and changes.

Evan: 12:43

Yeah. So let me ask you this Are all cases of gender dysphoria or gender identity disorder, whatever? I think it's, gender dysphoria is the right term. Are all cases of gender dysphoria? You know lifelong, you know understandings that you know I've always just been a woman, or I've always just been a man and I wasn't born in the right body, or is there such a... I think I've seen a term called a Rapid Pnset gender dysphoria. Can you talk a little bit about the difference between those two?

Melissa: 13:19

Sure. So no, not all cases of gender dysphoria are those lifelong cases, and especially even now we can diagnose Klinefelter syndrome, and those are the folks that actually diagnosed Klinefelter syndrome and those are the folks that actually, from a chromosome perspective, are XXY. There are absolutely cases where someone is truly in the wrong body by no fault of their own. The cases that are so concerning are particularly those late onset ones, and by late onset what we really mean is around 12 or after 12. And this is a child who maybe was born a girl and did ballet and also did soccer and, you know, like to get dressed up and wear pretty things and had a cute haircut and was walking through life relatively normally until some kind kind of trauma happened. And when a child hits puberty, their hormones are all shifting, their body is developing, and the autism spectrum plays a huge role in this, because while it's hard for a neurotypical kid to go through puberty, it's even harder for kids that are diagnosed or undiagnosed on the autism spectrum from the social perspective.

Evan: 15:00

Yeah, so I gave that sort of example earlier, a very similar one to the one that you just brought up, and it sounds like it's fairly common for this kind of trauma to present this way. Is it common for trauma to present as a new identity?

Melissa: 15:18

Yes, we call it DID. It's dissociative identity disorder, and that's where the trauma and so a key part of this is those identities don't know about each other. They're blind to the fact that others exist and they rule in different ways in different areas. But really what you're looking at is, depending on the level of trauma and the way we suppress it or if it's not addressed, people don't know that something happened. It's stored and, through this identity process in those teen years, this concept of being trans was never a thing 50 years ago and it certainly wasn't anything that was socially really talked about until more so over the past 10 years, and it's now an option over the past 10 years and it's now an option. So back in the day people did different things. We've gone through the furry trend where that was a big thing. We went through a trend where people called themselves pansexual. It used to be. What are some of the other things that, as teenagers growing up, you know we kind of went to.

Evan: 17:02

Well, I think most people had some phase or another where they were emo or or used pot or used some kind of recreational drugs or something like that Just pot.

Melissa: 17:13

Or used some kind of recreational drugs or something like that, and really what it is in all of these different examples and again, not always, but when there's trauma involved it's an escape. It's I need to escape the chaos that exists within me, and so I'm going to pretend to be a cat for a while, or I'm going to pretend that I'm a boy for a while, or I'm going to use pot to escape for a while, or become emo to mask who I am underneath and not let people see it.

Evan: 17:55

So this is not about language and social acceptance and cultural norms changing to make it safer for these kids who would have always been trans identifying anyway. This is as much, or maybe even more so, about trying to cope with severe trauma situations as it is anything that's organic.

Melissa: 18:19

I think it is wonderful that as a society we are so much more open to people who are changing that part of who they are and it has nothing to do with trauma. It was a misgendering, it was ambiguous genitalia, it is Kleinfelter's For people who truly just feel that they're in the wrong body. I think it's beautiful as a society that we can embrace that and say you know what? I love you as a person and I will embrace all of who you are.

Melissa: 19:03

My concern is the rapid increase in these cases and we know that there's a rapid increase in disclosed trauma and even among kids who transitioned, and then you hear stories of detransitioning. Every stinking time there's trauma, there's unresolved trauma and people say I wish somebody had helped me work through this trauma instead of just allowing me to. Really we're talking about exiling a part that was hurt and saying you no longer exist because I got hurt because of you, so I'm going to shift into somebody else that I can design and make who I want, and then everything will be fine. And it's just not fine because the trauma doesn't go away.

Evan: 20:09

Yeah, so in many cases, what sounds like gender dysphoria could actually just be a trauma response, and if we don't investigate the root causes of that trauma response or that trauma, we risk treating the symptom but not the wound.

Melissa: 20:26

Absolutely.

Evan: 20:26

Like putting a Band-Aid on a bullet wound.

Melissa: 20:28

That's a good T Swifty reference there. We can't put Band-Aids on bullet holes.

Evan: 20:36

So let's talk about the evidence. The UK Hillary Cass did an independent review just in the last year or so. She's called the research on youth transitions quote remarkably weak and said that clinicians abandon holistic care. Would you agree with that assessment?

Melissa: 20:57

I sure would. I think that with the increase in media on this, of social media influencers and just the media in general, I'll say I think there's a lot of clinicians that are well unknowledgeable and some who are just afraid Because deep down as a clinician right, I know that if I tell you something that you don't want to hear, or I ask you to look at something from another perspective, just to solidify where you stand on something, I recognize that if it doesn't align with your beliefs, you might walk away as a client.

Evan: 21:50

And could it not be more serious, right? So one of the things that we hear about a lot in the news and social media, especially the influencers my God, these influencers. They will come out and they will tell you that the statistics on transgendered suicides are exponentially high. They're through the roof. If Sure, they're not affirmed in you know, whatever belief that they have in that moment.

Melissa: 22:19

Yes, and we're a feelings driven world.

Evan: 22:22

Now, We've lost sight Very much so.

Melissa: 22:25

It's no longer about what are the facts. What are the facts of what happened? What are the facts of who I am? What are the facts of how I was raised as a clinician is?

Evan: 22:36

there fear that this patient or this client that I'm treating, if I don't handle them gently, if I don't follow best practices, this client could go home and commit suicide. And not just will I be liable for that potentially right Because of the society that we live in, but, like, just as a clinician, on a personal level, nobody wants somebody to go home and commit suicide, of course, because they were pressed into, you know, taking a stance or a position that they didn't want to take.

Melissa: 23:11

Well, and if I don't ask the question, there's an equal chance? Because the reality is, if we're looking at suicide statistics among transgendered individuals, the risk was there in the first place, the risk was there no matter what. And so, as a clinician, do I ask, do I not ask? Do I probe, do I not probe? And you know we were talking about this earlier. We have a group of emotionally fragile adolescents on our hands and you can't disagree with them. Otherwise, you know, there's emotional upheaval, and so adolescents thinking that they just deserve ultimate respect when it's not even necessarily given.

Evan: 24:20

Yeah, it's absolutely, absolutely wild to me the lack of real detailed study that's been done on this issue for as big of an issue as it appears.

Melissa: 24:36

Well, and longitudinally. How would they? Because all of this is still so new. You're talking about a 0.5% stable number, yeah, among adults, among adults. And now suddenly we have 3.3% of adolescents, which screams something changed. Something changed here. It's interesting because we're also seeing a significant rise in autism, and what we know from again research is that those who are diagnosed on the autism spectrum struggle with understanding social cues, socially engaging and interacting with peers. They tend to be more comfortable with same-sex peers. So what we saw 10, 15 years ago is that the rate of people with autism that identified as homosexual was higher than those that were not diagnosed on the autism spectrum. And it makes sense because here we get along with somebody of our gender more easily. They're easier to understand, they're easier to relate to, picking up on the social cues, sure, and they find love with someone in that way. What I think that's now morphed into is well, now I can just change my gender and then I can be normal like everyone else.

Evan: 26:23

It feels like such a zero to 100 approach that we've taken. I know that there are safeguards in place and you know in in most cases you don't have people that walk into a therapist's office and 55 minutes later get diagnosed with gender dysphoria and off they go in a few months.

Melissa: 26:43

It's actually highly undiagnosed in people that identify as transsexual.

Evan: 26:50

Okay.

Melissa: 26:50

Which clinically blows my mind, because if somebody is going to identify that way, then as a clinician we would have to diagnose them with gender dysphoria. Sure, we can't say that this is any different.

Evan: 27:06

Right.

Melissa: 27:07

And yet it's chronically underdiagnosed. Hmm some of that is a fear that if they're diagnosed with it then there's a stigma and they won't be able to transition because doctors will view it differently, just like any other mental health diagnosis. As soon as there's comorbidity here, people view it as a red flag for the medical side.

Evan: 27:37

And I guess that's where I'm kind of going with this as well is that, given that we have such a limited research base because, quite frankly, we haven't been in this business for that long Right Right, and also we're talking about things. Look, when it comes to ADHD and autism, there are a lot of not gentle medications, but there are a lot of medications that are stimulant-based or others that are maybe less long-term effective Mood-based, mood-based right that are less long-term effective than, for example, taking hormone blockers right, that are less long-term effective than, for example, taking hormone blockers right. So why do we, in the case of someone who potentially wants to, you know, has a gender dysphoria condition and wants to change their gender, sort of go directly to let's get you started on hormone blockers, as opposed to? Would it really be harmful to spend two, three, four, five years maybe your childhood years at least, walking through how you feel and why you're there?

Melissa: 28:45

Well, the question popping up in my head right now, as we're talking about this, is why do we care? Why, as a child, do you care what gender you are?

Evan: 29:06

Why does it matter? How does it impact how you do life day to day? Well, I think, especially for teenagers, gender, your biological sex, does a lot. It determines where you play sports and which teams you're on and what friend groups you hang out with. It can determine a lot of things at that stage of your life. But I also question whether or not that's a construct of ours that we've put into place, where we've overcomplicated things to a certain degree when it comes to gender. Now, certainly I think you and I are on the same page about biological sex. Men should be playing with men, boys should be playing with boys.

Melissa: 29:43

And that's what you were just talking about. You were talking about biological sex.

Evan: 29:47

Correct. You weren't talking about this social construct of gender, because I don't see that Agreed this social construct of gender, because I don't see that Agreed.

Melissa: 29:54

So if I don't know if I feel today like more of a boy or a girl, how does that impact my daily activities?

Evan: 30:10

The only way it possibly can is if your happiness is tied to the acceptance and appreciation of others.

Melissa: 30:18

And that's where it is and that's where everyone else needs to affirm who I am or who I feel like today in order for me to feel okay with myself. And the reality is we know that the brain, the prefrontal cortex that has to do with logic and reasoning and organization and all those fun higher level executive functioning concepts, doesn't fully develop until at least, if not well, after the age of 25. The age of 25. And so, as young adults, as adolescents, it's not harming anybody to sit in who I am and go through my day. I sit back and I say why is this even an issue today? Why is this even an issue today? That I need to figure out who I feel like I am today in order to function in society? You and I, as kids, didn't sit back and go. You know, do I feel like a human or a cat today?

Evan: 31:32

No, I don't think that was ever a question.

Melissa: 31:33

If I feel like a cat. Maybe I won't go to school because cats don't go to school. Or do I feel like a boy or a girl? It's not like I can decide which bathroom I want to use. It's not like I can change which gym class I'm participating in or which athletic program I'm in. It's set and so whatever it is that I'm questioning in my brain has zero bearing on what plays out in my day. I am stuck in my sympathetic nervous system, which is our fight or flight, our feelings, all those big energy things. And I'm stuck there because, from a factual standpoint, I can't look down and ask myself do I have a penis or a vagina? Because that's going to tell me how I need to proceed through my day. But I'm stuck in how I feel, which could be anything. I could feel like an attack helicopter today, but does that mean that I run around and wave my hands spinning, like, like, what are they called on? The top Blades, blades, propeller blades and start, you know, pew-pewing at people? They'd think I was crazy.

Evan: 33:04

They would indeed.

Melissa: 33:05

And so because we clearly can say that is not reality, right?

Evan: 33:11

No, you are not a Buick. You're not an attack helicopter, you're a human. But will you pretend with me todayick You're not an attack helicopter.

Melissa: 33:14

You're a human, but will you pretend with me today, cause I feel like an attack helicopter? Do you want to pretend with me? Not right?

Evan: 33:21

now, but maybe later.

Melissa: 33:22

Yeah, okay, that sounds fun, but you know I can't decide. Today I want to be a potato, so I'm going to sit here and not do anything.

Evan: 33:37

Don't we all wish we could do that?

Melissa: 33:38

You know the other. The other thing that I'm seeing is that youth, youth have this luxury, this luxury of feeling and using it as an it as an excuse for everything.

Evan: 33:56

That's pretty recent too, right. It is when I told my parents how I felt my dad was like okay, Right, Get your ass on the bus, kid.

Melissa: 34:06

And the reality as an adult is I can wake up in the morning and feel down, I can feel like not getting out of bed because I'm tired and it's rainy and I just don't really feel like adulting today. But I can't just decide. I'm not an adult. I have to get up and for a lot of us as adults, things like depression, we don't get to go be depressed because there's all these other people and responsibilities that we have. We need to suck it up and move forward and hopefully have outlets to deal with that and try to keep ourselves balanced. But kids today say I feel depressed and magically we're not in school, magically what's expected of us has decreased and if I have trauma, forget about it.

Evan: 35:06

I need a mental health day.

Melissa: 35:08

Sorry, you don't get one.

Evan: 35:12

So, but we don't I don't want to't want to over trivialize this right. So we understand that there are real issues. There are certainly some some these are very real issues yes, well, there are some situations where, as you've pointed out, there are, there are real disorders, there are real things going on here, not just feelings, and I think that when people use it from a feelings perspective, it really invalidates and downplays the real situations where people are deeply struggling.

Melissa: 35:46

slow down, let's do the hard work first.

Evan: 35:57

Don't exceptionalize these kids just because they're presenting in a certain way. Let them grow through it. Let them get to a stage where, even if the answer doesn't change, at least they've done the processing work to get there.

Melissa: 36:14

And they've grown as a human. They have sat in the discomfort of life and learned how to persevere, where our society today is about fast answers and quick solutions and no distress tolerance.

Evan: 36:33

Absolutely From an ethical standpoint. How do you see the Hippocratic Oath, for example, applying here? Are we doing harm by pushing affirmation too quickly?

Melissa: 36:45

I absolutely believe we are. And the flip side of that is going to say well, are we doing harm? If we don't, because then what if they go kill themselves? And I go back to if suicidality is there it was there before you. It didn't magically appear and this person is so miserable and literally in their own skin, whether it's by trauma or avoidance again, not talking about the very legitimate cases here when we push a quick solution and we don't let them walk through life and actually work through the issues because we're afraid to.

Evan: 37:44

How do you, as a clinician, if you've ever dealt with anything like this before, how do you let a client walk through it without? How do you let a client walk through it without necessarily affirming or validating what they're saying?

Melissa: 37:59

Sure. So I feel like you can always validate someone without agreeing. So somebody can come in and say I feel like I'm a boy and not a girl. Okay, well, help me understand what causes you to feel that way, and they tell me all the reasons that they feel that way, which often is well, just because.

Melissa: 38:28

I don't, it's a feeling right, Because it's a feeling, in these cases, Sure and okay, so I can understand that it feels that way. It feels that way. What are the facts? And we call this DBT. It's dialectical behavioral therapy, and many, many therapies come from here, but it is taking fact and taking feeling and looking at where the truth lies in the middle. A lot of our therapies, even EMDR work, looks at what are the facts. I know what are the feelings that I have and can we merge the two and see what we find in the center? We merge the two and see what we find in the center. So different therapies call it different things but nothing is looking at.

Evan: 39:25

I just want to go by how I feel today. Okay, how long does it take for you to decide whether someone is ready or not ready?

Melissa: 39:43

So, for example, ready or not ready to what?

Evan: 39:46

to take the next step on their journey. So, for example, we've talked about how there are, or you've talked about how there are, some people who present and they have true gender dysphoria. They have a real condition that needs to lead them in this direction, versus someone who, as you pointed out, may be hiding from trauma. Is this something that you meet with a client for one session and you could determine? Is it three months of sessions?

Melissa: 40:20

Is it a year? There's no finite timeline and different clinicians are going to look at things differently. There are some who want to affirm and just believe the first thing that everybody says, which is not clinical best practice. We're talking about needing to dig in and ask those hard questions, ask people to think about things and the reality is, if you ask the hard questions and they leave, you know the answer.

Evan: 40:57

Sure Sure. So it sounds like there's safeguards in clinical best practices, but they're applied inconsistently.

Melissa: 41:06

I think that different clinicians use different theories and models and come from different worldviews. So if someone has a bias against the LGBTQ lifestyle or transitioning in general, then they're probably going to take a lot more time to assess it and look for other things that could be coexisting or comorbid, whereas someone who is extremely supportive of you know what. If you feel like that, then you just go do it and everything will be okay and everything will be okay is far less likely to rule out all the other things, like autism, trauma, any other mental health issues, DID.

Evan: 42:09

It strikes me and I'll come back to this in a minute, but it always strikes me a little bit that we and I understand why because the human condition is such that we want others with us. Right, we want others to embrace us and to affirm us. But it does strike me that when we talk about things like medical conditions, an awful lot of people would probably go get a second opinion if they were told we need to do heart valve surgery on you, or we need to do heart valve surgery on you, they sure would. Or we need to do some kind of invasive surgery or take these pills. And yet I worry, or I wonder how many trans-identifying individuals, and especially youth, seek out other potential options to rule out before they go under the knife.

Melissa: 42:57

And I think, as parents, a lot of parents are afraid because if somebody gives this medical opinion or a clinical diagnosis, as a parent you want to trust those people that are involved with your child and fundamentally I think there's a fear that what if my child does self-harm? What if my child takes this path? You know what's better.

Evan: 43:31

And I feel like there's also a fair number of medical professionals. Certainly I don't know so much about on the therapy side, but certainly on the medical side there's an awful lot of those individuals who, once they've made up their determination about what should be the parents, stop mattering.

Melissa: 43:48

Yes, absolutely.

Evan: 43:49

Yeah, and I think as parents, that puts you in a difficult position, because then it becomes the child and the doctor versus the parent. Right and the doctor's telling the kid what they want to hear. The parent is too restrictive. And remember, kids already think that we are too restrictive too restrictive just just by the fact that we're parents.

Melissa: 44:12

Despite the fact that we know kids need consistency and structure and rules and boundaries to thrive. And seek those out whenever they can find them, Absolutely they do.

Evan: 44:22

And connection so tell me about. Let's talk about informed consent and for me, the concept of informed consent as it sounds right, being informed and being able to provide your consent for treatment, right, with an informed opinion. So I know what you're about to do, what the risks and harms are, what the upside is, what the downside is, and I'm willing to say let's do this right. But is that compromised when we're talking about a child in distress in this kind of a situation?

Melissa: 45:00

Well, first of all, let's just note that at 14 in most states, if not all, 14 is the age for mental health consent, and certainly it is that here in Pennsylvania, where we are. So once that child turns 14, they have to consent to the parent being involved. Under the age of 14, we look for dual consent. We want consent from this child saying I want to be here, and then we have to have consent from the parent allowing that child to be there. Now, medically speaking, once they turn 14, at least here in our state, they now get to consent to their own drug and alcohol counseling or treatment. They get to consent to many of their own choices in regard to pregnancy, birth control, sexual health which does. Do puberty blockers fall under that or not? I'm not sure to be honest with you and the third one being the mental health piece. But otherwise, until they're 18, they need parental consent in order to do these things.

Evan: 46:16

But we've heard in maybe it's not so much here in Pennsylvania but in other states, especially California, washington State, montana, even you know schools and medical professionals working with kids behind the backs of parents, and I guess some of that is state law related but just Well, and the school's overwhelming disrespect for the role and authority of parents.

Melissa: 46:50

Today, you know we're fortunate enough to live in a district that recognizes and supports the authority of the parent, and I think they know God help them if they would do anything like that to overrule the authority of the parents in our district, because it would be very interesting when in some other states maybe it's the same concept of I'm not explicitly handing my rights over to you, but they've slowly been taken and now you just kind of do what you want and I'm off here on the sideline questioning when I ever yielded my authority over. Yeah.

Evan: 47:29

It seems like every time we close our eyes for a second to catch a breath, they're 10 yards ahead of us with our kids and our rights as parents. And it's like how did this happen?

Melissa: 47:44

Right? Well, and this is no different than in the schools, when they send home the opt-out versus the opt-in consent. And how do we know? If the opt-out even came home? But if it's not returned saying you're opting your kid out, then they just go ahead and do it.

Evan: 48:01

Right.

Melissa: 48:01

And that's where they're playing the role of the parent as well.

Evan: 48:05

Absolutely so. That's the key informed consent. If we can't do a full explanation of all the underlying issues here, then we're really violating the first rule of medicine, which is first do no harm, Correct Right. So I think we need to take a look at that. Look, I want to get uncomfortable. Now we're going to start talking about money. We mentioned this before A phalloplasty can run $120,000, a vaginoplasty between $40,000 and $50,000, and the hormones create lifelong pharmaceutical customers. Do you think that there's financial incentives?

Melissa: 48:46

that are influencing the system. How many cha-chings are going off in my head right now?

Evan: 48:52

Money, money, money money.

Melissa: 48:54

John money.

Evan: 48:56

We're getting there.

Melissa: 48:57

But, oh my gosh, you're talking about people having to follow up with medical providers. How many times, as opposed to your average healthy individual? I mean, I go to the doctor when I'm sick.

Evan: 49:14

Sure.

Melissa: 49:16

Honestly, it's not a repetitive thing, and you're talking about people who now are not only having to have routine follow-ups, but with specialists that are being paid God knows how much money. You're talking about pharmaceutical companies making money hand over fist on these drugs that now these people are dependent on and can't get off of.

Evan: 49:44

Absolutely. I mean, we're talking about a transition that can cost $175,000, plus lifetime hormones.

Melissa: 49:54

I have a question. Can I ask a question quick?

Evan: 49:56

Absolutely.

Melissa: 49:56

So what happens when somebody wants to detransition? Do they pay for that too?

Evan: 50:00

A lot of that is not paid for by insurance.

Melissa: 50:03

You know what else is not paid for by a lot of insurances Infertility treatments, weight loss treatments, cosmetic work. Can I go get a liposuction and have my insurance company pay for it?

Evan: 50:17

No, no, but that's an elective surgery.

Melissa: 50:20

Correct, it's elective.

Evan: 50:23

But what's interesting to me is we're talking about a transition that can cost, say, between 70 and $175,000, plus lifetime hormone costs and all the other things that go into the pharmaceutical side Therapy. First treatments are in the range of what? 17 to 25,000, depending on how long it is.

Melissa: 50:45

And you'd have to do the math on that. I can tell you that for an average one hour session, at least here in Pennsylvania, we get anywhere typically around $120, paid for by insurance, and then you add somebody's copay or deductible or coinsurance on top of it.

Evan: 51:04

It's a fraction, even if we said that was $17,000, which is probably an extensive amount of money for a long period of time to undergo these treatments. That's a huge disparity and it begs the question why wouldn't we want them to go the mental health route first?

Melissa: 51:27

Well, what happens if we fix the issue?

Evan: 51:30

And I think therein lies the problem right, if we fix the issue, then we don't have those chunk costs, those $175,000 in costs, and we haven't created lifelong customers in our pharmaceutical industry, and not just the pharmaceuticals associated with this particular situation. But we also know from having looked at the research on this, and I think you can attest to this from a medical standpoint there's a lot of comorbidities that come along as people make these transitions when they go on these hormone blockers and they go on these other things. Other conditions come up. Early onset menopause, I think, is one that comes up.

Evan: 52:18

There could be issues with the way the muscle and tissue is built and so that can create things like arthritis and osteoporosis, and you know it can change your the way your blood pressure reacts, and so you could have high or low blood pressure. And there's all these different other medical conditions. Some of these are cancer drugs, Correct?

Melissa: 52:45

Cancer drugs with an, every medication we put in our body, I mean we. We just found out today Tylenol. Tylenol in pregnancy is now being linked to autism. Every single thing that we put in our body has known and unknown outcomes. And to think of putting these things for cancer in our children, I mean even in adults. Enhancer in our children, I mean even in adults. So we were at the memorial service for my dad earlier today and this just makes me think. About a couple of years ago he had tried to pursue getting a lung transplant, a double lung transplant, and they went through this laundry list of tests and rule outs and all this other stuff just to determine if he was actually a candidate. You do the lung replacement, you'll have five years at most because you'll have to be on all these different anti-rejection, anti-whatever drugs that will give you cancer and you will end up dying of cancer.

Evan: 54:11

So we can give you five for cancer, or you can get potentially five to 10 if you do nothing.

Melissa: 54:18

Correct. But even these meds right that were used to treat the potential rejection and at the end of the day he decided he wouldn't have done it even if he had been approved.

Evan: 54:31

Sure.

Melissa: 54:32

Because they all have side effects.

Evan: 54:37

They do, and I think they all have incentives. They sure do. But I say that and I don't mean to say that all clinicians, or really most clinicians, are malicious, but I think the incentives matter.

Melissa: 54:55

As a clinician, I really have no incentive because I'm not prescribing meds. I don't get any kind of kickback for surgeries. I don't have anything. The biggest thing that I'm risking is, if I don't delicately navigate this with my client, is my client going to go out and say awful things about me as a clinician If I don't tell them what they want to hear, is this person going to go and commit suicide and then I'll be blamed for it. Yeah, how, as a clinician, do I see the level of pain that might exist under the surface there and know I can't force this person to get help. I can't force them to take the help.

Evan: 55:45

Yeah, exactly. I mean no one's saying that doctors and clinicians are greedy villains here, but when billions of insurance dollars are flowing towards surgeries and drugs and not towards root cause therapy, when the investment's not there on the root cause therapy side, the system tilts.

Melissa: 56:02

And it's not invested by the clients usually either.

Evan: 56:04

No, and the kids are paying the price.

Melissa: 56:06

Correct.

Evan: 56:09

Melissa, my final question to you if you had one message for parents listening who are facing this with their kids right now, what would it be?

Melissa: 56:19

Pause and don't be afraid that your child is going to hate you for the rest of their life. And get a second opinion from a different provider that views things differently, not another one that believes the same way, but get other thoughts and other perspectives because, at the end of the day, this is your child. Whether you birthed that child or you didn't birth that child, this is your child and you get a voice into that. And the medical community is well known for they have all the answers, whereas, coming from a social work background, we believe you have all the answers. I don't think that's told to parents enough is. You really can trust your gut and your intuition and you will have support if you look in the right places. So stand up and parent your children.

Evan: 57:25

And that's what this comes down to. Gender dysphoria can be real, but trauma is also real and often hidden, if we let politics Absolutely