Developmental Snapshot: Teen But Not Parents of The Year Award

Well Defended Teen, Kauai, August 2017

Things are not easy right now for my 14 year old (and youngest son.)

It's been just me and him at home for the last few days. I'm his least favorite family member to hang out with.

His father was deployed to Puerto Rico as part of a Disaster Medical Assistance Team (DMAT), one older brother left for college three weeks ago and his other brother is sixth-grade camp counseling this week.

I've tried to give him rides to and from school whenever possible (it's not always) and to make the kind of food he likes for dinner.

I was rewarded with getting to watch one episode of Futurama,  before he tackles homework, with him two nights in a row (as long as I don't get too annoying, i.e, try to have too many conversations.)

He had to reschedule a student teacher conference in one of his classes because I could not get him to school at 7:30 am one day this week (I had left at 6:15 and could only return by 7:45.) But he tells me the teacher took it well. He says to me: "I said I don't have anyone at home.  My brother is at sixth grade camp as a counselor; my dad is in Puerto Rico-the teacher said "Really??"; and I don't know where my mom is...teaching I think".  

For the record: he does not know where his mom is but not because his mom did not tell him.

I feel a (small but real) pang of guilt: "I'm surprised the teacher has not called to find out why you are being abandoned."  He retorts: "Not abandoned. Everyone is out helping people."

Me, still guilty: "Helping people but nobody as precious and lovable as you."

Him, exhibiting an advanced mature defense mechanism (sublimation if you want to know) for his age: "Well, those people are JUST as precious and lovable to someone I'm sure".

Him: A+; Me: I don't know. B-? C+?

Till Later,

Anne

Five Things Child and Adolescent Psychiatrists Should Know about Caring for Trans and Gender Non-Conforming Youth

In just the last five years, public knowledge of transgender issues has expanded significantly. Even though celebrities like Laverne Cox and Caitlyn Jenner have graced magazine covers, and the stars of Transparent have collected Emmys, there are still struggles for recognition and acceptance, particularly among trans and gender-non-conforming (GNC) youth.

Ohio teen Leelah Alcorn’s suicide garnered international attention after it became clear that stigma and mistreatment related to her gender identity was a major factor in her depression and ultimate death. Indeed, trans and GNC youth are at dramatically increased risk of numerous adverse mental and physical health outcomes, from self-injury and eating disorders to substance abuse, STIs and attempted suicide. All of these negative outcomes are associated with exposure to discrimination and victimization based on gender expression. Stigma is a pathogen, and it’s as deadly as any virus or bacterium.

There is good news, however: many of these adverse outcomes can be prevented when trans and GNC youth are supported by their families, schools and communities. That’s where CAPs—always on the front lines, championing children’s health—have the chance to make a major impact. Yet it can feel confusing or overwhelming to incorporate all this new information into practice, even with the very best of intentions.  Following are five simple ideas that hopefully will demystify working with trans and GNC youth:

1. Gender and sex are not the same. And gender identity and sexual orientationaren’t the same thing either. This trips up many astute clinicians, as the two terms often are used interchangeably in common clinical parlance. Remember:

·         Sex is a biological identifier assigned at birth when the baby emerges and the doctor sees either male or female genitalia (it’s actually not even this simple, as someone can be born with female external genitalia yet possess an X and Y chromosome, as in cases of androgen insensitivity syndrome or 5-alpha reductase deficiency, but you get the idea).

·         Gender isn’t dependent on genitalia or chromosomes, but rather on how an individual identifies socially, his/her/their sense of role—man or woman as opposed to male or female.

Le Chevalier D'eon who was born male
in 1728, had an adventurous and courageous
destiny and lived as a female in their last 33 years

2. Gender doesn’t just refer to male or female. Gender binary refers to the common separation of the world into the two buckets of boy and girl. But here are a number of terms in common use, from the simple ‘non-binary’ to more complicated terms like ‘gender fluid’ and ‘neutrois.’ As with most descriptors in psychiatry, it’s useful to ask patients how they identify, and what they mean by the words they use to describe their gender.  

3. Names and pronouns are a big deal. If you’re uncertain which pronoun someone uses, consider using the following script (common already in many high schools and colleges): “You can call me Dr. ___, and I use she/her pronouns. What about you?” Then make sure that your office staff are aware, too. Using the wrong pronoun or name, known as “misgendering” and “deadnaming” respectively, can be incredibly hurtful. When you make a mistake (which you will), apologize, move on and do better.

·         Pro-tip: Yes, some trans and GNC people don’t feel the need for surgery or hormones, and they are still absolutely trans. Actually, “they” as a singular pronoun is not only acceptable, it was declared ‘Word of the Year’ by the American Dialect Society in 2015 for the very reason that it is acceptable and preferred to a pronoun that doesn’t fit.

4. Simple steps to be welcoming make a big difference. This can be as minor as placing “gender” on forms followed by a blank rather than requiring patients to circle “M” or “F.” You also can include preferred names/nicknames in many electronic health records so office staff know the right name/pronoun to use (especially useful when insurance cards and medical records are required to be kept in the patient’s legal name). Train your staff to be sensitive to LGBTQIA+issues. Put some issues of OUT, Teen Vogue and Curve in your waiting room—bonus points if you read a few articles yourself!  

5. Don’t try to change it. Therapy to change a person’s sexual orientation or gender identity is not just ineffective, it is damaging. So-called “conversion therapy” or “reparative therapy” is opposed by numerous professional organizations. By the time patients make their way to you, they’ve already been exposed to discrimination or worse. Go beyond the neutral stance and explicitly celebrate your patients’ identities. Better outcomes are linked directly to willingness to engage in medical and behavioral treatment. The more we can build trust with support, the safer and happier our patients will be.

Labeling and Feeling the Sunken Places

Jimmy and Lauren, WashU med students
at the WashU law school "Get Out"
screening and Discussion event
September 14, 2017

I'm a little flattered when my San Francisco airport to hotel Lyft driver, E..., looks at me in his inner rear mirror and categorically states that I look much too young for having had "nazi hunter" as my first professional aspiration.
I explain there were definitely original nazis when I was 10 and learning german (language skills being clearly essential for the job I wanted, though not for the reasons I intuited then---another story.)


I also explain that I ended up recycling much of my autodidact curriculum into my current and long term occupation: in particular the thirst to understand human behavior; the language skills not so much but the communication skills, yes.

What I don't quite tell him is that the obsession I had with understanding humanity and its less humane characteristics was educational but traumatic (with me as teacher and student and progressively more isolated from others in both quest and insights) and led me to a long and protracted sunken place.

I am borrowing that term "sunken place" from the brilliant metaphor by Jordan Peele in the movie "Get Out", which we saw last night at the WashU law school as part of a wonderful new series of events, where movies  are screened and then followed by a community panel/audience discussion and interaction on topics of vital importance.  I had attended such an event with Alba, one of our child psych fellows then, in the spring around "The Talk" from PBS. This film documents the harrowing conversations that American black parents have with their kids, particularly their sons, every day, in an effort to shield them from the fate of Anthony Lamar Smith and so many others, killed by cops because.... they were black.

 Am mentioning Mr. Smith by name because the cop who shot him was acquitted today.

The sunken place is my worst personal nightmare among a few: a place of no power, of paralysis, of broken spirit, body and mind. It is an apt metaphor for the depression I treat in others. It is a state I have visited and fear because, like in space travel, time in the sunken place obeys different rules and one could get trapped in there and not realize how much time is passing by.

Imagine then the power of Marva Robinson's words yesterday. One of the panelists, she is a practicing clinician with clear expertise in trauma and a former president of the Association of Black Psychologists.  I asked for comments on the sunken place and she volunteered that for her, it meant the place that any child of our community who is feeling topsy-turvy and insecure because of community events (such as the Ferguson events we St. Louisians are familiar with, though affected by them to profoundly different degrees depending on whether we are black or white.) So imagine a black child (I'm paraphrasing) who is going to school, in an environment where there will be typically no significant debriefing/discussion of community events. Her world is imploding and it's a non issue for others, who are going about their business.

This is a type of pain I think about a lot as a psychiatrist: similar to the plight of generation after generation of soldiers who finally emerge from the hell of the battle field and find an even greater hell: the sunken place hell of others being completely unaware of what they have been going through and are reeling from. This is described brilliantly in Pat Barker's regeneration trilogy.

Yes, and this is profoundly true: probably as or more damaging than trauma is the non acknowledgement or non response to it.  That creates isolation, disconnection, and leads to the sunken place.

Please, please, please heed that. I'm trying to.

Till Later,

Anne