Dr. Jack Krasuski: Dear colleague, welcome. It’s Dr. Jack this morning with Dr. Alma Spaniardi. Dr. Spaniardi just gave her talk on LGBTQ issues. Thank you so much for joining us.

Dr. Alma Spaniardi: My pleasure.

Dr. Jack Krasuski: One of the messages that you repeatedly brought up that I found very important was as clinicians that we want to make sure we pause and as we’re evaluating the kids and the teens, we’re dealing with some of these issues, that we don’t feel rushed into make some decisions, especially with gender affirming surgery and things like that. Let me put it this way. Sometimes come in and feel this real sense of emergency, like something needs to be done immediately. I think that sense of urgency can certainly transfer over us as clinicians. Our job is to do the job right and not quickly. Could you speak more to this point?

Dr. Alma Spaniardi: Absolutely. Everything should be done in a thoughtful way. I think that there is a sense of urgency because puberty is right around the corner, so these kids who want to be the opposite gender, there’s the chance their body is going to change and it’s almost like a runaway train. To know that there is a way of putting a pause button on so that you can essentially pause puberty but it’s not going to make any changes lifelong, then you have more time to explore with the family and the child exactly where things are going so that all the decisions are informed and you’ve really thought about them.

Then the decision is what puberty do you go through? You can pull off the blockers and then go through that natal puberty or decide to use hormones. It gives you a little bit more time so you don’t have to feel pressured because there is that puberty is looming and that is I think what the parents are feeling, but if you know the options then you say, let’s take a step back, let me have some time.

I think as a clinician that’s important because then we don’t feel pressured. We know we have some time. We have time to explore. We have time to think about things. We do have the technology for that.

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Guiding Patients Through Assessment and Therapy Across Time

Dr. Jack Krasuski: How do you guide the patient who’s facing these issues directly in their lives as well as the family who’s facing these issues in their child. How do you help them use this time? We’re perhaps buying some time in order to come to the right approach, but how do you guide them to what would be the right approach? How do you help them come to that clarity?

Dr. Alma Spaniardi: Of course, you’re looking for a primary psychiatric disorder first and foremost to make sure that you’re treating everything so that the child feels well enough to actually make decisions. That is one of the concerns. The rest of it is really just therapy looking at identity. Who am I? What am I? What do I want to be? What do I see for my future? Exploring those issues. What does it mean to be a man? What does it mean to be a woman? It’s more than just wearing a dress, wearing pants. There is a lot of thought in terms of what does the future look like. Fertility is very important for these young people, maybe something that they can’t even understand, using a teenage brain.

The hormones do affect the fertility going forward so it’s really important that they understand, and there are options to bank sperm and eggs, but then they have to go through the natal puberty. All of those options, to lay them out so they understand what they are. The same with the family. The family needs time. The child is understanding their identity. The family also needs time to understand what’s going on. They might be losing a son, losing all the hopes and dreams they had for that son, and have to understand now I have a daughter and it’s still the same person. All of that therapeutic work, which is very interesting, but takes time.

Helping Family Navigate Concerns, Culture and Child Safety

Dr. Jack Krasuski: Could you say a little bit more about how you help the family navigate? Because as you mentioned, you work with families who are very, very progressive and maybe even immediately accepting of this change, of this transition of this new identity, or what may be a new identity to them. Perhaps they’ve known or suspected it before. But on the other end you have families who are very, very rejecting. It just does not, either culturally or religiously, seem at all acceptable to them. You talk about meeting everyone where they are and starting from there. How do you help the families navigate to develop really acceptance of their child’s new identity but also their own new family identity? If one member of the family changes in that way, it changes the entire family’s identity. What could you tell us? How do you help families navigate?

Dr. Alma Spaniardi: Understanding misconceptions, understanding what their concerns are. I think safety is really the thing that is the most important to most families. My child is going to be unsafe in the world. I want to keep my child safe. This is going to put them in an unsafe situation.

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Dr. Jack Krasuski: Are you referring to the much higher rates of bullying and even violence against LBGTQ?

Dr. Alma Spaniardi: Bullying and violence and my child isn’t going to be accepted. They’re going to have a hard life. I don’t want that. I feel like that’s where the fear and the concern comes from, so I address those and also even just with the social transition, how can you prepare the family for the questions that are going to happen so they can explore and know what to answer, so that they know some of the things that might happen.

Dr. Jack Krasuski: By social transition, you mean changes in one’s clothes or hairstyles?

Dr. Alma Spaniardi: Exactly. Even that which is totally reversible, there are going to be questions from family. How do you approach family with that? Extended family? How do you explain it to the neighbors? The little things like that, but I feel like the overarching real concern is my child isn’t going to be safe in the world, and I want to keep my child safe. So to work with the family in that way and then also to shift their . . . when you have a child you think about their future and you plan in your head, as a parent, what the future is going to look like to help them shift over to something that’s different.  Which most parents have to do anyway because we have expectations for our children and then they live their own life.

That’s something that is happening regardless, but this is a little bit more extreme maybe so the family needs help with that. Then time, just like the child needs time to explore, the family needs time to explore. How is the family going to work now? They can do well, these families.

Dr. Jack Krasuski: I like the point you make of some of this coming to terms for let’s say the family so that they could be supportive of their child. It’s a sense of an internal change of identity as a family, but also it sounds like they need some guidance in navigating, kind of like the micro skills of like, well, how do I tell if I’m, let’s say the mom or the dad, how do I tell my siblings? How do we tell the grandparents? It’s not only a change in their mindset but it’s also then facing Iike, I’m going to have a series of conversations where I’m going to have to anticipate, what do we do when we get together as a family for Thanksgiving? How do we prepare the rest of the family so that they’re not going to be perhaps very rejecting of my child? There are different levels that they need help really to come to terms with and to know how to deal with in a very concrete way too.

Dr. Alma Spaniardi: Yes. And also, how can I support my child and that they know I’m supporting them? Because that’s really important for the child to be well. If the family is rejecting, how do we navigate that and how do I support my child and they feel supported by me? That’s very important also. There are groups. There are a lot of support systems outside of just the therapist or the psychiatrist as well that you can hook families up with so that there is a lot of support and a lot of information that they’re getting that is good information.

Finding Dependable, Accurate Information on Youth LGTBQ

Dr. Jack Krasuski: Right. And you mention it is hard to get good information because these issues have taken on, especially with transgenderism, they have been politicized. It sometimes becomes more about one’s political position rather than focusing on the individual. My touchstone is always I have a fiduciary duty to my patient and not to society as a whole, or indirectly to the parents, but my duty is to the patient and I need to work to make it right in the best way so that my patient can flourish. That’s my approach. But for people navigating through the information landscape that we have now, I think the more time some people may spend actually the more confused they might become. What are the particular sources that you would recommend that you find would be the most helpful, accurate and helpful for families at they’re looking into this?

Dr. Alma Spaniardi: For clinicians it’s definitely the W path.

Dr. Jack Krasuski: The W guide, yes.

Dr. Alma Spaniardi: But on that website is a lot of good resources, and there are community resources within geographic areas but also, I have at the end of my lecture some important sites for support and information, good information, because there is a lot of bad information on the internet as well, and it seems like people today, families, parents, and kids are all going on the internet to find information and that can be dangerous.

Dr. Jack Krasuski: The kids are probably two different places than the parents.

Dr. Alma Spaniardi: Absolutely, absolutely. Yea.

Dr. Jack Krasuski: Okay. Well, Dr. Spaniardi, thank you so much for joining us. I really appreciate you being here.

Dr. Alma Spaniardi: My pleasure.

Dr. Jack Krasuski: Thank you.

Dr. Alma Spaniardi: Thank you.