Norman Spack: How I help transgender teens become who they want to be

翻译人员: Yuanqing Edberg 校对人员: Rong Han

I want you all to think

我要你们都想想

about the third word that was ever said about you --

别人说到你的时候

说的第三个字。

or, if you were delivering,

或者如果你正在生孩子，

about the person you were delivering.

就是说到这个孩子时的第三个字。

And you can all mouth it if you want or say it out loud.

你可以不出声地说，

也可以大声地说出来。

It was -- the first two were, "It's a ..."

头两个字是：“是。。。个。。。”

Audience: (Mixed reply) Girl. Boy.

(Laughter)

Well, it shows you that --

你看，

I also deal with issues where there's not certainty

我处理的病例中还有

不能确定是男孩还是女孩的情况，

of whether it's a girl or a boy,

so the mixed answer was very appropriate.

所以说刚才混合型的答案是很合适的。

Of course, now the answer often comes not at birth but at the ultrasound,

是在做超声波而不是 出生的时候就揭晓了，

unless the prospective parents choose to be surprised,

除非准父母们选择

和我们那会儿一样等待一个惊喜。

like we all were.

But I want you to think about what it is that leads to that statement

不过我希望你们想一想

是什么决定刚才那句话里

on the third word,

第三个字是什么。

because the third word

因为第三个字

is a description of your sex.

描述的是你的性征，

我的意思是

And by that I mean,

made by a description of your genitals.

实际上描述的是你的外生殖器。

Now, as a pediatric endocrinologist,

作为一个儿童内分泌专家，

I used to be very, very involved and still somewhat am, in cases

我曾经治过的很多病人，

现在有时我也治一些这类病人，

是那些

in which there are mismatches in the externals

外部结构之间不一致，

or between the externals and the internals,

或着外部和内部器官不符的孩子，

and we literally have to figure out

这种情况下我们真的得研究一下

what is the description of your sex.

你的性征是什么。

But there is nothing that is definable at the time of birth

that would define you.

这里定义我指的，

And when I talk about definition,

I'm talking about your sexual orientation.

是你的性取向。

We don't say, "It's a ... gay boy!"

我们不说，“这是一个同性恋男孩。”

"A lesbian girl!"

“同性恋女孩。”

Those situations don't really define themselves

这些情况

more until the second decade of life.

要到十几岁才能显现出来。

Nor do they define your gender,

出生时也无法定义你的性别，

which, as different from your anatomic sex,

和你的身体性征不同的是，

describes your self-concept:

这里我指的是你的自我概念。

Do you see yourself as a male or female,

看作是男还是女，

or somewhere in the spectrum in between?

还是有点介于两者之间?

That sometimes shows up

这些有时候会在

in the first decade of life,

十岁以前显现出来。

but it can be very confusing for parents,

但是做父母的会难以确定，

because it is quite normative for children

儿童们也会表现出跨性别的行为。

to act in a cross-gender play and way,

and, in fact, there are studies that show

实际上有些研究显示，

that even 80 percent of children who act in that fashion

百分之八十

有这种行为表现的儿童

will not persist in wanting to be the opposite gender

到青春期开始的时候，

不会坚持想要变成另一性别。

at the time when puberty begins.

But, at the time that puberty begins --

但当他们青春期开始的时候，

that means between about age 10 to 12 in girls, 12 to 14 in boys --

也就是女孩在10到12岁之间

男孩在12岁到14岁之间，

with breast budding,

胸部开始隆起

or two to three times' increase in the gonads

或者男性的话， 性腺增大了两到三倍的时候，

in the case of genetic males,

by that particular point,

到这个时候，如果一个孩子说

the child who says they are in the absolute wrong body

自己是生在一个错误的身体里，

is almost certain to be transgender

那就几乎可以肯定是个变性人了。

and is extremely unlikely to change those feelings,

而且他们几乎没有可能改变这种感觉，

no matter how anybody tries reparative therapy

不管别人如何试图治疗他们，

or any other noxious things.

或者采用其他不善的手段。

Now, this is relatively rare,

so I had relatively little personal experience with this.

所以我个人在这方面的经验不多。

And my experience was more typical,

我的经验比较典型，

only because I had an adolescent practice.

仅仅是因为我给青少年看病。

And I saw someone age 24,

一个病人24岁，

genetically female, went through Harvard with three male roommates

遗传上来说是女性，

跟三个男室友一同上完哈佛，

who knew the whole story,

他们完全清楚是怎么回事。

a registrar who always listed his name on course lists as a male name,

注册时在课表上

他总是填上一个男性的名字。

毕业后他来找我，说，“帮帮我，

and came to me after graduating,

saying, "Help me. I know you know a lot of endocrinology."

我知道内分泌学你很在行。”

的确我治疗过很多

And indeed, I've treated a lot of people who were born without gonads.

天生没有性腺的人。

This wasn't rocket science.

这又不是什么火箭科学。

But I made a deal with him:

但我跟他达成了一个协议：

"I'll treat you if you teach me."

我可以给你治疗，但你要教我。

And so he did.

他教了我。

我真是接受了一场非同一般的教育，

And what an education I got

from taking care of all the members of his support group.

就是通过治疗他的支持小组里的成员

And then I got really confused,

但是然后我又有些糊涂了

我原以为治疗那么年轻的人 应该比较容易，

because I thought it was relatively easy at that age

to just give people the hormones

只需要给他们使用

of the gender in which they were affirming.

他们自己确认的性别的激素就可以了。

But then my patient married,

但是后来我的病人结婚了，

and he married a woman who had been born as a male,

他娶的这位女士，

出生的时候是个男的，

had married as a male, had two children,

作为男人结过婚，有两个孩子，

then went through a transition into female.

然后变成了女的。

And now this delightful female

现在这位可爱的女士，

was attached to my male patient -- in fact, got legally married,

跟我的男性病人在一起，

事实上他们已经合法结婚了，

because they showed up as a man and a woman, and who knew, right?

因为他们是一男一女。谁知道呢？

对吧？（笑声）

(Laughter)

And I was confused --

我糊涂的是，

"Does this make so-and-so gay?

这样谁和谁是不是同性恋了呢？

Does this make so-and-so straight?"

还是异性恋呢？

I was getting sexual orientation confused with gender identity.

我把性取向

跟性别认同混淆了。

And my patient said to me,

我的病人跟我说，

"Look, look, look.

“看，

If you just think of the following, you'll get it right:

只要这么想就不会错了：

Sexual orientation is who you go to bed with.

性取向是你和男的还是女的上床，

而性别认同是你作为 男的还是女的上床。“

Gender identity is who you go to bed as."

(Laughter)

And I subsequently learned from the many adults --

我随后从很多成年人那里得知－－

I took care of about 200 adults --

我看过大约200个成年人--

我从他们那里得知

I learned from them

that if I didn't peek as to who their partner was in the waiting room,

如果我不看，不偷偷地瞧一下

侯诊室里他们的伴侣是谁，

I would never be able to guess better than chance,

我永远也不可能猜出，

至少不可能比随机猜测更可靠地知道，

whether they were gay, straight, bi or asexual

他们在自己确认的性别中是

同性恋，异性恋，双性恋， 还是无性恋。

in their affirmed gender.

In other words,

换句话说，

one thing has absolutely nothing to do with the other.

这两件事完全没有任何关系。

And the data show it.

研究数据也证明这一点。

我治疗这200个成年人时，

Now, as I took care of the 200 adults,

I found it extremely painful.

发现这是一件非常痛苦的事。

These people -- many of them --

这些人，他们中很多人，

had to give up so much of their lives.

不得不放弃生活中的很大一部分。

有时候他们被父母，

Sometimes their parents would reject them,

siblings, their own children,

兄弟姐妹，或者亲生的子女所拒绝，

and then their divorcing spouse

还有他们闹离婚的配偶

would forbid them from seeing their children.

会禁止他们去探望自己的孩子。

It was so awful,

既然这么痛苦，为什么他们

but why did they do it at 40 and 50?

到了四五十岁还要做呢？

Because they felt they had to affirm themselves

因为他们觉得他们必须肯定自己，

不然就只有自杀了。

before they would kill themselves.

And indeed, the rate of suicide among untreated transgendered people

的确，

未接受治疗的变性人的自杀率

is among the highest in the world.

在世界上是最高的。

那么该做什么呢？

So, what to do?

I was intrigued, in going to a conference in Holland,

我去荷兰参加过一个很有意思的会议，

where they are experts in this,

他们那儿是这方面的专家，

我在那里看到了最不同寻常的事情。

and saw the most remarkable thing.

They were treating young adolescents

他们

对青少年进行非常严密的

after giving them the most intense psychometric testing of gender,

关于性别的心理计量测试，然后进行治疗。

and they were treating them by blocking the puberty that they didn't want.

他们治疗的方法是阻止

他们不想要的青春期。

因为小孩子看起来基本一样，

Because basically, kids look about the same,

each sex, until they go through puberty,

不管什么性别， 直到他们经过了青春期。

at which point, if you feel you're in the wrong sex,

那时候如果你觉得自己的性别不对，

you feel like Pinocchio becoming a donkey.

你会觉得就像匹诺曹变成驴子一样。

The fantasy that you had that your body will change

你幻想你的身体发育成

to be who you want it to be, with puberty,

你想要的样子，

actually is nullified by the puberty you get.

可这个幻想却恰恰会因为青春期的发育而破灭。

And they fall apart.

他们会因此而崩溃。

那就是为什么要让青春期暂停。

So that's why putting the puberty on hold -- why on hold?

为什么是暂停呢？因为你不能

You can't just give them the opposite hormones that young.

给那么小的孩子用相反性别的激素，

They'll end up stunted in growth,

那会使他们停止生长。

and you think you can have a meaningful conversation

而且你觉得有可能跟他们说明白

about the fertility effects of such treatment

激素治疗对生育能力的影响吗？

with a 10-year-old girl, a 12-year-old boy?

他们是才10岁的女孩，或12岁的男孩。

So this buys time in the diagnostic process

这样，就可以为诊断过程多争取到

四到五年的时间。

for four or five years,

这样可以更加确定，

so that they can work it out.

They can have more and more testing,

可以做更多的测试，

they can live without feeling their bodies are running away from them.

他们可以不用感觉

自己的身体正背离他们。

And then, in a program they call 12-16-18,

然后，在一个叫做12-16-18的项目中，

around age 12 is when they give the blocking hormones,

12岁时他们接受阻断激素，

and then at age 16, with retesting,

16岁时被重新测试，

they re-qualify to receive --

确认他们符合条件。

请记住，阻断激素是可逆转的，

now remember, the blocking hormones are reversible,

but when you give the hormones of the opposite sex,

但是一旦使用了相反性别的激素，

you now start spouting breasts and facial hair and voice change,

就开始了乳房的发育，胡须的生长，

或声音的变化，取决于你用的是什么了。

depending on what you're using,

那些效果是永久性的，

and those effects are permanent,

or require surgery to remove,

只能通过手术

or electrolysis,

或者是电蚀的方法来去除，

and you can never really affect the voice.

而且你几乎不可能真正改变声音。

所以这在十五六岁时是很重要的。

So this is serious, and this is 15-, 16-year-old stuff.

And then at 18, they're eligible for surgery.

到了十八岁，他们就可以接受手术了。

And while there's no good surgery for females to males genitally,

虽然女性转男性外生殖器方面 还没有什么好的手术疗法，

the male-to-female surgery has fooled gynecologists.

男转女的手术已经可以 瞒过妇科专家了。

That's how good it can be.

可以做到这种程度。

So I looked at how the patients were doing,

我就想看看病人们怎样了，

我发现他们和别人没什么两样，

and I looked at patients who just looked like everybody else,

except they were pubertally delayed.

只是青春期被延迟了。

But once they gave them the hormones

但是一旦给他们用上

consistent with the gender they affirm,

和他们确认的性别相符的激素，

他们看起来那么漂亮。

they look beautiful.

他们看起来完全正常，身高也正常。

They look normal.

They had normal heights.

You would never be able to pick them out in a crowd.

你永远也不可能

在人群里把他们挑出来。

So at that point, I decided I'm going to do this.

于是，我决定我也要这样做。

这是真正需要用到

This is really where the pediatric endocrine realm comes in,

儿童内分泌学的地方，

because, in fact, if you're going to deal with it in kids aged 10 to 14,

因为如果治疗的是

10到12岁，10到14岁的孩子，

that's pediatric endocrinology.

那就是儿童内分泌学的范畴。

So I brought some kids in,

于是我找了些孩子来。

and this now became the standard of care,

现在这些已纳入标准护理方案，

是由儿童医院发起的。

and the [Boston] Children's Hospital was behind it.

By my showing them the kids before and after,

当我给他们看治疗前后的孩子们，

people who never got treated and people who wished to be treated,

从没有接受治疗的人

和那些想要接受治疗的人，

and pictures of the Dutch --

还有一些荷兰人的照片后，

they came to me and said,

他们来对我说，

"You've got to do something for these kids."

“你必须为这些孩子做些什么。”

Well, where were these kids before?

那么， 这些孩子以前在哪里呢？

They were out there suffering, is where they were.

他们就生活在痛苦之中。

So we started a program in 2007.

在2007年我们开展了一个项目

它是第一个这类的项目，

It became the first program of its kind --

but it's really of the Dutch kind --

不过它实际上就是荷兰的项目

in North America.

搬到北美来。

And since then, we have 160 patients.

从那以后，我们有了160个病人。

Did they come from Afghanistan? No.

他们来自阿富汗吗？不是。

75 percent of them came from within 150 miles of Boston.

百分之七十五的人来自

波士顿周围150英哩（约240公里） 以内的地方。

And some came from England.

有些来自英国。

Jackie had been abused in the Midlands, in England.

杰姬在英国的米德兰被虐待过。

12岁的时候，

She's 12 years old there,

她像个女孩一样地生活，

she was living as a girl,

but she was being beaten up.

但是因此而被打。

It was a horror show, they had to homeschool her.

非常可怕。

他们只能在家里教她读书。

And the reason the British were coming

而英国人来这儿是因为

was because they would not treat anybody with anything under age 16,

他们不给任何

16岁以下的孩子们任何治疗。

which means they were consigning them to an adult body

这意味着他们被迫接受 他们不想要的成人身体，

no matter what happened,

不管发生了什么，

even if they tested them well.

也不管他们是不是做了很好的检查。

对杰姬来说，除此之外，

Jackie, on top of it, was, by virtue of skeletal markings,

按照骨骼标记，

destined to be six feet five.

她是注定要长到六呎五吋 （约1米95）的。

而且，她刚刚开始了

And yet, she had just begun a male puberty.

男性的青春期。

Well, I did something a little bit innovative,

我做了一点儿创新，

because I do know hormones,

因为我我确实对激素知道得比较多，

and that estrogen is much more potent

雌激素

in closing epiphyses, the growth plates,

对于关闭骨骼生长节，

and stopping growth, than testosterone is.

抑制生长比雄激素更有效。

So we blocked her testosterone with a blocking hormone,

所以我们

用了一种阻断激素来抑制她的雄激素，

but we added estrogen, not at 16, but at 13.

但我们在她13岁，而不是16岁时 就加上了雌激素。

And so here she is at 16, on the left.

这是左边是她，16岁。

And on her 16th birthday, she went to Thailand,

她16岁生日的时候去了泰国，

where they would do a genital plastic surgery.

做了外生殖器整形手术。

They will do it at 18 now.

他们现在只给18岁的人做了。

And she ended up 5'11".

她最后长到5呎11吋（约1米80）高。

But more than that, she has normal breast size,

但是另外，她胸部发育得大小正常。

because by blocking testosterone,

因为阻断了雄激素，

every one of our patients has normal breast size

我们的每一个病人

胸部大小都正常，

if they get to us at the appropriate age,

前提是他们在合适的年龄来找我们， 而不是太晚。

not too late.

最右边的是她。

And on the far right, there she is.

She went public -- semifinalist in the Miss England competition.

她公开了自己的身份，

进入了英国小姐竞赛的半决赛。

裁判们就能不能这么做起了争议。

The judges debated as to, can they do this?

And one of them quipped, I'm told,

可以选她吗？

我听说其中的一位打趣说，

"But she has more natural self than half the other contestants."

“但是她比很多其他的选手

更具有自然美。“

(Laughter)

（笑声）

And some of them have been rearranged a little bit,

虽然某些部分重新安排了一下，

but it's all her DNA.

但还都是她的DNA。

And she's become a remarkable spokeswoman.

她现在是一个了不起的发言人。

有人请她签约做模特儿，

And she was offered contracts as a model,

她就这事跟我开玩笑说：

at which point she teased me, when she said,

“如果你让我长到6呎1吋 （约1米85），

"You know, I might have had a better chance as a model

可能更有助于我的模特生涯。“

if you'd made me six feet one."

(Laughter)

（笑声）

Go figure.

So this picture, I think, says it all.

那么这张照片，我认为，说明了一切。

It really says it all.

真的。

These are Nicole and brother Jonas,

这是妮可和她兄弟琼那斯。

identical twin boys,

同卵的孪生兄弟，

and proven to be identical.

而且经过证明是同卵的。

妮可认定自己是女孩，

Nicole had affirmed herself as a girl as early as age three.

是早在她三岁的时候。

At age seven, they changed her name,

7岁时，他们为她改了名字，

而且在她刚刚开始男性青春期的时候

and came to me at the very beginnings of a male puberty.

就来找我了。

Now you can imagine looking at Jonas at only 14,

看看琼那斯14岁的样子，

that male puberty is early in this family,

他们家男性青春期开始得比较早，

because he looks more like a 16-year-old.

因为他看起来好像16岁。

这就更说明

But it makes the point all the more,

of why you have to be conscious of where the patient is.

为什么你需要意识到

你的病人处在什么阶段。

Nicole is on pubertal blockade in here,

妮可接受了青春期阻断，

and Jonas is just going -- biologic control.

而琼那斯正在经过青春期－ 这是最好的生物学对照。

This is what Nicole would look like

妮可本来会长成这样子，

if we weren't doing what we were doing.

如果我们没给她用药的话。

He's got a prominent Adam's apple.

他已经有一个明显的喉结

He's got angular bones to the face, a mustache,

面部的骨骼出现了棱角，还长了胡子。

还可以看到他们的身高也不一样，

and you can see there's a height difference,

因为他经过了一段快速生长期，

because he's gone through a growth spurt that she won't get.

而她不会有这段时期了。

现在妮可在用雌激素，

Now Nicole is on estrogen.

She has a bit of a form to her.

她已经开始发育出女性的形体。

This family went to the White House last spring,

他们一家去年春季去了白宫

because of their work in overturning an anti-discrimination --

因为他们在

逆转一条歧视法律中的贡献。

there was a bill that would block

缅因州有一个法案

the right of transgender people in Maine to use public bathrooms,

要禁止变性人

使用公共卫生间。

and it looked like the bill was going to pass,

看起来那个法案要通过了，

and that would have been a problem,

那就会很成问题。

but Nicole went personally to every legislator in Maine

但妮可在缅因访问了每一位立法人。

and said, "I can do this.

她说，“我能做到的。

If they see me, they'll understand

如果他们看到我，他们会明白

why I'm no threat in the ladies' room,

为什么我在女卫生间不构成什么威胁，

but I can be threatened in the men's room."

而我在男卫生间会受到威胁。“

And then they finally got it.

他们最终理解了。

现在我们还要做什么呢？

So where do we go from here?

Well, we still have a ways to go in terms of anti-discrimination.

在反歧视方面

我们还有很长一段路要走。

There are only 17 states that have an anti-discrimination law

现在只有17个州有

反歧视法律，

against discrimination in housing,

禁止在房屋居住

employment, public accommodation --

就业，公共场合歧视变性人。

only 17 states, and five of them are in New England.

只有17个州，其中五个是在新英格兰地区。

We need less expensive drugs.

我们需要便宜一些的药物，

They cost a fortune.

现在这些药非常昂贵。

而且我们要把这类病

And we need to get this condition out of the DSM.

从DSM（《精神疾病诊断与统计手册》）里排除。

It is as much a psychiatric disease as being gay and lesbian,

它如果是精神疾病，

那同性恋也是了，

and that went out the window in 1973,

可是1973年同性恋就不再被认为是了，

and the whole world changed.

随之全世界都改变了。

And this isn't going to break anybody's budget.

这不会导致任何人入不敷出；

因为这种情况并不常见。

This is not that common.

But the risks of not doing anything for them

但是如果我们什么也不做，

不仅是让他们都处于

not only puts all of them at risk of losing their lives to suicide,

自杀而失去生命的危险之中，

but it also says something about whether we are a truly inclusive society.

而且也让人怀疑

我们是否是一个真正包容的社会。

Thank you.

谢谢。

(Applause)

（掌声）