·1· · · · ·IN THE UNITED STATES DISTRICT COURT

·2· · · · · FOR THE SOUTHERN DISTRICT OF OHIO

·3· · · · · · · · · · · ·*· * *

·4· ·STACIE RAY, et al.,

·5· · · · · Plaintiffs,

·6· · · · VS· · · · · · · · · · · · · · · Case No.

· · · · · · · · · · · · · · · · · · · ·2:18-CV-00272

·7· ·AMY ACTON, et al.,

·8· · · · · Defendants.

·9· · · · · · · · · · · ·*· * *

10· · · · · · · ·Deposition of QUENTIN L. VAN METER,

11· ·M.D., Witness herein, called by the Plaintiffs

12· ·for examination pursuant to the Rules of Civil

13· ·Procedure, taken before me, Donald Correll, a

14· ·Notary Public in and for the State of Ohio, at

15· ·the ACLU of Ohio offices, 1108 City Park

16· ·Avenue, Suite 203, Columbus, Ohio, Suite 203,

17· ·Columbus, Ohio, on Friday, the 27th day of

18· ·September 2019, at 9:00 a.m.

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·1· · · ·EXAMINATION CONDUCTED· · · · · · · PAGE

·2· ·BY MS. INGELHART:· ·................· · · 7

·3· ·BY MR. BLAKE:· · · ·................· · 297

·4

·5· · · · · · · ·EXHIBITS MARKED

·6· ·(Thereupon, Plaintiffs' Exhibit 1, Ensuring

·7· ·Comprehensive Care and Support for

·8· ·Transgender and Gender-Diverse Children and

·9· ·Adolescents, was marked for purposes of

10· ·identification.)· ....................· ·67

11· ·(Thereupon, Plaintiffs' Exhibit 2,

12· ·Statement on gender-affirmative approach to

13· ·care from the pediatric endocrine society

14· ·special interest group on transgender

15· ·health, was marked for purposes of

16· ·identification.)· ....................· 144

17· ·(Thereupon, Plaintiffs' Exhibit 3, a

18· ·developmental, biopsychosocial model for

19· ·the Treatment of Children with Gender

20· ·Identity Disorder, was marked

21· ·for purposes of identification.)· ....· 162

22· ·(Thereupon, Plaintiffs' Exhibit 4,

23· ·transgender health, was marked

24· ·for purposes of identification.)· ....· 168

25

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·1· ·(Thereupon, Plaintiffs' Exhibit 5, Pro-Life

·2· ·Pediatric Group Stands Contrary to

·3· ·Established American Academy of Pediatrics,

·4· ·was marked for purposes of

·5· ·identification.)· ....................· 178

·6· ·(Thereupon, Plaintiffs' Exhibit 6, About

·7· ·Us, American College of Pediatrics, was

·8· ·marked for purposes of

·9· ·identification.)· ....................· 182

10· ·(Thereupon, Plaintiffs' Exhibit 7, Gender

11· ·Ideology Harms Children, was marked

12· ·for purposes of identification.)· ....· 189

13· ·(Thereupon, Plaintiffs' Exhibit 8, On the

14· ·Promotion of Homosexuality in the Schools,

15· ·was marked for purposes of

16· ·identification.)· ....................· 197

17· ·(Thereupon, Plaintiffs' Exhibit 9, American

18· ·College of Pediatricians, The Best for

19· ·Children, was marked for purposes of

20· ·identification.)· ....................· 201

21· ·(Thereupon, Plaintiffs' Exhibit 10, letter,

22· ·CV, and rebuttal expert report from Dr.

23· ·Van Meter, was marked for purposes of

24· ·identification.)· ....................· 209

25

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·1· ·(Thereupon, Plaintiffs' Exhibit 11,

·2· ·Certification of Birth of Stacie Marie Ray,

·3· ·was marked for purposes of

·4· ·identification.)· ....................· 213

·5· ·(Thereupon, Plaintiffs' Exhibit 12,

·6· ·Transgender, a state of mind in search of

·7· ·biology by Dr. Van Meter, PowerPoint

·8· ·photos, was marked for purposes of

·9· ·identification.)· ....................· 220

10· ·(Thereupon, Plaintiffs' Exhibit 13,

11· ·Long-Term Follow-Up of Transsexual Persons

12· ·Undergoing Sex Reassignment Surgery:

13· ·Cohort Study in Sweden, was marked for

14· ·purposes of identification.)· ........· 232

15· ·(Thereupon, Plaintiffs' Exhibit 14,

16· ·Consensus statement on management of

17· ·intersex disorders, was marked for purposes

18· ·of identification.)· .................· 248

19· ·(Thereupon, Plaintiffs' Exhibit 15, Global

20· ·Disorders of Sex Development Update since

21· ·2006:· Perceptions, Approach and Care, was

22· ·marked for purposes of

23· ·identification.)· ....................· 248

24

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·1· ·(Thereupon, Plaintiffs' Exhibit 16, Dear

·2· ·ISNA Friends and Supporters, was marked

·3· ·for purposes of identification.)· ....· 250

·4· ·(Thereupon, Plaintiffs' Exhibit 17,

·5· ·Breitbart, Doctors' Political Group Places

·6· ·Gender Ideology Above Biology, was marked

·7· ·for purposes of identification.)· ....· 263

·8· ·(Thereupon, Plaintiffs' Exhibit 18, Gender

·9· ·Identity Issues in Children and

10· ·Adolescents, was marked for purposes of

11· ·identification.)· ....................· 265

12· ·(Thereupon, Plaintiffs' Exhibit 19,

13· ·Breitbart, Judge Finds Father Guilty of

14· ·Family Violence For Not Using Transgender

15· ·Teen's Preferred Pronouns, was marked for

16· ·purposes of identification.)· ........· 281

17· ·(Thereupon, Plaintiffs' Exhibit 20,

18· ·Breitbart, $5.7 Million In TaxPayer Funds

19· ·For Study To Justify Sterilizing Children

20· ·Who Are Gender Confused, was marked for

21· ·purposes of identification.)· ........· 283

22· ·(Thereupon, Plaintiffs' Exhibit 21,

23· ·Emergency Petition For Writ of Mandamus,

24· ·was marked for purposes of

25· ·identification.)· ....................· 285

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·1· ·APPEARANCES:

·2· · · On behalf of Plaintiffs:

·3· · · · · ·Lambda Legal Defense and Education

· · · · · · ·Fund, Inc.

·4

· · · · By:· Kara Ingelhart

·5· · · · · ·Attorney at Law

· · · · · · ·105 West Adams Street

·6· · · · · ·26th Floor

· · · · · · ·Chicago, Illinois 60603

·7· · · · · ·(312)663-4413

· · · · · · ·kingelhart@lambdalegal.org

·8

· · · · · · ·And

·9

· · · · · · ·ACLU of Ohio

10

· · · · By:· Elizabeth Bonham

11· · · · · ·Attorney at Law

· · · · · · ·4506 Chester Avenue

12· · · · · ·Cleveland, Ohio 44103

· · · · · · ·(614)469-3200

13· · · · · ·flevenson@acluohio.com

14· · · On behalf of Defendants:

15· · · · · ·Calfee, Halter & Griswold, LLP

16· · · By:· Jason J. Blake

· · · · · · ·Attorney at Law

17· · · · · ·1200 Huntington Center

· · · · · · ·41 South High Street

18· · · · · ·Columbus, Ohio 43215

· · · · · · ·(614)621-7789

19· · · · · ·jblake@calfee.com

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·1· · · · · · · QUENTIN L. VAN METER, M.D.

·2· ·of lawful age, Witness herein, having been

·3· ·first duly cautioned and sworn, as hereinafter

·4· ·certified, was examined and said as follows:

·5· · · · · · · · · · ·EXAMINATION

·6· ·BY MS. INGELHART:

·7· · · · · ·Q.· ·Good morning.

·8· · · · · ·A.· ·Good morning.

·9· · · · · ·Q.· ·My name is Kara Ingelhart.· I'm a

10· ·staff attorney at Lambda Legal, and I represent

11· ·the plaintiffs.

12· · · · · ·A.· ·Okay.

13· · · · · · · · MS. INGELHART:· If we could go

14· ·around the table.

15· · · · · · · · MS. BONHAM:· Elizabeth Bonham,

16· ·ACLU of Ohio, for the plaintiffs.

17· · · · · · · · THE WITNESS:· Okay.

18· · · · · · · · MR. BLAKE:· Jason Blake, counsel

19· ·for defendant -- well, ODH and others.

20· · · · · · · · THE WITNESS:· Quentin Van Meter,

21· ·pediatric endocrinologist in private practice

22· ·in Atlanta, Georgia.

23· ·BY MS. INGELHART:

24· · · · · ·Q.· ·So you've given expert testimony

25· ·before, right?

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·1· · · · · ·A.· ·I have.

·2· · · · · ·Q.· ·Okay.· But I'm still going to go

·3· ·over some basic rules, just as a refresher.· We

·4· ·need to speak audibly for Don here, so that he

·5· ·can get a clear record.· Inevitably, one of us

·6· ·will nod our head or shake our head to indicate

·7· ·yes or no, but we'll need to then follow up

·8· ·with the actual words.

·9· · · · · · · · I'm going to try very hard not to

10· ·talk over you to allow you all the time you

11· ·need to answer a question, and I'm also going

12· ·to try very hard to make sure that when I ask a

13· ·question it's clear that I'm done when I'm

14· ·done.· If you do answer a question, I'll assume

15· ·that you understood it.

16· · · · · · · · Today's just a regular

17· ·conversation, though you're sworn to testify

18· ·honestly under oath.· Is there any reason that

19· ·you think you couldn't testify truthfully

20· ·today?

21· · · · · ·A.· ·No.

22· · · · · ·Q.· ·Okay.· And lastly, we can take

23· ·breaks at your leisure anytime you need to.

24· · · · · ·A.· ·Okay.· Let me silence my phone, if

25· ·you don't mind.

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·1· · · · · ·Q.· ·Sure.· And the breaks, just so

·2· ·long as there's not a pending question.· So if

·3· ·you need to take a break, let me know, then you

·4· ·can answer the question, and we'll do that. I

·5· ·drink a lot of liquids, so we'll take some

·6· ·breaks.· Efficient breaks.

·7· · · · · · · · Okay.· What areas of expertise are

·8· ·you qualified, in your opinion, to give expert

·9· ·testimony?

10· · · · · ·A.· ·General pediatric medicine and

11· ·pediatric endocrinology.

12· · · · · ·Q.· ·Okay.· How many depositions have

13· ·you given?

14· · · · · ·A.· ·This would be a guess.· About 15.

15· · · · · ·Q.· ·Okay.· And for all 15 was the

16· ·subject matter pediatrics or pediatric

17· ·endocrinology?

18· · · · · ·A.· ·Yes.

19· · · · · ·Q.· ·So have you ever given deposition

20· ·testimony where you were not serving as an

21· ·expert witness?

22· · · · · ·A.· ·Yes.

23· · · · · ·Q.· ·And what was that?

24· · · · · ·A.· ·That was a malpractice case.

25· · · · · ·Q.· ·Okay.· You've never been involved

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·1· ·in litigation as a party; is that correct?

·2· · · · · ·A.· ·I was.

·3· · · · · ·Q.· ·Okay.· Okay.· And that was for the

·4· ·malpractice?

·5· · · · · ·A.· ·Yes.· That was a malpractice case,

·6· ·yes.

·7· · · · · ·Q.· ·Okay.· So for those 14 other

·8· ·depositions, were they related to challenges to

·9· ·laws, like actual statutory law?

10· · · · · ·A.· ·No.

11· · · · · ·Q.· ·Okay.· Regulations or policies?

12· · · · · ·A.· ·A few of them were, but most of

13· ·them had to do with medical expert issues

14· ·related to endocrinology and the practice

15· ·thereof.

16· · · · · ·Q.· ·Okay.· So in those cases about

17· ·pediatric endocrinology, was one party a

18· ·government entity in all of those cases?

19· · · · · ·A.· ·No.

20· · · · · ·Q.· ·Okay.· In some of those cases was

21· ·the government a party?

22· · · · · ·A.· ·I do not believe so.

23· · · · · ·Q.· ·Okay.· So all of the parties in

24· ·all these cases were private, both plaintiffs

25· ·and defendants?

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·1· · · · · ·A.· ·For the medical malpractice cases,

·2· ·but the cases where I've done depositions

·3· ·regarding the subject of transgender health,

·4· ·there were not governed entities involved.

·5· · · · · ·Q.· ·And were you in all those cases an

·6· ·expert for the defense or for the plaintiffs?

·7· · · · · ·A.· ·For the defense.· And I want to

·8· ·restate my prior.· This was one case in

·9· ·Hamilton County, Ohio involving the DEFAS, or

10· ·the equivalent to Child Protective Services.

11· · · · · ·Q.· ·Okay.

12· · · · · ·A.· ·So that's one case.· And there

13· ·were multiple plaintiffs in that case.· One of

14· ·which was a government entity.

15· · · · · ·Q.· ·Okay.· So can you recall what

16· ·these cases were specifically?

17· · · · · ·A.· ·The ones dealing with transgender

18· ·health specifically?

19· · · · · ·Q.· ·Sure.

20· · · · · ·A.· ·Okay.· There were school systems

21· ·it British, Columbia.· There was the DEFAS in

22· ·Ohio, in Hamilton County, Ohio.· Okay.· There

23· ·also was in North Carolina the famous Bathroom

24· ·Bill.· I had to do an affidavit for that.

25· · · · · ·Q.· ·Okay.

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·1· · · · · ·A.· ·So that's three.· Okay.· Just to

·2· ·clarify, now that I go through each one of

·3· ·them, those were the ones that had to do with

·4· ·government entities.

·5· · · · · ·Q.· ·And those were government

·6· ·entities, all three of those?

·7· · · · · ·A.· ·Yes.

·8· · · · · ·Q.· ·Okay.· But those are not the

·9· ·extent of your deposition testimony in the

10· ·space of transgender issues?

11· · · · · ·A.· ·No.

12· · · · · ·Q.· ·What other cases have you given

13· ·deposition testimony in related to transgender

14· ·issues?

15· · · · · ·A.· ·Issues of patient care.

16· · · · · ·Q.· ·Okay.· But what were those cases

17· ·specifically?· Can you recall?

18· · · · · ·A.· ·Let me think.· I'm having

19· ·difficulty recalling each specific case.· Given

20· ·some time I probably can come back and revisit

21· ·that question.

22· · · · · ·Q.· ·Okay.

23· · · · · ·A.· ·But I don't want to give an

24· ·improper answer.

25· · · · · ·Q.· ·Okay.· Perhaps we'll revisit these

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·1· ·questions when we pull out your CV later on.

·2· · · · · ·A.· ·Okay.

·3· · · · · ·Q.· ·About how many times -- oh.

·4· ·Actually, how did you come to be involved, just

·5· ·generally or specifically, if that's more

·6· ·helpful for you to explain, the transgender

·7· ·issues cases?· How did you come to be an expert

·8· ·in those cases?

·9· · · · · ·A.· ·From my fellowship training at

10· ·Johns Hopkins back in 1978 through 1980.

11· ·Transsexual, as it was called then, was part of

12· ·our curriculum in the fellowship.

13· · · · · ·Q.· ·Okay.

14· · · · · ·A.· ·And we had children with disorders

15· ·of sexual differentiation who presented at

16· ·Johns Hopkins, because it was sort of an

17· ·epicenter, if you will, for referral of those

18· ·patients from around the world and clearly from

19· ·the United States.

20· · · · · · · · So we had a lot of patients who

21· ·had issues with ambiguity of genitalia or

22· ·medical conditions where hormones were produced

23· ·early or were overproduced by tumors, and they

24· ·looked at the behavioral aspects of the effects

25· ·of that and issues of their psychological

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·1· ·wellness.· And so that was part of our

·2· ·fellowship.

·3· · · · · ·Q.· ·Okay.

·4· · · · · ·A.· ·So it began then, and it laid

·5· ·quiet for a number of years until the

·6· ·transgender issue sort of began to surface in

·7· ·the United States in the early 1990s.· I had a

·8· ·case, but that was a rarity.· And then in the

·9· ·early 2000s to mid 2000s, the number of

10· ·transgender clinics began to expand

11· ·exponentially, and so there was a lot more.

12· ·There were guidelines produced, and that

13· ·brought everything to the attention and sort of

14· ·woke up the concept.· So then everyone began

15· ·paying attention to it, and those of us who had

16· ·experience prior to that began to speak out.

17· · · · · ·Q.· ·Okay.· So perhaps I wasn't super

18· ·clear.· That's all helpful, and we will

19· ·continue to explore your expertise and

20· ·training.· How did you come to be involved in

21· ·the litigation matters?

22· · · · · ·A.· ·I was asked by people who were

23· ·involved in legal battles to be an expert

24· ·witness.

25· · · · · ·Q.· ·Okay.

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·1· · · · · ·A.· ·And I had actually given a

·2· ·presentation on the subject of transgender

·3· ·medicine and its history, and that sparked

·4· ·people's interest in my world view on the

·5· ·subject.

·6· · · · · ·Q.· ·Okay.· So when people searched for

·7· ·experts, your presence in the community was

·8· ·easily accessible?

·9· · · · · ·A.· ·Yes.

10· · · · · ·Q.· ·Got it.· Okay.· All right.· How

11· ·many times have you given trial testimony?

12· · · · · ·A.· ·I can think of two.

13· · · · · ·Q.· ·Okay.

14· · · · · ·A.· ·One was a case in Springfield,

15· ·Illinois about a malpractice case involving

16· ·maltreatment of a patient.· It had nothing to

17· ·do with transgender.· The other was a murder

18· ·case in California when I was a resident.

19· · · · · ·Q.· ·And was that murder case related

20· ·to transgender issues at all?

21· · · · · ·A.· ·No.

22· · · · · ·Q.· ·Okay.· And how long ago did you

23· ·say those were?

24· · · · · ·A.· ·The murder case was in -- it's an

25· ·approximation -- 1975.· And the malpractice

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·1· ·case in Springfield, Illinois was I believe two

·2· ·years ago.

·3· · · · · ·Q.· ·Okay.· You just stated previously

·4· ·right here that you had given a presentation on

·5· ·transgender issues, and that's how people came

·6· ·to know your position in the community as

·7· ·holding yourself out as an expert of sorts.

·8· ·Can you talk a little bit about what that

·9· ·presentation was?

10· · · · · ·A.· ·It was a presentation in -- I

11· ·believe it was Fort Worth, Texas.· It was a

12· ·presentation for teenagers and their families,

13· ·and it was one of a number of subjects

14· ·presented at that particular forum, and I was

15· ·asked to speak on the history of transgender

16· ·medicine.

17· · · · · ·Q.· ·Okay.· And about when was that?

18· · · · · ·A.· ·And time goes by very fast.· I'm

19· ·going to state, about four years ago.

20· · · · · ·Q.· ·Okay.· And so you said it was a

21· ·conference for teens and families.· Was it a

22· ·kind of a multi-disciplinary conference?· Did

23· ·they invite speakers besides medical doctors to

24· ·come and educate, or was it strictly about

25· ·medicine?

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·1· · · · · ·A.· ·It was not just medicine alone.

·2· ·It was individuals who had undergone issues in

·3· ·their lives that they would wish to speak to

·4· ·the teenagers about to give them personal

·5· ·experience.

·6· · · · · ·Q.· ·Okay.

·7· · · · · ·A.· ·And then there were behavioral

·8· ·health specialists that talked.· There were

·9· ·authors there who spoke on things that they had

10· ·written.· Books that they had written.

11· · · · · ·Q.· ·Okay.· And this was in Fort Worth.

12· ·Do you know who invited you to speak?

13· · · · · ·A.· ·The name of the conference was

14· ·Teens 4 Truth.

15· · · · · ·Q.· ·Okay.· And so Teens 4 Truth, is

16· ·that an organization?

17· · · · · ·A.· ·I don't know.· I think it was just

18· ·the organization of the conference.· I don't

19· ·know that it exists as an entity.

20· · · · · ·Q.· ·Okay.· Teens 4 Truth.· So you know

21· ·the name of the conference, and just an

22· ·individual who held themselves out as a staff

23· ·member for Teens 4 Truth reached out to you?

24· · · · · ·A.· ·Called and said they had heard --

25· ·I can't remember how they heard specifically.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·But they said, could you speak to

·3· ·us on this subject?

·4· · · · · ·Q.· ·Okay.· Did you attend any of the

·5· ·other panels or presentations?

·6· · · · · ·A.· ·I did.

·7· · · · · ·Q.· ·Okay.· So the behavioral health

·8· ·specialists, what were the themes or primary

·9· ·messages that were being conveyed by those

10· ·experts?

11· · · · · ·A.· ·That teens have a lot of things

12· ·that basically weigh on them as they grow up,

13· ·and that the teens and the families need to

14· ·essentially communicate effectively and deal

15· ·with deep-seeded emotional problems and

16· ·depression and anxiety mostly.

17· · · · · ·Q.· ·Okay.

18· · · · · ·A.· ·And that to bury those things or

19· ·not talk about them or have families not

20· ·recognize them brings harm to those

21· ·individuals, and therefore there should be an

22· ·avenue of communication where the families

23· ·recognize the teens feel comfortable enough to

24· ·talk to their parents about these issues.· And

25· ·so that instead of hiding them or burying them,

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·1· ·that they should deal with those, because

·2· ·there's a great deal of suffering and agony

·3· ·that happens as a result of that.

·4· · · · · ·Q.· ·Okay.· Were those behavioral

·5· ·specialists also providing information or

·6· ·speaking on the issues of transgender issues?

·7· · · · · ·A.· ·I think I was the -- I think there

·8· ·was a mention of transgender health by one of

·9· ·the presenters, but most of them were on the

10· ·subjects of anxiety and depression dealing with

11· ·sexuality.

12· · · · · ·Q.· ·Okay.· So what again was the name

13· ·of the conference?· I'm sorry.

14· · · · · ·A.· ·Teens -- No. 4 -- Truth.

15· · · · · ·Q.· ·Oh, okay.· Perhaps if I remind

16· ·you, you may recall.· That's a Baptist

17· ·anti-LGBT conference.· Does that characterize

18· ·it accurately?

19· · · · · ·A.· ·No.

20· · · · · · · · MR. BLAKE:· Objection.

21· ·BY MS. INGELHART:

22· · · · · ·Q.· ·Okay.· But is it a Baptist

23· ·affiliated organization?

24· · · · · · · · MR. BLAKE:· Objection.

25· · · · · · · · THE WITNESS:· I was unaware that

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·1· ·it had any religious affiliation to it.

·2· ·BY MS. INGELHART:

·3· · · · · ·Q.· ·Okay.· Were the topics -- you

·4· ·said, primarily, though, they were about sexual

·5· ·orientation and gender identity, correct?

·6· · · · · · · · MR. BLAKE:· Objection.

·7· · · · · · · · THE WITNESS:· Primarily about

·8· ·depression and anxiety and how it manifests as

·9· ·someone's developing their sexuality.

10· ·BY MS. INGELHART:

11· · · · · ·Q.· ·Okay.· And do you use the term

12· ·developing their sexuality to include the terms

13· ·like sexual orientation and gender identity or

14· ·specifically --

15· · · · · ·A.· ·All of it.· It's all inclusive.

16· · · · · ·Q.· ·Okay.· Were you paid to attend

17· ·that conference?

18· · · · · ·A.· ·My air fare and my lodging was

19· ·taken care of, and the meals were provided.· So

20· ·that was all.

21· · · · · ·Q.· ·Okay.· So there's like no

22· ·honorarium?

23· · · · · ·A.· ·I did not receive an honorarium.

24· · · · · ·Q.· ·And were you reimbursed for those

25· ·payments?

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·1· · · · · ·A.· ·I was reimbursed for the air fare.

·2· ·The lodging was paid for.· It was a conference

·3· ·site, and it was taken care of.

·4· · · · · ·Q.· ·Sure.· Okay.· So there was like an

·5· ·exchange of repayment to you like via a check

·6· ·or something?

·7· · · · · ·A.· ·I can't remember specifically.

·8· · · · · ·Q.· ·Okay.· Okay.· All right.· Have you

·9· ·ever given testimony at a legislative hearing,

10· ·for instance?

11· · · · · ·A.· ·I do not believe I have.

12· · · · · ·Q.· ·Okay.· Have you ever given

13· ·testimony at all in a legislative setting?

14· · · · · ·A.· ·Again, I don't believe I have. I

15· ·mean, in regard to transgender specifically. I

16· ·have given testimony in the Georgia State

17· ·Legislative Committees in hearings for issues

18· ·of general pediatric health.

19· · · · · ·Q.· ·Got it.· I was speaking generally.

20· · · · · ·A.· ·Yeah.· Okay.

21· · · · · ·Q.· ·Thank you.· Thank you for clearing

22· ·that up.

23· · · · · ·A.· ·Yeah.

24· · · · · ·Q.· ·Okay.· And how did you come to

25· ·testify?· Were you a public participant?· Did

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·1· ·you seek to speak at these events?

·2· · · · · ·A.· ·I did.· I was the Chairman of the

·3· ·Legislative Committee of the George Chapter of

·4· ·the American Academy of Pediatrics at the time.

·5· · · · · ·Q.· ·Okay.· So you weren't invited to

·6· ·speak.· You affirmatively decided to go speak

·7· ·at those?

·8· · · · · ·A.· ·Yes.

·9· · · · · ·Q.· ·Got it.· Any other like government

10· ·related speaking engagement type events that

11· ·you can recall you participated in?

12· · · · · ·A.· ·No.

13· · · · · ·Q.· ·Okay.· What about government

14· ·education?· Perhaps an agency, like a health

15· ·agency, asks you to come meet with them to

16· ·discuss your expertise.· Anything ever like

17· ·that?

18· · · · · ·A.· ·I have been asked but unable to

19· ·attend because of time constraints.

20· · · · · ·Q.· ·Okay.· And so none of this sort of

21· ·government related testimony that you provided

22· ·has been about issues related to transgender

23· ·people; is that correct?

24· · · · · ·A.· ·In hearings, yes.· That's correct.

25· · · · · ·Q.· ·Okay.· Okay.· Sorry.· Thank you

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·1· ·for the clarification.· Okay.· How many times

·2· ·have you been disclosed as an expert in

·3· ·litigation?· Do you know?

·4· · · · · ·A.· ·I'd have to guess.

·5· · · · · ·Q.· ·That's fine.

·6· · · · · ·A.· ·Did you say deposed?

·7· · · · · ·Q.· ·Disclosed?

·8· · · · · ·A.· ·Disclosed.· Okay.

·9· · · · · ·Q.· ·Yeah.· Thank you.

10· · · · · ·A.· ·25 times.

11· · · · · ·Q.· ·Okay.· And in all of those, was

12· ·your subject matter expertise related to

13· ·pediatrics or pediatric endocrinology

14· ·specifically?

15· · · · · ·A.· ·Yes.

16· · · · · ·Q.· ·Did any of those cases involve

17· ·trans issues?

18· · · · · ·A.· ·Some of them did.

19· · · · · ·Q.· ·Okay.

20· · · · · ·A.· ·More recently.· The ones more

21· ·recently.

22· · · · · ·Q.· ·Okay.· You said --

23· · · · · · · · MS. INGELHART:· Can you repeat

24· ·back?· How many times has he been disclosed?

25· ·Apologies.

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·1· · · · · · · · THE COURT REPORTER:· 25.

·2· · · · · · · · MS. INGELHART:· Thank you.

·3· ·BY MS. INGELHART:

·4· · · · · ·Q.· ·Okay.· So 25 times, but you've

·5· ·only been deposed about 14 times.· Were you

·6· ·deposed in each of the cases related to trans

·7· ·issues?

·8· · · · · ·A.· ·No.

·9· · · · · ·Q.· ·Okay.· Do you happen to know what

10· ·the underlying issues were in all of those

11· ·matters in which you were disclosed as an

12· ·expert?

13· · · · · · · · MR. BLAKE:· Objection.

14· · · · · · · · THE WITNESS:· I can't remember.

15· ·BY MS. INGELHART:

16· · · · · ·Q.· ·Okay.· Do you recall whether you

17· ·were a witness for plaintiffs or defense across

18· ·those cases?

19· · · · · ·A.· ·Most often, it was for the

20· ·plaintiffs.

21· · · · · ·Q.· ·Okay.

22· · · · · ·A.· ·In the malpractice cases, most

23· ·often those were the plaintiffs.· I think I did

24· ·two malpractice cases where I was for the

25· ·defense.

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·1· · · · · ·Q.· ·Okay.· Have you been on the

·2· ·plaintiff side in the cases where you've been

·3· ·disclosed as an expert where transgender issues

·4· ·are at issue?

·5· · · · · ·A.· ·In one case.

·6· · · · · ·Q.· ·What was that case?

·7· · · · · ·A.· ·That was the Hamilton, Ohio case.

·8· · · · · ·Q.· ·Got it.· Okay.· And then in all of

·9· ·the other cases where you've been disclosed as

10· ·an expert, were you counsel for the defense in

11· ·all but the Hamilton case?

12· · · · · · · · MR. BLAKE:· Objection.

13· ·BY MS. INGELHART:

14· · · · · ·Q.· ·Or not counsel.· I'm sorry.

15· ·Expert for the defense.

16· · · · · ·A.· ·I believe so.

17· · · · · ·Q.· ·Okay.· Thank you.· How many times

18· ·have you executed an expert report?

19· · · · · ·A.· ·Again, this is sheerly a guess,

20· ·because I was not prepared to have all the

21· ·specifics at hand.· So it's coming through

22· ·memory.· I would say a dozen times.

23· · · · · ·Q.· ·Okay.· So you've given expert

24· ·deposition testimony about 14 times but only

25· ·produced reports about a dozen times; is that

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·1· ·right?

·2· · · · · ·A.· ·That doesn't match.· So it would

·3· ·have to be at least 14 times.

·4· · · · · ·Q.· ·Okay.· Okay.· And those reports,

·5· ·were they majority related to trans issues?

·6· · · · · ·A.· ·No.

·7· · · · · ·Q.· ·Okay.· About how many of those

·8· ·were related to trans issues?

·9· · · · · ·A.· ·I'm going to guess about five or

10· ·six.

11· · · · · ·Q.· ·Okay.· And the others were related

12· ·to what?

13· · · · · ·A.· ·Just malpractice.

14· · · · · ·Q.· ·Okay.· All right.· And in the

15· ·cases in which you have executed an expert

16· ·report that was related to trans issues, were

17· ·you an expert for the defense exclusively?

18· · · · · ·A.· ·No.· I was an expert for the

19· ·plaintiff in the Hamilton County case.

20· · · · · ·Q.· ·Okay.· And there was a report in

21· ·that case?

22· · · · · ·A.· ·Yeah.

23· · · · · ·Q.· ·Do you recall what cases you

24· ·executed expert reports for related to trans

25· ·issues?

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·1· · · · · ·A.· ·Okay.· So again I think I've

·2· ·written this down, and I'm going to do this

·3· ·without any papers in front of me.

·4· · · · · ·Q.· ·That's okay.

·5· · · · · ·A.· ·Hamilton County, Ohio case, the

·6· ·North Carolina Bathroom Bill case, two cases in

·7· ·Canada, the case Grimm Versus Gloucester County

·8· ·in Virginia.· I'm blocking on any others at the

·9· ·moment.

10· · · · · ·Q.· ·Okay.· And do you know the

11· ·difference between an expert report and an

12· ·expert declaration, correct?

13· · · · · ·A.· ·I'm sure I do.

14· · · · · ·Q.· ·Okay.· So if I were to ask you

15· ·whether you know how many cases you've executed

16· ·an expert declaration, would you be able to

17· ·speak to that?

18· · · · · ·A.· ·No.

19· · · · · ·Q.· ·Okay.· So down the line we've

20· ·talked about trans issues related to government

21· ·testimony, as well as in litigation.· Have you

22· ·ever in litigation testified or written a

23· ·report regarding intersex or sexuality issues?

24· · · · · ·A.· ·No, I have not.

25· · · · · ·Q.· ·So your expert testimony that has

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·1· ·resulted in deposition testimony or in a report

·2· ·or a declaration has been pretty much

·3· ·exclusively trans related as --

·4· · · · · ·A.· ·To clarify that.· It's impossible

·5· ·to discuss trans issues without bringing in

·6· ·some background knowledge about disorders of

·7· ·sexual differentiation.· So DSTs.· Am I -- is

·8· ·that how you...

·9· · · · · ·Q.· ·That's helpful.

10· · · · · ·A.· ·Okay.· So they are distinct, in

11· ·general.· So in terms of not confusing one with

12· ·the other, it's important, and my reports have

13· ·mentioned specifically disorders of sexual

14· ·differentiation, I believe, in almost every

15· ·trans case.

16· · · · · ·Q.· ·Okay.· And so is the only reason

17· ·intersex issues are included in those reports

18· ·in trans specific type cases about the

19· ·distinction, or is there another reason you --

20· · · · · ·A.· ·It's about the distinction.· It's

21· ·also about clarification of actually what is a

22· ·disorder of sexual differentiation, because it

23· ·tends to be a matter of opinion in some cases

24· ·in terms of the science of DSDs as they are

25· ·recognized by the organization.· The

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·1· ·professional organization.· It's one specific

·2· ·thing, but it has been expanded quite broadly

·3· ·by proponents who say the incidence is as high

·4· ·as maybe one percent or .3 percent of patients

·5· ·across the country -- or humans across the

·6· ·country.· So that's a difference of opinion.

·7· · · · · ·Q.· ·Okay.· But I think that was about

·8· ·intersex issues, and I think you said it's

·9· ·impossible to do testimony about trans issues

10· ·without talking about intersex issues.· Why is

11· ·it impossible?

12· · · · · ·A.· ·Because it's an educational

13· ·process.

14· · · · · ·Q.· ·Okay.

15· · · · · ·A.· ·I mean the purpose of what I'm

16· ·trying to do is provide background in science

17· ·and education, so that people can make a

18· ·reasonable decision.

19· · · · · ·Q.· ·Okay.· But are they related, trans

20· ·issues and intersex issues?

21· · · · · ·A.· ·Very rarely.

22· · · · · ·Q.· ·Okay.· In the case of Schneider V.

23· ·Lujan, you testified in deposition in that

24· ·case, right?

25· · · · · ·A.· ·Remind me specifically where

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·1· ·that -- the name is not --

·2· · · · · ·Q.· ·In Okaloosa County.

·3· · · · · ·A.· ·In Florida.· Yes, I actually -- I

·4· ·was able to write a report.

·5· · · · · ·Q.· ·Okay.· So you didn't give a

·6· ·deposition?

·7· · · · · ·A.· ·I did not.

·8· · · · · ·Q.· ·Okay.· And then about what did you

·9· ·provide testimony in that case?

10· · · · · ·A.· ·Just background information about

11· ·transgender.

12· · · · · ·Q.· ·You provided testimony in the case

13· ·of Kimora Gilmer, correct?

14· · · · · ·A.· ·Correct.

15· · · · · ·Q.· ·What court was that?· Do you

16· ·recall?

17· · · · · ·A.· ·I do not.

18· · · · · ·Q.· ·Okay.· And what did you provide

19· ·testimony about there?

20· · · · · ·A.· ·Again, basic information

21· ·background about transgender issues.

22· · · · · ·Q.· ·Okay.· And in the Grimm case that

23· ·you mentioned, your testimony was about trans

24· ·issues, right?

25· · · · · ·A.· ·It was specifically about the fact

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·1· ·that there was -- it was related to documented

·2· ·science that showed either benefit or lack of

·3· ·benefit or harm based on use of rest rooms.

·4· · · · · ·Q.· ·Okay.

·5· · · · · ·A.· ·That's very specifically focused.

·6· · · · · ·Q.· ·Okay.· Was that similar testimony

·7· ·to what you provided in the Carncano case?

·8· · · · · ·A.· ·Yes.

·9· · · · · ·Q.· ·In North Carolina?

10· · · · · ·A.· ·Yes.

11· · · · · ·Q.· ·Okay.· And did you provide

12· ·deposition testimony in either of those two

13· ·cases?

14· · · · · ·A.· ·No.· Wait a minute.· Let me just

15· ·think back on that.

16· · · · · ·Q.· ·Sure.

17· · · · · ·A.· ·North Carolina, and what was the

18· ·other one?

19· · · · · ·Q.· ·The Gavin Grimm case in the

20· ·Eastern District of Virginia.

21· · · · · ·A.· ·Yeah.· I was deposed for that,

22· ·yes.

23· · · · · ·Q.· ·Okay.· Do you recall the Cooley V

24· ·Paul case?

25· · · · · ·A.· ·The name is not registering.· I'm

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·1· ·sorry.

·2· · · · · ·Q.· ·Okay.· What about Jessica

·3· ·Siefert's case?

·4· · · · · ·A.· ·Yes.

·5· · · · · ·Q.· ·Where was that?

·6· · · · · ·A.· ·Let me think for a minute.· I'm

·7· ·forgetting exactly specifically the

·8· ·jurisdiction.

·9· · · · · ·Q.· ·Do you recall what your testimony

10· ·was about?

11· · · · · ·A.· ·It was about parents -- oh,

12· ·Siefert is Ohio.· That's Hamilton County, Ohio.

13· ·Yes.· Is that -- I'm remembering correctly?

14· · · · · ·Q.· ·It wasn't In Re:· JNS, in Hamilton

15· ·County, Ohio?

16· · · · · ·A.· ·I don't think so.

17· · · · · ·Q.· ·Okay.· All right.· Go ahead.

18· · · · · ·A.· ·I think Siefert is Ohio.

19· · · · · ·Q.· ·Okay.· Can you tell me about what

20· ·your testimony was there?

21· · · · · ·A.· ·It was giving information about

22· ·trans health and the concepts of affirmation

23· ·therapy versus counseling therapy.

24· · · · · ·Q.· ·Okay.· And what do you mean,

25· ·affirmation?

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·1· · · · · ·A.· ·Affirmation is a term that's used

·2· ·to do social transition, medical transition and

·3· ·surgical transition.

·4· · · · · ·Q.· ·Okay.· And then counseling?

·5· · · · · ·A.· ·Counseling was the pathway that

·6· ·Dr. Kenneth Zucker proposed and used for about

·7· ·30 plus years.

·8· · · · · ·Q.· ·Okay.· And what was that?

·9· · · · · ·A.· ·That is basically an in-depth

10· ·psychological evaluation of the patient,

11· ·family, and ongoing counseling of the patient

12· ·to basically discover what's going on in terms

13· ·of their psychological background.

14· · · · · ·Q.· ·Okay.· And so in that case, where

15· ·you discussed the benefits and the science of

16· ·affirmation versus counseling, did you have

17· ·professional conclusions about which was the

18· ·better course of treatment?

19· · · · · ·A.· ·Yes.

20· · · · · ·Q.· ·And what was that?

21· · · · · ·A.· ·Is that the counseling, which is

22· ·referred to as watch and wait, which there's

23· ·nothing just watching and waiting.· It's very

24· ·intense and consistent.· It is that there is

25· ·clear benefit there that those patients that go

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·1· ·through that -- this was a minor, okay, at the

·2· ·time -- have a very high likelihood of

·3· ·resolving their gender incongruence with the

·4· ·benefit of counseling, appropriate counseling,

·5· ·in-depth counseling.· And that if that is the

·6· ·case, affirmation with hormones and social

·7· ·circumstances and then, if chosen, surgery,

·8· ·provide far more complications for that

·9· ·patient's life, and their quality of life that

10· ·is diminished significantly compared to those

11· ·who went through counseling alone.

12· · · · · ·Q.· ·Okay.· And just so I'm clear, is

13· ·the counseling course of treatment ever

14· ·colloquially referred to as conversion therapy?

15· · · · · ·A.· ·It is often mislabeled as

16· ·conversion therapy.· It is, in truth, affirming

17· ·one's sex, if possible.· Most often it's

18· ·focused on the issues of depression and anxiety

19· ·and the childhood adverse events that created

20· ·the background for which set this patient up to

21· ·have a world view that they were born into the

22· ·wrong body.

23· · · · · ·Q.· ·Okay.· And I'm sorry.· In the

24· ·Hamilton County case, that's juvenile court.

25· ·That was an issue of custody?

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·1· · · · · ·A.· ·Custody.

·2· · · · · ·Q.· ·Okay.· And the subject matter you

·3· ·discussed was trans related.· What specifically

·4· ·were your conclusions in that case?

·5· · · · · ·A.· ·That intervention with medical

·6· ·therapy at the time would be inappropriate

·7· ·until the patient was of the age of consent.

·8· · · · · ·Q.· ·Okay.· Okay.· Okay.· In the cases

·9· ·where you say you simply provided background on

10· ·trans issues, what party hired you?

11· · · · · ·A.· ·It was either the family of the

12· ·patient -- most often it was representing the

13· ·family of the patient.· I can't recall

14· ·specifically other entities which, you know,

15· ·compensated me for my time.· It was usually the

16· ·attorneys for the person who was involved.· Or

17· ·if they were being sued, the families and the

18· ·entities asked me for expert opinion.

19· · · · · ·Q.· ·What were the parties' position?

20· ·Why did they need you?

21· · · · · ·A.· ·Because they needed somebody to

22· ·give an opinion that essentially stated that

23· ·the possibility of social affirmation, medical

24· ·affirmation and surgical affirmation was more

25· ·harmful than beneficial.

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·1· · · · · ·Q.· ·Okay.· So just to be clear, they

·2· ·needed somebody to testify that affirmative

·3· ·care treatment for trans folks to affirm the

·4· ·trans identity of somebody was not the correct,

·5· ·in your opinion --

·6· · · · · ·A.· ·That's correct.

·7· · · · · · · · MR. BLAKE:· Objection.

·8· ·BY MS. INGELHART:

·9· · · · · ·Q.· ·Okay.· Thank you for that.

10· ·Without sharing any attorney work product or

11· ·privileged conversations what did you do to

12· ·prepare for today?

13· · · · · ·A.· ·I read the statements that I had

14· ·made.· I read Dr. Ettner's statement, and I

15· ·read Dr. Gordon's rebuttal in my statement.

16· · · · · ·Q.· ·Okay.· So you -- oh, sorry.· Go

17· ·ahead.

18· · · · · ·A.· ·And also there was a judgment I

19· ·think that was recently handed down on the

20· ·order regarding dismissal, and I read through

21· ·that.

22· · · · · ·Q.· ·Okay.· So you read the three

23· ·experts' reports in this case and the recent

24· ·order and opinion?

25· · · · · ·A.· ·Three expert reports.· It was

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·1· ·Gordon and Ettner, the two that I had.

·2· · · · · ·Q.· ·And didn't you say yours?

·3· · · · · ·A.· ·And mine.· Okay.· Yes.

·4· · · · · ·Q.· ·Okay.· You didn't review anything

·5· ·else?

·6· · · · · ·A.· ·There was a mention in Dr.

·7· ·Gordon's rebuttal that one of the references

·8· ·that I used did not support what I had said,

·9· ·and I went back to look at that, and I had to

10· ·agree that the specific statistic that I had

11· ·quoted from that was not in that article.· So I

12· ·must have missed references unwittingly.

13· · · · · ·Q.· ·Okay· So you went out and reviewed

14· ·that publication?

15· · · · · ·A.· ·Yes.

16· · · · · ·Q.· ·Got it.· Okay.· Who first

17· ·contacted you about being an expert in this

18· ·matter?

19· · · · · ·A.· ·Mr. Blake did.

20· · · · · ·Q.· ·Okay.· Okay.· Did you have any

21· ·prior interaction with Mr. Blake?

22· · · · · ·A.· ·No.

23· · · · · ·Q.· ·What about with the State of Ohio?

24· · · · · ·A.· ·No.· Well, excuse me.· Hamilton

25· ·County, Ohio.

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·1· · · · · ·Q.· ·Okay.· So any interaction with the

·2· ·Ohio Department of Health?

·3· · · · · ·A.· ·No.

·4· · · · · ·Q.· ·Okay.

·5· · · · · ·A.· ·Unless Child and Protective

·6· ·Services is under that umbrella.· I don't know

·7· ·the spectrum.

·8· · · · · ·Q.· ·I also don't know.

·9· · · · · ·A.· ·Okay.

10· · · · · ·Q.· ·Any prior relationship with the

11· ·law firm of Mr. Jake Blake -- Mr. Jason Blake,

12· ·Calfee?

13· · · · · ·A.· ·No.

14· · · · · ·Q.· ·Okay.· When did counsel reach out

15· ·to you?

16· · · · · ·A.· ·It was late May of this year.

17· · · · · ·Q.· ·Okay.· Are you being compensated

18· ·for rendering your opinion in this matter?

19· · · · · ·A.· ·I am.

20· · · · · ·Q.· ·Okay.· How are you being

21· ·compensated?

22· · · · · ·A.· ·A retainer fee of $1,500, and then

23· ·review of records in preparation of records at

24· ·$350 per hour.· Deposition $450 per hour,

25· ·unless it's out of state, where I'm out of the

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·1· ·office.· So today the payment for my day's work

·2· ·here is $3,500.

·3· · · · · ·Q.· ·Got it.· Okay.· So you're not

·4· ·separately being paid like by the hour for

·5· ·deposition testimony?· It's a lump sum for

·6· ·payment?

·7· · · · · ·A.· ·It is a lump sum for this, yes,

·8· ·for the deposition day.

·9· · · · · ·Q.· ·Thank you.· Okay.· Do you know

10· ·roughly what you've billed to date for this

11· ·matter?

12· · · · · ·A.· ·I think it's been -- It might be

13· ·upwards of $2,800.· Something around that

14· ·amount.

15· · · · · ·Q.· ·Okay.

16· · · · · ·A.· ·I can look up, specifically.

17· · · · · ·Q.· ·Not including today?

18· · · · · ·A.· ·Not including today.

19· · · · · ·Q.· ·Okay.· Got it.· You're being

20· ·offered as an expert in pediatric endocrinology

21· ·in this matter, correct?

22· · · · · ·A.· ·That's correct.

23· · · · · ·Q.· ·Do you consider yourself to be an

24· ·expert in gender dysphoria?

25· · · · · ·A.· ·In that it is part of

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·1· ·transgenderism, and transgenderism falls on the

·2· ·shoulders of endocrinology to provide medical

·3· ·treatment.· So we have to have a background and

·4· ·expertise in the foundation of what is

·5· ·transgenderism.· And so for that reason,

·6· ·literature when I research writing has been --

·7· ·and so in that case, I would say yes.

·8· · · · · ·Q.· ·Okay.· So you consider yourself an

·9· ·expert in gender dysphoria.· I heard you

10· ·mention transgender issues.· So you consider

11· ·yourself an expert in transgender issues as

12· ·well?

13· · · · · ·A.· ·Yes.

14· · · · · ·Q.· ·And what about intersex

15· ·conditions?

16· · · · · ·A.· ·Yes.

17· · · · · ·Q.· ·Okay.· What makes you an expert in

18· ·those issues?

19· · · · · ·A.· ·Training, clinical experience and

20· ·active interest in research and review of

21· ·literature.

22· · · · · ·Q.· ·Okay.· So is any pediatric

23· ·endocrinologist who consumes literature and

24· ·digests it on gender dysphoria an expert in it?

25· · · · · ·A.· ·Not necessarily.

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·1· · · · · ·Q.· ·Okay.· What do you consider

·2· ·yourself to be a expert in?· Anything besides

·3· ·these things?

·4· · · · · · · · MR. BLAKE:· Objection.

·5· · · · · · · · THE WITNESS:· Pediatric

·6· ·endocrinology, in general, and pediatrics as

·7· ·well.

·8· ·BY MS. INGELHART:

·9· · · · · ·Q.· ·Okay.· How long have you practiced

10· ·as a medical physician?

11· · · · · ·A.· ·I graduated from medical school in

12· ·1973.· I finished my residency in 1976.· And so

13· ·actually actively practicing as a licensed

14· ·physician from 1976 to the present.

15· · · · · ·Q.· ·Okay.· Have you always been

16· ·affiliated with like a hospital institution, or

17· ·have you ever been in private practice?

18· · · · · ·A.· ·I was in the Navy for 20 years.

19· ·During which time I was affiliated with

20· ·academic institutions and the Navy Medical

21· ·Corp.· Upon retirement, after a 20-year career

22· ·in the Navy, I went into private practice but

23· ·maintained academic and clinical teaching

24· ·positions, adjunct positions, at Emory

25· ·University and Morehouse College of Medicine.

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·1· · · · · ·Q.· ·So you're currently adjunct.· Is

·2· ·that accurate?

·3· · · · · ·A.· ·Yes.

·4· · · · · ·Q.· ·And then you're in private

·5· ·practice also now?

·6· · · · · ·A.· ·Yes.

·7· · · · · ·Q.· ·Thank you.· And what areas of

·8· ·practice have you specifically held yourself

·9· ·out as?

10· · · · · ·A.· ·Pediatric endocrinology and

11· ·pediatrics.

12· · · · · ·Q.· ·Where did you go to school?

13· · · · · ·A.· ·Medical College of Virginia, in

14· ·Richmond, Virginia.

15· · · · · ·Q.· ·When did you graduate?

16· · · · · ·A.· ·1973.

17· · · · · ·Q.· ·Did you do a residency after that

18· ·then?

19· · · · · ·A.· ·I did.

20· · · · · ·Q.· ·And where was that?

21· · · · · ·A.· ·And that was at Oakland Naval

22· ·Hospital, internship and residency in

23· ·pediatrics.· And then my fellowship at Johns

24· ·Hopkins in pediatric endocrinology from 1978 to

25· ·1980.

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·1· · · · · ·Q.· ·Okay.· And do you hold any other

·2· ·certifications or -- forgive me if I'm not

·3· ·using the accurate, you know, medical term for

·4· ·certifications or kind of specialization --

·5· ·official recognition?

·6· · · · · ·A.· ·Basically, pediatrics and

·7· ·pediatric endocrinology certification.

·8· · · · · ·Q.· ·Okay.· Can you please describe

·9· ·your education or training related to gender

10· ·dysphoria?

11· · · · · ·A.· ·So it began in the fellowship

12· ·years, and then the issue remained very quiet,

13· ·because it was not a common issue in pediatrics

14· ·at all.· My first transgender case in 1993 or

15· ·'94 was a patient that came to my office. A

16· ·military dependent child.· The sex was male.

17· ·He had been advised to transition to female --

18· ·he was 13 at the time -- by a psychiatrist in

19· ·Los Angeles.· The family moved often, and there

20· ·was an opportunity for sort of a clean break in

21· ·friendships and what all.· So the family was

22· ·advised to go ahead and raise this child

23· ·subsequently as a female, and that patient came

24· ·to me for hormone therapy.

25· · · · · · · · It was sort of out of the blue. I

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·1· ·called all of the people that I knew that were

·2· ·my mentors in pediatric endocrinology across

·3· ·the country, in San Francisco, in Baltimore,

·4· ·in St. Louis, and said, what is your

·5· ·experience?· What do we do with this?· This is

·6· ·not an issue that we have seen, literally,

·7· ·since fellowship days, and we were really not

·8· ·dealing with transgender children at that point

·9· ·in time.· The experience was with the

10· ·transgendered adults at Hopkins.· And not

11· ·practicing adult endocrinology, I had

12· ·essentially no clinical experience in the

13· ·interim period.

14· · · · · · · · Nobody could tell me what to do.

15· ·No one had any guidelines.· Nobody had any idea

16· ·of what was appropriate.· I was advised that I

17· ·needed to have an attorney devise an informed

18· ·consent, an assent, to cover myself for any

19· ·potential damage that might be done that I was

20· ·unaware of by doing cross-sex hormones in this

21· ·child.· And so I launched on that with the

22· ·assent and consent for the parents and began

23· ·treating that male with estrogens.

24· · · · · · · · Within six months, the family

25· ·moved again, and I referred that family to a

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·1· ·pediatric endocrinologist at the Naval and

·2· ·Medical Center in Bethesda, Maryland, since

·3· ·they were moving to the Washington, D.C. area,

·4· ·and I never heard.· I'm not sure the patient

·5· ·actually ever made it there.· I called the

·6· ·person that I had referred to, and he indicated

·7· ·he'd never seen the family.· So I don't know

·8· ·what happened.

·9· · · · · ·Q.· ·Okay.

10· · · · · ·A.· ·But that's how rare it was to deal

11· ·with transgendered issues in children at that

12· ·time.

13· · · · · ·Q.· ·And what was that time again?

14· · · · · ·A.· ·1993, 1994.

15· · · · · ·Q.· ·Okay.· So that's when you first

16· ·were reintroduced to the issue and first time

17· ·you had seen that since your time at Johns

18· ·Hopkins?

19· · · · · ·A.· ·Since my fellowship.· Right.

20· · · · · ·Q.· ·okay.· And that's a pretty long

21· ·span.

22· · · · · ·A.· ·That's correct.

23· · · · · ·Q.· ·Do you have an opinion about why

24· ·it was such a long span between those

25· ·incidents?

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·1· · · · · ·A.· ·Because it was a very uncommon

·2· ·condition.· It was exceedingly rare.

·3· · · · · ·Q.· ·Okay.

·4· · · · · ·A.· ·In terms of reported cases and

·5· ·people who professed to have clinical

·6· ·experience that were available in published

·7· ·literature.

·8· · · · · ·Q.· ·Okay.

·9· · · · · ·A.· ·And recognized by academic

10· ·institutions.

11· · · · · ·Q.· ·And it's no longer rare?

12· · · · · ·A.· ·No.

13· · · · · ·Q.· ·Do you have an opinion about why

14· ·the incidence of transgender patients

15· ·presenting themselves to physicians like

16· ·yourself is less rare?

17· · · · · ·A.· ·It is clearly my opinion.· I have

18· ·some indirect statistics that do not show

19· ·causality, but the advent of the internet and

20· ·available information to children and the

21· ·advocacy of the transgender movement has made

22· ·it a forefront issue.· The combination of those

23· ·two things has exponentially increased people's

24· ·sense that it exists and that it is a real

25· ·entity that is biologically based.

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·1· · · · · ·Q.· ·And so people's awareness makes --

·2· ·how does that awareness affect the rate of

·3· ·incidence?

·4· · · · · ·A.· ·The study that was published by

·5· ·Lisa Littman showed there was sort of a social

·6· ·contagion among adolescent females

·7· ·particularly.· The ratio of incidence from

·8· ·twice as many males as females in the

·9· ·background for any number of years, from

10· ·published studies back in the 1970s, '80s, and

11· ·'90s and even in the early 2000s, to the point

12· ·where it is now twice as many females as males,

13· ·and the age of onset in these females is mid

14· ·adolescence.

15· · · · · ·Q.· ·Okay.· So what I heard you say was

16· ·that there's a social contagion.· What is the

17· ·social contagion?

18· · · · · · · · MR. BLAKE:· Objection.

19· · · · · · · · THE WITNESS:· The presence on the

20· ·internet of YouTube videos, suggestions of what

21· ·to say to your physician, helpful guidelines --

22· ·hopefully helpful -- to guide patients who have

23· ·issues toward the idea that they are

24· ·transgender.

25· ·BY MS. INGELHART:

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·1· · · · · ·Q.· ·Okay.· How is that a contagion? I

·2· ·don't think I understand your use of that term.

·3· · · · · · · · MR. BLAKE:· Objection.

·4· · · · · · · · THE WITNESS:· It is the increase

·5· ·cannot be explained by purely social

·6· ·acceptance.· Okay?· The sociologists who have

·7· ·reviewed this in the UK, particularly in the

·8· ·Scandinavian, can't explain a hundred fold

·9· ·increase in the incidence of transgenderism

10· ·since 2010.

11· ·BY MS. INGELHART:

12· · · · · ·Q.· ·Okay.· So you're saying that the

13· ·cultural acceptance of trans folks does not

14· ·explain?

15· · · · · ·A.· ·It does not explain that.

16· · · · · ·Q.· ·Okay.

17· · · · · ·A.· ·I'm not a sociologist, but the

18· ·sociologists who are trying to figure this out

19· ·have explained that they are quite alarmed by

20· ·this and in their world view as sociologists

21· ·can't explain that it is purely acceptance that

22· ·brought this about.

23· · · · · ·Q.· ·And who are those sociologists?

24· · · · · ·A.· ·People who publish.· I don't know

25· ·the names specifically.

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·1· · · · · ·Q.· ·Okay.· And so for the cause and

·2· ·effect, if the effect is that there's a higher

·3· ·rate now, what are you saying is the cause

·4· ·then?

·5· · · · · · · · MR. BLAKE:· Objection.

·6· · · · · · · · Answer if you know.

·7· · · · · · · · THE WITNESS:· It's sort of a

·8· ·recruiting of patients online.

·9· ·BY MS. INGELHART:

10· · · · · ·Q.· ·Okay.· And who's recruiting?

11· · · · · · · · MR. BLAKE:· Objection.

12· · · · · · · · Answer if you know.

13· · · · · · · · THE WITNESS:· The nature of what

14· ·is online when you Google transgender is

15· ·explaining that transgenderism is a biologic

16· ·entity, that if you are concerned and upset

17· ·about any issues at all, consider this as a

18· ·option and come see us, and go to this website,

19· ·and tell your doctor this, and it's -- those

20· ·kinds of websites exist.

21· ·BY MS. INGELHART:

22· · · · · ·Q.· ·Okay.· Okay.· So I apologize.

23· ·Could you just explain to me your understanding

24· ·of the word recruitment?

25· · · · · · · · MR. BLAKE:· Objection.

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·1· · · · · · · · THE WITNESS:· It's sort of an

·2· ·enticement, if you will, to consider

·3· ·transgenderism as the answer to what they're

·4· ·feeling about their lives.

·5· ·BY MS. INGELHART:

·6· · · · · ·Q.· ·Okay.· Doesn't recruitment kind

·7· ·of, again -- active -- activity or an active

·8· ·choice or an action?

·9· · · · · · · · MR. BLAKE:· Objection.

10· · · · · · · · THE WITNESS:· If someone publishes

11· ·something on the internet that says, this is

12· ·the answer, read this list, come here, call

13· ·these people, go to this clinic, I would call

14· ·that recruitment.· That's an active -- somebody

15· ·has to go to that site, somebody has to be

16· ·interested in it to read it, but if you will,

17· ·they're not -- no, they're not doing telephone

18· ·robo calls and saying.

19· · · · · · · · I guess if you're using the word

20· ·recruitment that way, no, it's not happening.

21· ·But if you have access to the internet and you

22· ·type in a word and you get to a website that it

23· ·encourages you to consider that as an option,

24· ·perhaps recruitment isn't the right -- but

25· ·encouragement.· Let's call it encouragement

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·1· ·then.

·2· ·BY MS. INGELHART:

·3· · · · · ·Q.· ·Okay.· And those websites are

·4· ·being created by entities.· Is that what you

·5· ·meant by the transgender movement?· Are they

·6· ·creating these platforms?

·7· · · · · ·A.· ·I don't know who creates them.

·8· ·Some of them are created individually, and

·9· ·they're personal things.· Personal stories, if

10· ·you will.

11· · · · · ·Q.· ·Okay.· But previously you talked

12· ·about the transgender movement and recruitment.

13· ·So is that --

14· · · · · ·A.· ·The transgender movement, I'm

15· ·referring to W-Path as an entity, because it is

16· ·an organization that is a social advocacy

17· ·organization.

18· · · · · ·Q.· ·Okay.· During your fellowship --

19· ·your fellowship was on pediatric endocrinology

20· ·at Johns Hopkins, correct?

21· · · · · ·A.· ·Correct.

22· · · · · ·Q.· ·Okay.· And I think you mentioned

23· ·before that you didn't actually treat any

24· ·children who had had transsexualism as it was

25· ·called at the time or gender disorder as we

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·1· ·call it now?

·2· · · · · ·A.· ·Yes.· Those patients were not

·3· ·recognized as existing in the world of academic

·4· ·medicine and publication in the academic

·5· ·institutions.· It was not part of a fellowship

·6· ·training.· We touched on that, because the

·7· ·adult endocrine service at Johns Hopkins

·8· ·refused to work with the adult patients who

·9· ·were transsexual, and professor John Money who

10· ·was on the faculty and taught us basically

11· ·introduced -- we had to deal with those

12· ·patients.· Adult endocrinologists would not

13· ·deal with those patients.· So their hormone

14· ·therapies, their medical follow-up, was done by

15· ·the pediatric endocrine division.

16· · · · · ·Q.· ·So you treated those patients?

17· · · · · ·A.· ·We treated them in the sense that

18· ·we had to review their cases and be part of it,

19· ·but we did not do primary interviews.· We did

20· ·not recommend the surgeries.· All that was sort

21· ·of done through the psycho hormonal division

22· ·and John Money.

23· · · · · ·Q.· ·So what was your treatment?· I'm

24· ·sorry.

25· · · · · ·A.· ·We had to follow those patients.

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·1· ·We had to examine those patients.· We had to

·2· ·talk about, you know, their medical conditions.

·3· · · · · ·Q.· ·Okay.

·4· · · · · ·A.· ·And it was new enough and without

·5· ·any essential checklist of what to be watching

·6· ·for, it was sort of experiential.· Things were

·7· ·done.· What did we see?

·8· · · · · ·Q.· ·Okay.· So you didn't actually

·9· ·provide any treatment for people with

10· ·transsexual gender identity disorder or gender

11· ·dysphoria during your fellowship, correct?

12· · · · · · · · MR. BLAKE:· Objection.

13· · · · · · · · THE WITNESS:· It was done by

14· ·attendings, and we were, as fellows, observers.

15· ·BY MS. INGELHART:

16· · · · · ·Q.· ·Okay.· So you, personally, did

17· ·not?

18· · · · · ·A.· ·I did not.

19· · · · · ·Q.· ·Okay.· In your report you mention

20· ·that you had, quote, an above average exposure

21· ·to children with disorders of sexual

22· ·differentiation.· What do you mean by above

23· ·average exposure to?

24· · · · · ·A.· ·Because of the sheer number of

25· ·patients that were referred to Johns Hopkins,

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·1· ·that fellowship program had larger numbers of

·2· ·children with DSTs than other endocrine

·3· ·programs have.· In University of California San

·4· ·Francisco and in other programs that were not

·5· ·sort of the epicenters, you would see disorders

·6· ·that were much milder.· Kids with adrenal

·7· ·hyperplasia, who were virilized, females that

·8· ·were virilized or males that were

·9· ·undervirilized.· But most often the ones that

10· ·required any kind of surgical intervention that

11· ·was going to be considered in young childhood,

12· ·all of them, you know, they sort of funneled

13· ·towards Johns Hopkins.

14· · · · · · · · I think Cornell Hospital Children

15· ·Services had a number of patients above the

16· ·average of other centers, as well, at the time.

17· ·But Hopkins was sort of -- it's where all of

18· ·the pathways of hormonal actions were actually

19· ·discovered in the lab, and so because of that

20· ·it was sort of the epicenter of referrals.

21· · · · · ·Q.· ·Okay.· So at the epicenter, about

22· ·how many children were you exposed to?

23· · · · · ·A.· ·In the fellowship years, easily a

24· ·hundred.

25· · · · · ·Q.· ·Okay.· Again, what was the actual

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·1· ·nature of the exposure?

·2· · · · · ·A.· ·Direct patient care.· Evaluation

·3· ·and direct patient care.

·4· · · · · ·Q.· ·So treatment?

·5· · · · · ·A.· ·Yes.· Treatment.· Absolutely.

·6· · · · · ·Q.· ·Okay.· What kind of treatment did

·7· ·you provide to those patients?

·8· · · · · ·A.· ·We provided hormonal replacement

·9· ·therapy for those where it was appropriate to

10· ·solve the problem.· We treated some kids who

11· ·were boys who were undervirilized with

12· ·testosterone, with human chorionic

13· ·gonadotropin, in order to diagnose what was

14· ·going on and also begin some initial

15· ·treatments.· The urologists and the GYN

16· ·surgeons did surgical revisions on those

17· ·patients.· We did not.

18· · · · · ·Q.· ·Okay.

19· · · · · ·A.· ·But we worked hand in hand with

20· ·them to know the complications of the surgeries

21· ·and what needed to be done for surgical

22· ·follow-up.· So all of that was done as sort of

23· ·a conjoined clinic.

24· · · · · ·Q.· ·Okay.· So were any of the children

25· ·that you treated for their DSD also

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·1· ·transgender?

·2· · · · · ·A.· ·No.

·3· · · · · ·Q.· ·Have you been certified by the

·4· ·World Professional Associates of Transgender

·5· ·Health, WPATH?

·6· · · · · ·A.· ·No.

·7· · · · · ·Q.· ·Okay.· You've never completed any

·8· ·course work with WPATH initiative committee,

·9· ·right?

10· · · · · ·A.· ·No.

11· · · · · ·Q.· ·Are you familiar with it?

12· · · · · ·A.· ·I was not familiar with any

13· ·certification whatsoever.

14· · · · · ·Q.· ·Okay.· Are you familiar with the

15· ·WPATH's standards of care?

16· · · · · ·A.· ·Yes.

17· · · · · ·Q.· ·And do you disagree with them?

18· · · · · ·A.· ·I do.

19· · · · · ·Q.· ·Would you like to share what you

20· ·disagree with?

21· · · · · ·A.· ·Well, currently, the iteration is

22· ·the seventh version of their standards of care

23· ·and the eighth version is coming out, I

24· ·understand.· We don't know -- it's supposed to

25· ·be in January perhaps.· The recommendation for

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·1· ·puberty blocking at early age, at the onset of

·2· ·puberty, the recommendation of cross-sex

·3· ·hormone therapy, is counter to the proven

·4· ·science of the adverse effects of those

·5· ·entities as use, and the recommendation for

·6· ·surgery.· This is all related to children in

·7· ·particular.

·8· · · · · ·Q.· ·Okay.· And so the basis for your

·9· ·opinion there is what again?

10· · · · · ·A.· ·Is that the current medical

11· ·literature calls into question the safety of

12· ·and the efficacy of those interventions.

13· · · · · ·Q.· ·And what medical literature?

14· ·Could you be more specific?

15· · · · · ·A.· ·The very comprehensive article by

16· ·Lawrence Mayer and Paul McHugh, which is

17· ·probably the preeminent, most thorough, highly

18· ·referenced, cross referenced, balance

19· ·presentation of the issue of transgender health

20· ·that's ever been published.

21· · · · · ·Q.· ·Okay.· Have you made any public

22· ·comments to voice your disagreement with the

23· ·WPATH standards of care?

24· · · · · ·A.· ·Yes, I have.

25· · · · · ·Q.· ·Okay.· In what context were those

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·1· ·public comments?

·2· · · · · ·A.· ·They were in court CME courses.

·3· ·They were in interviews for publication, print

·4· ·publication, and also radio interviews as well.

·5· · · · · ·Q.· ·Okay.· Were those public comments

·6· ·in your personal capacity?

·7· · · · · ·A.· ·Yes.

·8· · · · · ·Q.· ·Or like your personal/professional

·9· ·capacity?

10· · · · · ·A.· ·Yes.

11· · · · · ·Q.· ·Okay.· Not on behalf of another

12· ·organization?

13· · · · · ·A.· ·No.

14· · · · · ·Q.· ·Okay.· Have you had any other

15· ·training since your fellowship ended in 1980?

16· · · · · ·A.· ·Ongoing CME.

17· · · · · ·Q.· ·Any training in psychiatry?

18· · · · · ·A.· ·Not psychiatry, specifically.· The

19· ·behavioral health as it relates to general

20· ·pediatrics and specifically as it relates to

21· ·pediatric endocrinology.· Depression is a very,

22· ·very prominent entity in Type 1 diabetes

23· ·patients.· It's clearly an entity in patients

24· ·who have disorders of sexual differentiation.

25· ·It's a large part of anything that requires

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·1· ·compliance.· Any kind of disorder which is not

·2· ·going away, it impinges on the mental health of

·3· ·the patient.· And so we are always reminded and

·4· ·trained to recognize depression and anxiety and

·5· ·social interactions of these patients with

·6· ·their peers, with their family and educational

·7· ·environment.

·8· · · · · ·Q.· ·Okay.

·9· · · · · ·A.· ·So it's part of our everyday

10· ·evaluation of every endocrine patient that

11· ·comes into the office.· If you have

12· ·particularly issues with poor growth, delayed

13· ·puberty, those issues are very, very important

14· ·to pay attention to.· We were trained that it's

15· ·basically a basic tenet of pediatric

16· ·endocrinology.· Anything that affects self

17· ·image is going to need to be paid attention to.

18· ·So every endocrine visit in the office for

19· ·whatever purpose the patient's there, we always

20· ·ask the issues about depression, anxiety,

21· ·school performance, interaction with peers.

22· · · · · ·Q.· ·Okay.

23· · · · · ·A.· ·As an assessment for, you know,

24· ·how they're doing.

25· · · · · ·Q.· ·So that was training from the

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·1· ·beginning on through your --

·2· · · · · ·A.· ·On -- the beginning ongoing, yes.

·3· · · · · ·Q.· ·Okay.· Do you hold yourself out as

·4· ·an expert in psychiatry?

·5· · · · · ·A.· ·No, I do not.

·6· · · · · ·Q.· ·Okay.· Do you have any training in

·7· ·psychology beyond what we just discussed?

·8· · · · · ·A.· ·No.

·9· · · · · ·Q.· ·And do you hold yourself out as an

10· ·expert in psychology?

11· · · · · ·A.· ·As it relates to illness, in terms

12· ·of behavioral health, yes.· Not as a licensed

13· ·physiologist.

14· · · · · ·Q.· ·Okay.· Sorry.· I couldn't read my

15· ·own writing.· So that experience at Hopkins, is

16· ·that the foundation of your expertise in issues

17· ·relating to sex differentiation as it relates

18· ·to gender identity?

19· · · · · ·A.· ·It was the beginning of that, yes.

20· · · · · ·Q.· ·Does board certification in

21· ·pediatrics require any course work on gender

22· ·dysphoria?

23· · · · · ·A.· ·It has not, because it's not been

24· ·part of a curriculum.· They're trying to

25· ·develop some curriculum.· I understand it's in

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·1· ·several medical schools, but it's not been part

·2· ·of medical education specifically.

·3· · · · · ·Q.· ·Okay.· And I think you mentioned

·4· ·this.· You're required to complete continuing

·5· ·medical education courses to maintain your

·6· ·Georgia license?

·7· · · · · ·A.· ·That's correct.

·8· · · · · ·Q.· ·Okay.· Are any of those courses

·9· ·required courses on trans related issues?

10· · · · · ·A.· ·No.

11· · · · · ·Q.· ·What about intersex related

12· ·issues?

13· · · · · ·A.· ·Not specifically requested.

14· · · · · ·Q.· ·Okay.· Or gender issues at all?

15· · · · · ·A.· ·Nothing is required specifically.

16· · · · · ·Q.· ·Okay.· But are there courses

17· ·offered on trans issues that you could take as

18· ·a part of your continuing medical education?

19· · · · · ·A.· ·There were CME presentations, but

20· ·unfortunately they're -- the few that I've

21· ·attended have not been really educational.

22· ·They're just sort of opinion pieces, if you

23· ·will, and it's sort of a certain reliable group

24· ·of individuals who are invited to speak and

25· ·only those individuals and no one else at major

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·1· ·CME conferences with professional societies is

·2· ·invited or allowed to speak.

·3· · · · · ·Q.· ·So you have, though, attended some

·4· ·continuing medical education courses that

·5· ·relate to trans issues?

·6· · · · · ·A.· ·Yes, I have.

·7· · · · · ·Q.· ·Okay.· They just weren't required?

·8· · · · · ·A.· ·They were not required.

·9· · · · · ·Q.· ·Got it.· Okay.· What about have

10· ·you attended continuing education on intersex

11· ·issues?

12· · · · · ·A.· ·Yes, I have.

13· · · · · ·Q.· ·Okay.· And gender issues,

14· ·generally, as well?

15· · · · · ·A.· ·Yes, I have.

16· · · · · ·Q.· ·Okay.· And you received credit for

17· ·all of those?

18· · · · · ·A.· ·I did.

19· · · · · ·Q.· ·Okay.· Okay.· I think you said

20· ·here today and in your report that you've

21· ·maintained a continued interest in gender

22· ·discordance since your fellowship and have read

23· ·extensively the literature in scientific peer

24· ·reviewed journals, have attended national and

25· ·international pediatric endocrine conferences

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·1· ·where the subjects presented and discussed.

·2· ·Why did you have that continued interest in

·3· ·gender discordance after your fellowship ended?

·4· · · · · · · · MR. BLAKE:· Objection.· Go ahead.

·5· · · · · · · · THE WITNESS:· Because of what I

·6· ·knew about valid science, I was quite concerned

·7· ·that invalid science was being represented by

·8· ·the individuals presenting on the side of

·9· ·affirmation therapies.· And I decided that was

10· ·something that if I was going to pick a

11· ·subject -- there's so many subjects in medicine

12· ·where there are controversies, but this I saw

13· ·as a really significant harm to children.

14· · · · · · · · And because of my compassion and

15· ·care for kids, in general, this was an area

16· ·where my colleagues, when I would have

17· ·discussions -- who had no clinical experience

18· ·whatsoever -- had just essentially accepted

19· ·guidelines that I knew, and I had actually,

20· ·when the endocrine society guidelines were

21· ·proposed, we were invited to comment on them.

22· · · · · · · · And the comments that I made for

23· ·both the first iteration of the Endocrine

24· ·Society and guidelines and the second and also

25· ·the comments that I made about the Pediatric

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·1· ·Endocrine Society guidelines as they were

·2· ·presented -- because we had as members an

·3· ·opportunity to comment on those cases --

·4· ·nothing that I said was ever responded to, and

·5· ·I was somewhat taken aback and surprised that I

·6· ·didn't receive any kind of affirmation that I

·7· ·had even sent in an opinion.

·8· · · · · · · · And what came out was essentially

·9· ·everything that I was critical of just was

10· ·passed through and accepted as the guidelines,

11· ·and that particularly hit a chord with me that

12· ·this is an area, if I'm going to focus my

13· ·energies at my age on something, I can either

14· ·be angry about dishonesty as I see it, my

15· ·personal opinion in presenting pseudo science,

16· ·as I would call it, on perhaps 10 or 15

17· ·different subjects and not be effective with

18· ·any of them.

19· ·BY MS. INGELHART:

20· · · · · ·Q.· ·Okay.

21· · · · · ·A.· ·And so I've always been an

22· ·advocate of child development and emotional

23· ·health.· In 1994 I wrote a set of guidelines

24· ·for the State of Georgia called the Children's

25· ·Agenda, in which I presented this as an entity

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·1· ·for the American Academy of Pediatrics to use

·2· ·as a sort of, if you will, a Bill of Rights for

·3· ·children.· So that it could be presented to

·4· ·state legislators at the beginning of their

·5· ·legislative session, much like Japan has such a

·6· ·Bill of Rights for children, if you will.

·7· · · · · · · · And that any legislative effort

·8· ·that would be carried out in the state had to

·9· ·go back to this if you want to think of it as a

10· ·Bill of Rights for kids, and make sure that any

11· ·legislative effort that they proposed was not

12· ·contrary to that, for that set of rights.

13· · · · · · · · And so I wrote this for the State

14· ·of Georgia as a project, and it was

15· ·comprehensive.· It had to do everything with

16· ·education.· It had to do with accessibility to

17· ·health care, support of family structure, the

18· ·right of the family and the responsibilities of

19· ·the family.· All these things.· And I presented

20· ·it to the American Academy of Pediatrics, and

21· ·it was soundly defeated in committee.· They

22· ·wouldn't even bring it to the floor as a

23· ·proposal, and that shocked me.· I was really

24· ·upset, and I went to the people in the

25· ·administrative part of the American Academy of

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·1· ·Pediatrics and said, what happened?

·2· · · · · · · · And one of the more senior

·3· ·individuals in the AAP said to me, it's a hot

·4· ·button issue here.· We cannot make statements

·5· ·about what is best for children here, because

·6· ·it's going to offend certain individuals.· It

·7· ·will offend single moms.· It will offend same

·8· ·sex individuals.· It will affect adoptive

·9· ·parents of any kind, and so we can't offend

10· ·anybody.· So we're not going to make -- we

11· ·can't make this statement.

12· · · · · · · · And I said, you know the social

13· ·science is clear about the benefits, the clear

14· ·advantage of a child growing up in society in

15· ·an intact family where the child was conceived

16· ·by consent of both parents, and those parents

17· ·have a commitment to that child until that

18· ·child takes its last breath.· And social

19· ·science says that child, a child in those

20· ·circumstances, has higher education, less drug

21· ·abuse, alcohol abuse, you know, criminal

22· ·behavior, et cetera, et cetera, hands down, but

23· ·we can't say that.

24· · · · · ·Q.· ·And what society was that for?

25· · · · · ·A.· ·American Academy of Pediatrics.

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·1· · · · · ·Q.· ·Okay.· One second.· Okay.· And

·2· ·when was that presentation you gave?

·3· · · · · ·A.· ·1994.

·4· · · · · ·Q.· ·1994?

·5· · · · · ·A.· ·Mm-hmm.

·6· · · · · ·Q.· ·Okay.· And they said that they

·7· ·couldn't make a statement?

·8· · · · · ·A.· ·They refused to endorse it.

·9· · · · · · · · (Thereupon, Plaintiffs' Exhibit 1,

10· ·Ensuring Comprehensive Care and Support for

11· ·Transgender and Gender-Diverse Children and

12· ·Adolescents, was marked for identification

13· ·purposes.)

14· ·BY MS. INGELHART:

15· · · · · ·Q.· ·Okay.· So I'm going to introduce

16· ·to you Plaintiffs' Exhibit 1, and I have copies

17· ·for everyone.· Okay.· So do you recognize this

18· ·document here?

19· · · · · ·A.· ·I do.

20· · · · · ·Q.· ·Can you tell me what it is?

21· · · · · ·A.· ·It is a policy statement written

22· ·by Jason Rafferty.

23· · · · · ·Q.· ·On behalf of whom?

24· · · · · ·A.· ·On behalf of the American Academy

25· ·of Pediatrics.

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·1· · · · · ·Q.· ·Okay.· Can we turn to Page No. 4

·2· ·here?

·3· · · · · ·A.· ·Mm-hmm.

·4· · · · · ·Q.· ·Do you see the section in the top

·5· ·left starting with the bold heading,

·6· ·gender-affirmative care?

·7· · · · · ·A.· ·Yes.

·8· · · · · ·Q.· ·Okay.· Can you read for us that

·9· ·first sentence?

10· · · · · ·A.· ·In gender-affirmative care model

11· ·(GACM), pediatric providers offer

12· ·developmentally appropriate care that is

13· ·oriented toward understanding and appreciating

14· ·the youth's gender experience.· A strong,

15· ·nonjudgmental partnership with youth and their

16· ·families can facilitate exploration of

17· ·complicated emotions and gender-diverse

18· ·expressions while allowing questions and

19· ·concerns to be raised in a supportive

20· ·environment.

21· · · · · ·Q.· ·Okay.· And so just real quick, to

22· ·turn back to the first page, can you read this?

23· ·Let's see.· Yeah, this top line on the first

24· ·page that begins about policy statement.

25· · · · · ·A.· ·Policy statement organizational

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·1· ·principles to guide and define the child health

·2· ·care system and/or improve the health of

·3· ·children.

·4· · · · · ·Q.· ·Okay.· I remember you said this

·5· ·was from the American Academy of Pediatrics.

·6· · · · · ·A.· ·That's correct.

·7· · · · · ·Q.· ·So this is a policy statement of

·8· ·the American Academy of Pediatrics?

·9· · · · · ·A.· ·It is.

10· · · · · ·Q.· ·Okay.· And so we've just reviewed

11· ·that in their policy statement they endorse the

12· ·gender affirmative care model?

13· · · · · ·A.· ·They certainly do.

14· · · · · ·Q.· ·Okay.· And so below where you just

15· ·read, the AAP highlights some primary messages

16· ·that are conveyed through GACM.· Can you review

17· ·the first bullet point there?

18· · · · · ·A.· ·Yeah.· Transgender identities and

19· ·diverse gender expressions do not constitute a

20· ·mental disorder.

21· · · · · ·Q.· ·Okay.· And then -- okay.· You know

22· ·what, we'll come back to this.

23· · · · · · · · So do you have any reason to

24· ·believe that the policy proposal that you

25· ·submitted that went nowhere wasn't reviewed by

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·1· ·all of your colleagues or by the AAP?

·2· · · · · · · · MR. BLAKE:· Objection.

·3· · · · · · · · THE WITNESS:· It was reviewed by a

·4· ·subcommittee before it was presented to what

·5· ·was called the Chapter Chairman's Forum.· These

·6· ·are opportunities for membership and state

·7· ·chapters, and the Georgia State Chapter

·8· ·sponsored this on my behalf to present an idea

·9· ·for the academy to consider as a policy

10· ·statement.· So it was rejected in committee

11· ·before it ever got to a vote, and there is a

12· ·vote taken among what was then called the

13· ·Chapter Chairman's Forum.· And it never got to

14· ·that stage because the committee decided to nix

15· ·it before it could get to the floor.

16· ·BY MS. INGELHART:

17· · · · · ·Q.· ·Okay.· But the American Academy of

18· ·Pediatrics has this policy in place for

19· ·considering policy statements, correct?

20· · · · · ·A.· ·They develop policy statements by

21· ·getting an interested committee together, and

22· ·they make policy statements based on people who

23· ·are invited to give their opinion.

24· · · · · ·Q.· ·And that procedure is not

25· ·necessarily flawed, is it?

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·1· · · · · ·A.· ·It's terribly flawed.

·2· · · · · ·Q.· ·Okay.

·3· · · · · ·A.· ·A review of the policy statements

·4· ·of the American Academy of Pediatrics was done

·5· ·and published in the Journal of Pediatrics. I

·6· ·don't have the exact reference, but it's been

·7· ·within about -- I'm remembering within the past

·8· ·10 years.· It said that the development of the

·9· ·policy statements is flawed in the majority of

10· ·the policy statements.· It's the American

11· ·Academy of Pediatrics criticizing itself about

12· ·its development of policy statements.

13· · · · · ·Q.· ·Interesting.· Okay.

14· · · · · ·A.· ·This particular policy statement

15· ·was critiqued by a clinical psychologist last

16· ·name of Cox, and he published his critical

17· ·analysis of this evaluation and indicated that

18· ·it was flawed to the point where many of the

19· ·references that Dr. Rafferty used to make

20· ·statements that supported what he was saying

21· ·actually said exactly the opposite and did not

22· ·support them at all.· This is an independent.

23· ·This was not asked for.· It was just published

24· ·very quickly after this, and this was an

25· ·individual who'd come to this, went through

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·1· ·every reference in here and essentially said

·2· ·this is an embarrassment.

·3· · · · · ·Q.· ·And when was that?

·4· · · · · ·A.· ·This was within the last year,

·5· ·because this was published initially in

·6· ·September, and within a month of its

·7· ·publication, a month or two, Dr. Cox came out

·8· ·and published a rebuttal to this and said this

·9· ·is a travesty.

10· · · · · ·Q.· ·Okay.· So in your children's

11· ·agenda that you proposed to the committee in

12· ·Georgia that you tried to introduce, what

13· ·rights did it provide for children

14· ·specifically?

15· · · · · ·A.· ·It said the children need to --

16· ·should have the opportunity for education to

17· ·their full extent to be educated, that their

18· ·education should be tailored to their specific

19· ·needs and abilities, that they should have food

20· ·and shelter.· They should have a family unit to

21· ·support them and unconditionally provide care

22· ·for them throughout their entire life, that

23· ·ideally the children should be -- this is an

24· ·ideal.· This is not condemning anybody who

25· ·doesn't do this, but it is for the purpose of

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·1· ·saying if you are going to pass legislation

·2· ·that in any way promotes things that will

·3· ·inherently prevent these opportunities, you

·4· ·should not pass that legislation.· So it was

·5· ·not condemnation of anything, but it was sort

·6· ·of a golden ideal.

·7· · · · · · · · Again, a child should be conceived

·8· ·purposely.· And it doesn't happen.· This is

·9· ·real life.· Okay?

10· · · · · ·Q.· ·Mm-hmm.

11· · · · · ·A.· ·But the reality is if you want to

12· ·give the best opportunity, a couple in a

13· ·committed, functional relationship, should want

14· ·a child, conceive the child, take care of that

15· ·child from birth until that child's death.· If

16· ·they pre-decease the child, obviously, that's

17· ·not going to happen.

18· · · · · · · · And the elements that were

19· ·important for that child were to be educated,

20· ·fed, clothed, and not emotionally abused.

21· · · · · ·Q.· ·Okay.· So it was a part of your

22· ·advocacy in this children's rights document

23· ·that different sex parents are preferred?

24· · · · · · · · MR. BLAKE:· Objection.

25· · · · · · · · THE WITNESS:· An intact biological

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·1· ·family.· And I didn't condemn adoption.· Our

·2· ·oldest child's adopted.· Adoption is a very

·3· ·complex issue.· Even under the best of

·4· ·circumstances, where parents are loving the

·5· ·child, providing no intended negative

·6· ·consequences of child rearing, that child still

·7· ·grows up, as we have learned from our

·8· ·daughter's experience and her networking with

·9· ·other adopted adolescents and adults in her

10· ·life, it is a burden.· It's a burden for the

11· ·child who's adopted.· Some of them handle the

12· ·burden seemingly effortlessly, but many suffer

13· ·quietly and live with that and have to work

14· ·through all the issues.

15· · · · · · · · So it's not ideal to be adopted

16· ·and be raised.· It's ideal to be conceived and

17· ·reared by your biologic parents.· It's just

18· ·sociologically it's the best outcome.· It's not

19· ·to say that anything that happens that's not in

20· ·those guidelines is intended harm.· It's just

21· ·that's the perfect thing.· Make sure that what

22· ·we do is in every circumstance where we have

23· ·control we don't do something that adds another

24· ·burden to the child in the child's life.· We

25· ·don't provide them education.· We don't provide

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·1· ·them adequate nutrition.· We don't provide them

·2· ·sound parenting in a family that's not

·3· ·psychologically detrimental.· All those things

·4· ·are important to avoid happening, if you can.

·5· · · · · · · · So in the sense of, you know, it's

·6· ·all about what is absolutely the best

·7· ·circumstance for the child?· What is the best

·8· ·circumstance?· And we know what that is.

·9· ·BY MS. INGELHART:

10· · · · · ·Q.· ·So those guidelines, based on

11· ·those themes and principles, rearing a child by

12· ·same sex parents would not qualify or would

13· ·increase burdens on the children?

14· · · · · · · · MR. BLAKE:· Objection.

15· · · · · · · · THE WITNESS:· There are published

16· ·studies which show adverse outcomes.

17· ·BY MS. INGELHART:

18· · · · · ·Q.· ·Have you read any studies that

19· ·there are not adverse outcomes?

20· · · · · ·A.· ·I've read reports.· Yes, I have.

21· · · · · ·Q.· ·Okay.

22· · · · · ·A.· ·They're not validated studies.

23· ·They are individual case studies.· Not

24· ·cross-sectional.· The big studies that

25· ·essentially take the general population without

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·1· ·a recruitment of population.· It's a review of

·2· ·existing data without asking patients to come

·3· ·and present ideas to you.· The only studies

·4· ·done like that, the published studies show that

·5· ·there are decreased rates of education, higher

·6· ·increased drug abuse, sexual abuse, et cetera,

·7· ·et cetera, in the lives of those patients.

·8· · · · · ·Q.· ·And you've read the entire defend

·9· ·of pot body of that research?

10· · · · · · · · MR. BLAKE:· Objection.

11· · · · · · · · THE WITNESS:· No, I have not.

12· · · · · · · · MS. INGELHART:· Okay.

13· · · · · · · · THE WITNESS:· I have not read the

14· ·entire body.

15· ·BY MS. INGELHART:

16· · · · · ·Q.· ·Okay.· But for the ones that you

17· ·disagree with, you disagree with based on

18· ·methodology?

19· · · · · ·A.· ·Yes.

20· · · · · ·Q.· ·Okay.· So how do you keep up with

21· ·the scientific literature on gender dysphoria?

22· · · · · ·A.· ·I read everything that is

23· ·published that I can find, and there is ample

24· ·opportunity to read the broad spectrum of

25· ·opinions, not just what -- I read everything

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·1· ·that I can find that comes across,

·2· ·predominantly on the internet.· It's an access

·3· ·way to get printed literature, public

·4· ·discussions, synopses of presentations.· So I

·5· ·read everything.· If the word transgender is in

·6· ·it, I read it.

·7· · · · · ·Q.· ·Okay.· So about how many articles

·8· ·then would you say you read per week?

·9· · · · · ·A.· ·Five or ten.

10· · · · · ·Q.· ·Okay.· So per month?

11· · · · · ·A.· ·Times four.

12· · · · · ·Q.· ·Okay.· All right.· And since about

13· ·five years ago, you've been keeping up with

14· ·this practice?

15· · · · · ·A.· ·Since 19 -- 2004, actually.· 2004,

16· ·it's very interesting, because there was what

17· ·we call a throwaway journal called,

18· ·Contemporary Pediatrics, a cover story about

19· ·transgender.· It was out of the Boston service.

20· ·This was before they had really established

21· ·their transgender clinic officially, which Dr.

22· ·Norman Spack did in 2007, I believe, and it was

23· ·an article written that basically said this is

24· ·the new new.· This is transgenderism.· This is

25· ·what these children need.

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·1· · · · · · · · And it caught my attention,

·2· ·because I happened to know one of the authors.

·3· ·Actually, the lead author.· She was a fellow

·4· ·staff pediatrician in the Navy.· So I said, oh,

·5· ·there she is.· And I read through and I

·6· ·thought, wait a minute.· Where is the science

·7· ·here?· Where are you speaking from?

·8· · · · · · · · Now, I've never had a conversation

·9· ·with her subsequently.· Something that's on my

10· ·to do list, if I can get some time, and I don't

11· ·know that she's still in Boston or not.· But

12· ·that caught my eye, and it was sort of at that

13· ·point in time I thought, wait a minute.· How is

14· ·this brought up as a standard issue describing

15· ·many children when we're not seeing those? I

16· ·mean the endocrinologists don't see this.· We

17· ·don't see this at all.· This is in a pediatric

18· ·journal, not an endocrine publication.· Where

19· ·is this coming from?· How did that happen?

20· · · · · · · · And then subsequently Dr. Spack,

21· ·from Boston, presented at the combined

22· ·Pediatric Endocrine Society/European Society

23· ·for Pediatric endocrinology meeting in New

24· ·York.· I can't specifically remember the exact

25· ·year, but it was soon after that, and he gave a

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·1· ·plenary session for CME, and I sat in the back

·2· ·of the room, and my jaw dropped, because I was

·3· ·hearing things that were contrary to what we

·4· ·knew.· And so I said, I'm interested in this.

·5· ·This has piqued my curiosity.

·6· · · · · · · · And so at that point in time I

·7· ·began to saying, what is he talking about?

·8· ·What's his experience?· And it was at that

·9· ·meeting entirely anecdotal.· There was no

10· ·published research.· He did refer to the Dutch

11· ·study, the Dutch protocol, which had been

12· ·started in early 2000 in the Netherlands, and I

13· ·read that and I said, well, wait a minute, wait

14· ·a minute, wait a minute.· They're talking about

15· ·the few kids who fail the intensive

16· ·psychological background, and they talked about

17· ·the desistance, if you will, in gender identity

18· ·disorder, as it was called by Dr. Zucker at

19· ·that time and referred to as GID by Dr. Spack

20· ·and others who were members of WPATH.

21· · · · · · · · And I thought, wait a minute.· You

22· ·didn't even bring up the psychological

23· ·evaluation.· You just went from, hi, I'm

24· ·transgender, to now we do social transition and

25· ·medical transition.· And you skipped the big

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·1· ·issue, which is the evaluation.· The in-depth

·2· ·evaluation of the child and the in-depth

·3· ·continuous treatment of the child and their

·4· ·family.· You skipped by that, and you went

·5· ·right to social affirmation and on to medical

·6· ·treatment.· Why did you do that?· How did that

·7· ·happen?

·8· · · · · · · · I've never spoken to Dr. Spack.

·9· ·I've never had a conversation, never

10· ·communicated directly by writing or phone or

11· ·anything.· I was just flabbergasted that at a

12· ·preeminent meeting of world -- you know,

13· ·endocrine consortium that he presented that,

14· ·and there was no questioning.· No questioning

15· ·at all.

16· · · · · · · · And I'm not very confrontational.

17· ·I'll be very honest.· In the back of the room,

18· ·as I sat there, I was more in a state of shock

19· ·than I was to raise my hand and say, excuse me,

20· ·Dr. Spack, but where did you get this

21· ·information?· How can you state what you're

22· ·stating?

23· · · · · · · · And he reminded me very much of

24· ·Dr. John Money, who did exactly that kind of

25· ·thing.· I had an idea.· This is what I'm going

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·1· ·to do, and we're going to see what happens.

·2· · · · · ·Q.· ·Okay.· So about 10 years ago you

·3· ·started keeping up with the literature in a

·4· ·very dedicated fashion.

·5· · · · · · · · MR. BLAKE:· Objection.

·6· ·BY MS. INGELHART:

·7· · · · · ·Q.· ·Does any of that literature affect

·8· ·your treatment of your patients?

·9· · · · · ·A.· ·My review of the literature keeps

10· ·essentially reconfirming my concerns about not

11· ·doing harm to children.· Above all, not doing

12· ·harm and having total compassion for these

13· ·kids, and the more I read about how what I'm

14· ·doing is supposed to be harmful, I'm very, very

15· ·cognizant of the fact that when the patient

16· ·that I treat walks in the room and I state to

17· ·them empirically at the very beginning and

18· ·throughout, I am your advocate.· I am looking

19· ·for your welfare, and I will not let go of you

20· ·throughout this whole process.· You may have

21· ·concerns.· I'm not judging you for anything,

22· ·but I am trying to gather information and

23· ·present to you what I believe is valid science,

24· ·so that you can understand it, and you can make

25· ·an appropriate decision.

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·1· · · · · · · · And I tell them that I,

·2· ·personally, cannot in good faith give them

·3· ·hormone therapy that blocks puberty or that

·4· ·physically changes them, because I would be

·5· ·doing them harm, and that is medical

·6· ·malpractice, and I can't do that to them. I

·7· ·just cannot do that.· So that I will do

·8· ·everything in my power to find the counseling,

·9· ·to make sure the evaluation is done first.

10· · · · · · · · And what happens in my own

11· ·personal experience in the transgender

12· ·patients, who are already filtered, okay --

13· ·people know who I am.· So if they come to my

14· ·office, they either are aware of my opinion or

15· ·they aren't, and so they've come to me to

16· ·basically treat their child or to get a

17· ·treatment plan.· So I don't have hundreds of

18· ·patients.· Okay?· And so the ones that I do

19· ·have absolutely unequivocally 100 percent of

20· ·them come from dysfunctional families and have

21· ·had a number of adverse childhood events in

22· ·their lifetime.· Death of a parent, sexual

23· ·abuse, death of a sibling, severe physical

24· ·trauma, multiple moves, and they are

25· ·significantly depressed and have anxiety.· And

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·1· ·that's the basis from which I start is to say,

·2· ·we need to find a therapist who can deal with

·3· ·all these emotional turmoils.· We need to have

·4· ·a therapist who's willing to work with all

·5· ·members of the family and interview them

·6· ·extensively and figure out what the dynamics

·7· ·are, the psychological dynamis of that child's

·8· ·environment.· And if we don't do that, we are

·9· ·doing an intense disservice to the child.

10· · · · · ·Q.· ·Okay.· So what you were just

11· ·referring to about the evaluation and patients

12· ·coming to you seeking hormones, was all of

13· ·that and subsequent about specifically children

14· ·patients who present or think that they have

15· ·gender dysphoria?

16· · · · · ·A.· ·Yes.

17· · · · · ·Q.· ·Okay.· How many patients like that

18· ·have you had?

19· · · · · ·A.· ·15.

20· · · · · ·Q.· ·Oh.· 15?

21· · · · · ·A.· ·Mm-hmm.

22· · · · · ·Q.· ·Okay.· This year?

23· · · · · ·A.· ·No, no.· There are 15 active

24· ·patients so far that have been recruited over

25· ·the past three or four years.

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·1· · · · · ·Q.· ·Okay.· So 15 active patients, and

·2· ·active means you still currently have a

·3· ·relationship?

·4· · · · · ·A.· ·Yes.

·5· · · · · ·Q.· ·Okay.· That's all of the children

·6· ·who have come to you presenting this kind of

·7· ·issue where they want hormone treatment?

·8· · · · · · · · MR. BLAKE:· Objection.

·9· · · · · · · · THE WITNESS:· They come in with a

10· ·diagnosis of gender incongruence.

11· ·BY MS. INGELHART:

12· · · · · ·Q.· ·Okay.· And they come in to you.

13· ·They're recruited, you said?

14· · · · · ·A.· ·No.

15· · · · · ·Q.· ·Okay.

16· · · · · ·A.· ·The patients, they just call the

17· ·office and say, I need to make an appointment.

18· · · · · ·Q.· ·Okay.

19· · · · · ·A.· ·Some of them are referred by their

20· ·primary care physicians.

21· · · · · ·Q.· ·Okay.· 15 active.· Were there any

22· ·before that?

23· · · · · ·A.· ·No.

24· · · · · ·Q.· ·Okay.· When did the first of those

25· ·15 come to your office?

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·1· · · · · ·A.· ·Three or four years ago.

·2· · · · · ·Q.· ·Okay.· Thank you.· Do these

·3· ·children have other pediatric endocrine issues,

·4· ·so that they remain in your treatment?

·5· · · · · ·A.· ·The most recent one did.

·6· · · · · ·Q.· ·Okay.· But there's 15 active?

·7· · · · · ·A.· ·Yeah.

·8· · · · · ·Q.· ·And so what treatment are you

·9· ·providing to those 14 that don't have other

10· ·endocrine issues?

11· · · · · ·A.· ·Supportive education, evaluation

12· ·of all of their physical complaints that are

13· ·related.· And even non-endocrine, because I'm

14· ·at heart a pediatrician.· So I recognize, you

15· ·know, other system complaints that need

16· ·attention as well and sort of educate them on

17· ·those things without stepping on the toes of

18· ·the primary care physician in offering specific

19· ·treatment.· At least I give them a

20· ·comprehensive world view of everything about

21· ·them that I can glean from their history and

22· ·physical exam.· And then I maintain support of

23· ·the family and the child to keep in touch and

24· ·make sure that I'm having conversations with

25· ·their mental health care providers.

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·1· · · · · ·Q.· ·Okay.· So you have an intake

·2· ·appointment?

·3· · · · · ·A.· ·Yes.

·4· · · · · ·Q.· ·Okay.· And then after that?

·5· · · · · ·A.· ·The intake is staged, so that

·6· ·initially the first appointment is a thorough

·7· ·physical exam and a total review of medical

·8· ·history, and then it is sort of focusing on

·9· ·their specific complaint about transgender

10· ·issues.· I interview the child and the family

11· ·all together.· I find out what kind of mental

12· ·health support they're using and who that

13· ·person is.· If they haven't had any, then I

14· ·suggest like through their primary care a

15· ·general behavioral health person, because

16· ·that's a very difficult choice.· It has to be a

17· ·good fit.· It has to be somebody personality

18· ·wise.· It has to be somebody you know doesn't

19· ·have an agenda up front, that's not a

20· ·transgender specialist.· There is no such

21· ·reality of somebody who is not an activist, who

22· ·just does transgender health only, in terms of

23· ·mental health.· If they advertise that as

24· ·colleagues I interviewed and talked to, say

25· ·I've been doing this for 37 years in treating

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·1· ·transgender health in Atlanta, I sort of

·2· ·question them and say, okay, what else do you

·3· ·do?· And they often do nothing but transgender

·4· ·health issues.

·5· · · · · · · · Transgender is a psychological

·6· ·issue at its core, and you don't have to be

·7· ·trained in transgender only issues.· You need

·8· ·to recognize the world's literature in

·9· ·transgender, but you need to be able to

10· ·recognize depression, anxiety and delve into

11· ·the adverse childhood events.· And if you can't

12· ·do that, you shouldn't really be in mental

13· ·health to begin with.

14· · · · · · · · So any clinical psychologist can

15· ·deal with those core issues and needs to know

16· ·how to do that work with families to figure out

17· ·what's going on in the background, and that's

18· ·the only requirement I recommend is somebody

19· ·who can do that and is willing to do that.

20· · · · · · · · I've actually interviewed over the

21· ·phone a person who is sort of a transgender

22· ·oriented expert, and I had a wonderful

23· ·conversation with that particular psychologist,

24· ·who agreed with me totally that the issues need

25· ·to be delved into and that that was her

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·1· ·practice.· So I felt very good about referring

·2· ·patients to her specifically, because she was

·3· ·going to -- at least she stated and I believed

·4· ·that she was going to be dealing with the core

·5· ·issues, or the foundation for all of these

·6· ·issues.

·7· · · · · ·Q.· ·And you believe that people who

·8· ·have a lot of trans experience as psychological

·9· ·professionals and hold themselves out that way

10· ·don't deal with all of the other underlying

11· ·medical issues that you were highlighting?

12· · · · · · · · MR. BLAKE:· Objection.· Misstates.

13· · · · · · · · Go ahead.

14· · · · · · · · THE WITNESS:· Okay.· What my

15· ·experience is in my testimony and listening to

16· ·and being questioned by and reading depositions

17· ·of individuals who have testified as experts,

18· ·the one particular individual who's the head of

19· ·the transgender clinic in Cincinnati, she

20· ·specifically said she had never had a patient

21· ·that came in that didn't go immediately to

22· ·social and medical transition, that 100 percent

23· ·of the patients who walk in the door are

24· ·transitioned.

25· · · · · · · · I have had conversations with

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·1· ·parents and in some cases, cases where I've

·2· ·done a medical statement of expert opinion,

·3· ·where the family freely admits that no one

·4· ·talked to them about any psychological issues.

·5· ·My second most recent transgender patient, I

·6· ·spoke to her psychological therapist about this

·7· ·particular child.

·8· · · · · · · · A male who was a transfemale, and

·9· ·this particular patient had not had any mental

10· ·health interventions until this psychologist

11· ·took up the case about a year ago, when the

12· ·child was having cutting behavior at school and

13· ·was referred by the school through their

14· ·psychological support services to a clinical

15· ·mental health professional.· This child had

16· ·suffered inordinately from adverse events from

17· ·shortly after birth all the way up through the

18· ·present time and had never had an evaluation

19· ·but was recommended by the school that they

20· ·needed to consider transgender as the answer,

21· ·that they had some conversations with this

22· ·child.

23· · · · · · · · And so the clinical psychologist

24· ·said suddenly, in February, that this child

25· ·decided that she was going to take on a male

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·1· ·name and a male persona at school.· And she

·2· ·said, so I went through, and since doing that

·3· ·the child seems to be remarkably happy, has

·4· ·stopped any self-harming behaviors.

·5· · · · · · · · And I said, okay, have you

·6· ·interviewed the biological father?· No.· Have

·7· ·you interviewed this person?· No.· I said,

·8· ·well, I think it's probably important to delve

·9· ·deeper into that.

10· · · · · · · · So my experiences in dealing with

11· ·the cases where I've been asked to step in or

12· ·review that very often the initial evaluation

13· ·is not done.· And as a matter of fact, this

14· ·document states that any such evaluation is

15· ·essentially harmful.· This Dr. Rafferty said,

16· ·psychological evaluation is totally unnecessary

17· ·and does harm.

18· ·BY MS. INGELHART:

19· · · · · ·Q.· ·Okay.· I have a few questions.

20· ·We'll come back to that one.· Okay.· So in the

21· ·anecdote you just shared you said that the

22· ·child began -- sorry.· The child that you just

23· ·referred to in that anecdote, what sex were

24· ·they assigned at birth?

25· · · · · ·A.· ·Male.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·No.· Excuse me.· Female.· I'm

·3· ·sorry.· Female.

·4· · · · · ·Q.· ·Okay.

·5· · · · · ·A.· ·Assigned female, decided to take

·6· ·on a male persona in February.

·7· · · · · ·Q.· ·Okay.· And the medical

·8· ·professional that you spoke with treating that

·9· ·person, that child, said that since transition

10· ·they were remarkably happy?

11· · · · · ·A.· ·Yes.

12· · · · · ·Q.· ·Okay.· Before you said that of the

13· ·15 patients that you deal with right now with

14· ·trans issues, each and every one came from a

15· ·dysfunctional family; is that correct.

16· · · · · ·A.· ·They had significant family

17· ·dysfunction, yes.

18· · · · · ·Q.· ·Okay.· Could you give an example

19· ·of such family dysfunction?

20· · · · · ·A.· ·Divorce.

21· · · · · ·Q.· ·Okay.

22· · · · · ·A.· ·Alcohol or drug abuse, mental

23· ·health issues of the parent, severe depression

24· ·or anxiety in the parent, death of a sibling,

25· ·death of a parent, frequent moves.· Things that

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·1· ·are classified as adverse childhood events.

·2· · · · · ·Q.· ·Okay.· Thank you.· And who

·3· ·classifies those as adverse childhood events?

·4· · · · · ·A.· ·It's a list.· It's a published

·5· ·list from -- I can't quote you the

·6· ·organization, but there's a published list of

·7· ·adverse childhood events, such as a

·8· ·questionnaire that's proposed to be asked at

·9· ·all general pediatric visits.· It's a screen

10· ·for adverse childhood events.

11· · · · · ·Q.· ·Okay.

12· · · · · ·A.· ·There's a published screen.

13· · · · · ·Q.· ·Yeah.· So that list, that

14· ·screening is publicly used and accessed by most

15· ·pediatricians?

16· · · · · ·A.· ·Yes.

17· · · · · ·Q.· ·Okay.

18· · · · · ·A.· ·It's available.· It's not often

19· ·used.

20· · · · · ·Q.· ·Oh, okay.

21· · · · · ·A.· ·That's the problem.· The

22· ·publications that say this should be part of a

23· ·pediatric well visit, they're trying to

24· ·advocate to get pediatricians to pay attention

25· ·to that.

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·1· · · · · ·Q.· ·Okay.· Why is it not often used?

·2· · · · · ·A.· ·Because pediatricians don't often

·3· ·delve into behavioral health.

·4· · · · · ·Q.· ·Okay.· Amongst the list of adverse

·5· ·conditions or experiences, is being raised by

·6· ·parents of the same sex among that list?

·7· · · · · ·A.· ·No.

·8· · · · · ·Q.· ·Okay.· Okay.· So I think we got

·9· ·into this because we were talking about the

10· ·treatment of those 15 patients that you have

11· ·now.· You do an intake, and you refer them to a

12· ·psychologist, because as you've stated you're

13· ·not an expert at who is a psychologist.· From

14· ·that point, what's your relationship with those

15· ·witnesses?

16· · · · · ·A.· ·As a place to come and sort of be,

17· ·if you will, a gate keeper to make sure that

18· ·the mental health issues are being dealt with.

19· · · · · ·Q.· ·Okay.· But you're not an mental

20· ·health expert, right?

21· · · · · ·A.· ·No.· But I'm in touch with

22· ·what's -- plus I provide education that is age

23· ·appropriate about what the risks and benefits

24· ·are of moving forward with affirmation,

25· ·medical, surgical or social.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·And so I will present those to the

·3· ·patient, because areas, a dream and a hope, and

·4· ·then there is reality, and I want to make sure

·5· ·that they have their dreams and hopes and all

·6· ·the reality all in front of them at all times

·7· ·in a level that they can understand.

·8· · · · · · · · So if I have a 10-year-old child,

·9· ·I kind of go back through, and I interview.· On

10· ·subsequent times I'll interview the parent, and

11· ·if I have only seen one parent, which is very

12· ·often the case, I will ask to visit with the

13· ·other parent if it's at all possible.· The

14· ·biologic parent, the step parent, anybody

15· ·that's been in an authority role in this

16· ·child's interface.· I want to have a chance to

17· ·interview those people.· Siblings, if possible.

18· ·So that I can -- serve a broad spectrum of

19· ·what's going on in the relations of these kids.

20· · · · · ·Q.· ·Okay.

21· · · · · ·A.· ·So that happens spread over time,

22· ·because you can't get all that done.· You can't

23· ·get everybody in the office at the same time.

24· ·Plus with younger children in particular, I

25· ·want to see what it is they remember that we

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·1· ·talked about at the prior visit, and really

·2· ·commonly they don't remember or they state they

·3· ·don't remember.

·4· · · · · · · · And so I want to make sure they

·5· ·have an understanding.· And I specifically ask,

·6· ·you know, your sex is male or female.· You're

·7· ·at odds with that as believing who you are.

·8· ·Are you aware that you can never become another

·9· ·sex?· And in the concrete thinking nine or

10· ·ten-year-old, they tend not to get that.· They

11· ·don't understand that.· In an older adolescent,

12· ·they can wrap their head around that as a

13· ·concept.· So it's all based on age and mental

14· ·capacity and other things to see, what do you

15· ·understand?· Because I don't want you to have a

16· ·sense that you were told something that is not

17· ·actually true.· You need to be aware.

18· · · · · · · · And for parents I provide them

19· ·with a list of references and say, this is

20· ·contrary to what you're telling me you've

21· ·understood, you've read and reviewed, from your

22· ·online searches.· I'm going to give you actual

23· ·references that would show a different opinion.

24· ·Understand that the reason I'm giving them to

25· ·you is because it's in contrast to what you've

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·1· ·picked up in the way of information so far.

·2· ·Among those, I try to choose references that

·3· ·actually are balanced in terms of they have

·4· ·looked at everything.· They haven't just gone

·5· ·to things that support an opinion and put those

·6· ·in as references, but they have actually looked

·7· ·at another side of the story, an affirmation

·8· ·pathway.· What are the things?· And those are

·9· ·brought up as references, and then they are

10· ·evaluated for their scientific validity, and

11· ·they're included in the treatise that I give

12· ·them.

13· · · · · · · · So it's important I -- you know, I

14· ·said, you need to know everything.· I don't

15· ·want you just to go down not knowing what's

16· ·really out there.· And so that's an arduous

17· ·process, and it cannot be handled in just a

18· ·single visit.· So the subsequent visits are all

19· ·about what do we know?· What are you thinking?

20· ·What questions do you have for me?

21· ·Understanding that I will not be the one that's

22· ·going to provide hormone therapy.

23· · · · · ·Q.· ·Got it.· So your subsequent visits

24· ·are conversational check-ins?

25· · · · · ·A.· ·Yes.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·And if certain things are

·3· ·happening and females who are menstruating and

·4· ·if they are having issues with discomfort of

·5· ·binding the breasts and things like that, I

·6· ·talk to them about, you know, how to alleviate.

·7· ·You know, if you're going to be wearing a

·8· ·breast binder, please take it off if you can at

·9· ·night.· Wear it as little number of hours per

10· ·day as you can tolerate, because it basically

11· ·crushes the tissue, and it creates secondary

12· ·issues with shoulder musculature and posture

13· ·and things like that that sort of give them

14· ·some secondary problems.· And so I try to point

15· ·out the things they could do to alleviate those

16· ·things that may be done at the present time.

17· · · · · ·Q.· ·Okay.· And that medical advice

18· ·that you're giving in those contacts for breast

19· ·binding, those aren't necessarily expertise

20· ·related to endocrinology; is that correct?

21· · · · · · · · MR. BLAKE:· Objection.

22· · · · · · · · THE WITNESS:· It's more general

23· ·pediatrics.

24· ·BY MS. INGELHART:

25· · · · · ·Q.· ·The materials that you provide to

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·1· ·patients and family, what's in that treatise

·2· ·specifically?

·3· · · · · ·A.· ·A balanced presentation.

·4· · · · · ·Q.· ·Okay.· What is a balanced

·5· ·presentation?

·6· · · · · ·A.· ·Means that I looked at the

·7· ·opinions of both sides of an issue.· It's like

·8· ·how we do with clinical research.· You know,

·9· ·clinical research has to be balanced in order

10· ·to be ethical.· It doesn't mean that you have

11· ·to have equal numbers of references.· It

12· ·doesn't mean that you have to do -- if there is

13· ·something that's published that is opposite of

14· ·that, you need to make sure that the person

15· ·knows that you are aware of that and that it's

16· ·discussed.· And if you're invalidating that,

17· ·the reason why that you would invalidate it.

18· · · · · ·Q.· ·Okay.

19· · · · · ·A.· ·So you haven't just quoted things

20· ·that you like.· You've quoted things that you

21· ·find contrary.

22· · · · · ·Q.· ·Okay.· Okay.· One more question,

23· ·and then we'll take a quick break.

24· · · · · ·A.· ·Okay.

25· · · · · ·Q.· ·So are you providing -- would you

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·1· ·characterize those ongoing check-ins as a type

·2· ·of counseling?

·3· · · · · ·A.· ·In part, it's counseling.

·4· · · · · ·Q.· ·Okay.· And you have these meetings

·5· ·with patients as well as family members,

·6· ·correct?

·7· · · · · ·A.· ·Yes.

·8· · · · · ·Q.· ·Okay.· Do the family members and

·9· ·the patients understand that you are not a

10· ·mental health professional?

11· · · · · ·A.· ·They do.

12· · · · · · · · MS. INGELHART:· Okay.· All right.

13· ·Let's take a quick bio break.

14· · · · · · · · THE WITNESS:· Okay.

15· · · · · · · · (Thereupon, a break was taken.)

16· · · · · · · · MS. INGELHART:· Okay.· Back on the

17· ·record.

18· ·BY MS. INGELHART:

19· · · · · ·Q.· ·When we were discussing your

20· ·practice with the 14 or 15 children who

21· ·presented to you as gender dysphoric, you said

22· ·that, or something along the lines of, that

23· ·people know who you are, and therefore seek you

24· ·out.· Is that kind of --

25· · · · · · · · MR. BLAKE:· Objection.

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·1· · · · · · · · THE WITNESS:· This is essentially

·2· ·an opinion based on the fact that there's a

·3· ·transgender clinic at Emory University.· Three

·4· ·years ago when they reviewed the number of

·5· ·patients that were referred per year that were

·6· ·active patients, not referred per year, they

·7· ·had I think in the mid thirties.· Two years

·8· ·later they had increased AD patients that were

·9· ·active patients in their clinic.· They were

10· ·essentially the only advertised transgender

11· ·center in town that is academic based.

12· · · · · · · · There is a treatment facility in

13· ·Decatur, Georgia called Queer Med, and I didn't

14· ·realize.· I guess it's a franchised type of a

15· ·medical, because it exists in other cities I've

16· ·been told, and there is a family practice

17· ·doctor there who dispenses testosterone and

18· ·estrogen, does not use puberty blockers.· He's

19· ·a family practice doctor.· And the use of

20· ·puberty blockers is essentially restricted

21· ·because of insurance costs and whatnot to

22· ·pediatric endocrinologists and adult

23· ·oncologists, and so that person is unable to

24· ·write the prescription and have them be

25· ·accepted so doesn't do that.

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·1· · · · · · · · So there are some, evidently, sort

·2· ·of lesser, not academic affiliated places for

·3· ·transgender patients to go in the Atlanta

·4· ·metropolitan area.· But the Emory Clinic has at

·5· ·last full count 80 active patients in the year.

·6· ·Well, I have 15 active patients over the past

·7· ·three or four years.· I am in a practice that

·8· ·sees about 20 percent of the endocrine

·9· ·population in the Atlanta metro area and the

10· ·Emory Children's Health Care Consortium sees

11· ·about 80 percent.· I haven't really figured out

12· ·the proportionality of that, but I'm thinking

13· ·that if the majority of patients are going to

14· ·Emory, that they don't come to me for a

15· ·particular reason, and it's just sheerly a

16· ·guess.

17· ·BY MS. INGELHART:

18· · · · · ·Q.· ·Okay.· Do your patients or their

19· ·parents tell you why they choose to come to

20· ·you?

21· · · · · ·A.· ·A couple of them have said, you

22· ·know, I know who you are.· I've seen a video

23· ·presentation of one of your lectures, and I'm

24· ·here for that reason.· I came for a second

25· ·opinion.· One in particular.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·That's sort of the one that sticks

·3· ·in my mind.

·4· · · · · ·Q.· ·Okay.· And so what are you

·5· ·implying?· They've seen your videos, and

·6· ·therefore they come to you?

·7· · · · · ·A.· ·That I am all about psychologic

·8· ·counseling and not about social, medical and

·9· ·surgical affirmation.

10· · · · · ·Q.· ·Okay.· So is your goal to help

11· ·your patients align their gender with their

12· ·assigned sex through that counseling?

13· · · · · · · · MR. BLAKE:· Objection.

14· · · · · · · · THE WITNESS:· My goal is to make

15· ·sure they're mentally healthy and that that has

16· ·been addressed.

17· ·BY MS. INGELHART:

18· · · · · ·Q.· ·Okay.· Does being mentally healthy

19· ·relate to having a gender identity that aligns

20· ·with your birth assigned sex?

21· · · · · · · · MR. BLAKE:· Objection.· Vague.

22· ·Relevance.

23· · · · · · · · THE WITNESS:· So I do not believe

24· ·that gender incongruence is an issue that is

25· ·separate from emotional trauma and emotional

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·1· ·malagendment (sic).

·2· ·BY MS. INGELHART:

·3· · · · · ·Q.· ·Okay.· But you know the parents of

·4· ·these children, the guardians of these

·5· ·children, some come to you because they are

·6· ·aware of your medical opinions on trans issues,

·7· ·correct?

·8· · · · · · · · MR. BLAKE:· Objection.

·9· · · · · · · · THE WITNESS:· Some of them.

10· ·BY MS. INGELHART:

11· · · · · ·Q.· ·Okay.· These 15 children are the

12· ·only ones you've ever treated with these

13· ·issues?

14· · · · · · · · MR. BLAKE:· Objection.

15· · · · · · · · THE WITNESS:· Yes.· I'm familiar

16· ·with many more cases, because I've been

17· ·contacted by families who say, what resources

18· ·would you recommend for me in my community?

19· ·BY MS. INGELHART:

20· · · · · ·Q.· ·I understand.· Okay.· So all 15

21· ·are currently active?

22· · · · · ·A.· ·Yes.

23· · · · · ·Q.· ·Okay.· So none have left your

24· ·care?

25· · · · · ·A.· ·Some have strayed away, and we've

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·1· ·had to recontact them.· One in particular I

·2· ·think we are attempting to kind of get back in

·3· ·touch with, and I don't know whether or not

·4· ·their purpose is they don't intend to come

·5· ·back, but they're not very communicative.· It's

·6· ·been like nine months since I've seen that

·7· ·patient.

·8· · · · · ·Q.· ·Okay.· And what's your interest in

·9· ·reaching back out to them to reconnect?

10· · · · · ·A.· ·I care for them.· I deeply care

11· ·for these kids.

12· · · · · ·Q.· ·So do you believe or do you think

13· ·professionally that through psychotherapy you

14· ·can get a transgender patient to stop being

15· ·transgender?

16· · · · · · · · MR. BLAKE:· Objection.

17· · · · · · · · THE WITNESS:· I believe that the

18· ·desistance, so-call desistance rate, is

19· ·extremely high in both males and females, and

20· ·that if that is the case, then my job would be

21· ·to essentially minimize the kinds of medical

22· ·and psychological trauma that they're going to

23· ·have in their lifetime.

24· · · · · · · · And so if we have emotional issues

25· ·that need healing, which I think is every

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·1· ·single case, and I can work them through and

·2· ·they come out the other end without depression

·3· ·and anxiety, that past the age of consent it's

·4· ·their choice of what they're going to choose to

·5· ·do.· But as a child who cannot really consent

·6· ·and whose brain is not capable, I believe, of

·7· ·making those kinds of decisions,

·8· · · · · · · · I worry about them, you know,

·9· ·falling into harm, and the harms are

10· ·unequivocally described in medical literature.

11· ·We are giving them a medical condition for the

12· ·rest of their life.· They will need hormones

13· ·for the rest of their life.· They will need

14· ·surgical manipulation and repair for the rest

15· ·of their life.· They will not have biologic

16· ·function of the surgically altered body parts

17· ·for the rest of their life.

18· · · · · · · · So there's just so much about

19· ·human physiology that's so complex.· We have to

20· ·warn them about cancers, and we have to warn

21· ·them about stroke, and we have to warn them

22· ·about cardiovascular disease that they would

23· ·not have had if we hadn't have done these

24· ·things to them.· And so to me that's a list of

25· ·horrific complications that far -- and of

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·1· ·course the big one is what if they're going to

·2· ·kill themselves, because the suicide rate or

·3· ·suicide attempt rate is so much higher.

·4· · · · · · · · And the answer to that is that the

·5· ·data that is constantly referred to about the

·6· ·41 percent of trans kids who are not allowed to

·7· ·be socially affirmed will kill themselves -- or

·8· ·attempt to kill themselves.· Not a completed

·9· ·suicide but an attempt at suicide.· That is

10· ·actually from a study which didn't separate out

11· ·those which were counseled only and those that

12· ·actually had surgical interventions and medical

13· ·intervention.· It was every one of the patients

14· ·in the group.· The real article when you take

15· ·it apart is that it's a misrepresentation of

16· ·statistics to essentially push people -- and

17· ·this is stated over and over again.· What would

18· ·you rather have, a dead child or a trans boy or

19· ·a trans girl?· Okay?

20· · · · · · · · And that's really not fair,

21· ·because the statistical evaluation doesn't show

22· ·that that's going to happen.· The only

23· ·nonselective, nonbiased study about suicide

24· ·completion is the Dhejne study from Sweden.

25· ·Where every single patient, whether they wanted

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·1· ·to be included in the study or not, in the

·2· ·country of Sweden everybody's medical records

·3· ·are known.

·4· · · · · · · · So if they want to look at a

·5· ·population study, they don't have to do a

·6· ·survey and say, if you are trans or if you are

·7· ·this or if you are that, are you interested in

·8· ·being part of a study, please call this number.

·9· ·We're interested in interviewing you and

10· ·hearing your opinions.· This was completely

11· ·devoid of selection bias.

12· ·BY MS. INGELHART:

13· · · · · ·Q.· ·Okay.

14· · · · · ·A.· ·And a 20 fold increase in suicide

15· ·completion in those who were affirmed and

16· ·surgically treated.· Now, they did not have in

17· ·their data those that were just medically and

18· ·not surgery confirmed.· They also did not have

19· ·in their data a comparison of those who had

20· ·counseling only.· Okay?· They didn't.

21· · · · · ·Q.· ·Okay.· So --

22· · · · · ·A.· ·That study is criticized as

23· ·flawed, because there was no control.

24· · · · · ·Q.· ·Right.· Right.· Yes.

25· · · · · ·A.· ·Okay?

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·So if that criticism is to be a

·3· ·gold standard, okay, then all the studies that

·4· ·are being done now moving forward prospectively

·5· ·in the United States and around the world need

·6· ·to have a control group.

·7· · · · · ·Q.· ·Right.

·8· · · · · ·A.· ·And none of them do, on purpose.

·9· ·And the reason that they claim and they're

10· ·approved to do the clinical study in the NIH

11· ·study is, well, we're going to help cause them

12· ·to kill themselves otherwise.· So we don't have

13· ·a control group.· If we have a control group

14· ·who are just socially counseled and -- and --

15· ·so what's called watch and wait, the maddening

16· ·thing is that watch and wait is not a passive

17· ·non-intervention.· It's an aggressive

18· ·intervention.· Okay?

19· · · · · · · · And conversion therapy, so-called,

20· ·or affirmation therapy, is actually converting.

21· ·An attempt to convert one sex to the other.

22· ·Which can't happen.

23· · · · · ·Q.· ·Hold on real quick.· So are you

24· ·saying that affirmation counseling is

25· ·conversion therapy?

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·1· · · · · ·A.· ·Is an attempt to convert a male to

·2· ·a female.

·3· · · · · ·Q.· ·Got it.· So --

·4· · · · · ·A.· ·That's actually a conversion.· To

·5· ·me, that would be conversion.

·6· · · · · ·Q.· ·I just wanted to be clear on the

·7· ·terms.

·8· · · · · ·A.· ·Affirmation is not really anything

·9· ·other than trying to convert a male into a

10· ·female or vice versa.· Okay?· Conversion

11· ·therapy, as it's called, is actually going to

12· ·the psychological aspect of what's going on to

13· ·maintain, not convert.· Not convert anything

14· ·but to maintain a congruence between the

15· ·concept of who the patient believes they are as

16· ·their gender, which is a psychologically based

17· ·thing -- it has no biologic basis whatsoever --

18· ·compared to biology and to get those aligned.

19· ·Because that happens as a result of

20· ·undercurrent psychological -- and then it self

21· ·propels.· Okay?

22· · · · · · · · Are these people traumatized

23· ·emotionally from society?· Of course, they can

24· ·be.· But in this particular paper it talks --

25· ·which is one of its fallacies -- it says that

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·1· ·all of the psychologic morbidity is essentially

·2· ·caused by society.· There is no internal basic

·3· ·psychologic struggle as a basis for gender

·4· ·incongruence, and that is patent nonsense.

·5· · · · · ·Q.· ·Can you explain what that patent

·6· ·nonsense is?

·7· · · · · ·A.· ·Because we know that gender is a

·8· ·psychologically based concept.· It has no

·9· ·biology.· And that sex is biology.· The

10· ·American Psychological Association, the APA,

11· ·DCM5, stated absolutely and utterly clearly

12· ·gender identity is a very fluid thing.· People

13· ·go in and out of that, on and off, throughout

14· ·their lives.· People don't go in and out of a

15· ·sex.

16· · · · · ·Q.· ·Okay.· So I think I saw that in

17· ·your report.· The DSM-5 and the APA handbook

18· ·state what again?· I'm sorry.

19· · · · · ·A.· ·That there is no biologic basis

20· ·for gender, and the gender identity concept is

21· ·a fluid state.

22· · · · · ·Q.· ·And you reviewed that recently?

23· · · · · ·A.· ·Yes.

24· · · · · ·Q.· ·Okay.· Okay.· So many questions.

25· ·The study -- I think you referred to the term

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·1· ·desist, correct?

·2· · · · · ·A.· ·Yes.

·3· · · · · ·Q.· ·Okay.· And just for the record,

·4· ·could you repeat what that definition is?

·5· · · · · ·A.· ·Okay.· So desistance is the term

·6· ·that has been applied to patients who had

·7· ·gender identity disorder and who through

·8· ·counseling came to align their gender identity

·9· ·with their sex.

10· · · · · ·Q.· ·Okay.· And do you know what like

11· ·the study was that you were referring to for

12· ·that desistance rate?

13· · · · · ·A.· ·There are several studies.

14· ·There's Kenneth Zucker's published studies of

15· ·all 560 of his patients, and then there is a

16· ·study from the Dutch protocol, Voorhees, I

17· ·believe is one of the authors of that that

18· ·looked at the desistance rate.

19· · · · · ·Q.· ·Okay.· And then the 19-fold

20· ·increase of completed suicides.· What study is

21· ·that?

22· · · · · ·A.· ·That's Dhejne.

23· · · · · ·Q.· ·And that's spelled D --

24· · · · · ·A.· ·-- j-e-i-n-e, I believe.

25· · · · · ·Q.· ·Thank you.· Okay.· Okay.

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·1· · · · · ·A.· ·It's often referred to as the

·2· ·Swedish study.

·3· · · · · ·Q.· ·Yeah.· I think I've heard that.

·4· ·Okay.· Great.· We'll come back to that.· Are

·5· ·these materials a part of the education

·6· ·materials that you provide to your patients and

·7· ·their families?

·8· · · · · ·A.· ·Yes.

·9· · · · · · · · MS. INGELHART:· Okay.· We'd like

10· ·to request that.· Do you want us to submit a

11· ·formal discovery request for that set of

12· ·documents, that treatise?

13· · · · · · · · MR. BLAKE:· You're requesting the

14· ·treatise?

15· · · · · · · · MS. INGELHART:· Yes.· Correct.

16· · · · · · · · MR. BLAKE:· Okay.· Noted.

17· · · · · · · · MS. INGELHART:· Would you like us

18· ·to --

19· · · · · · · · MR. BLAKE:· Is that something that

20· ·you can easily get?

21· · · · · · · · THE WITNESS:· Yes.

22· · · · · · · · MR. BLAKE:· Okay.· Yeah, we should

23· ·be able to produce that.

24· · · · · · · · MS. INGELHART:· Okay.· Cool.

25· ·Thanks.

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·1· · · · · · · · THE WITNESS:· Specifically, just

·2· ·the Dhejne setting?

·3· · · · · · · · MS. INGELHART:· No.· The whole

·4· ·treatise.

·5· · · · · · · · THE WITNESS:· Okay.· And then the

·6· ·article, Mayer McHugh?

·7· · · · · · · · MS. INGELHART:· Sure.

·8· · · · · · · · THE WITNESS:· Okay.

·9· · · · · · · · MS. INGELHART:· The ones that --

10· ·I'm not sure how you classify your treatise,

11· ·but the bundle of materials that you provide

12· ·that you said was balanced.

13· · · · · · · · THE WITNESS:· Sure.

14· ·BY MS. INGELHART:

15· · · · · ·Q.· ·Okay.· You referred your patients,

16· ·these 15 patients, out to outside mental health

17· ·professionals who provide the counseling.· Are

18· ·they in the watch and wait program, the

19· ·counseling that you were talking about?· Is

20· ·that the kind of treatment they're receiving?

21· · · · · ·A.· ·No.· It's just general mental

22· ·health care.

23· · · · · ·Q.· ·Okay.· But as it regards to

24· ·treating their gender dysphoria symptoms?

25· · · · · ·A.· ·The symptoms of dysphoria are the

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·1· ·depression and the anxiety.

·2· · · · · ·Q.· ·Okay.

·3· · · · · ·A.· ·It's whether or not it's the

·4· ·undercurrent or the reaction or a combination

·5· ·of that, that's what's being addressed is

·6· ·depression and anxiety.

·7· · · · · ·Q.· ·But would you consider that that

·8· ·treatment plan is the watch and wait, as you

·9· ·described it before?

10· · · · · ·A.· ·Interestingly enough, it is what's

11· ·recommended by the endocrine society

12· ·guidelines, which says in-depth, comprehensive

13· ·evaluation of the patient and their family and

14· ·appropriate treatment.

15· · · · · ·Q.· ·Okay.

16· · · · · ·A.· ·So I'm following that part of the

17· ·endocrine society guidelines.· And if I do, the

18· ·medical part never happens.

19· · · · · ·Q.· ·Okay.· And so if one of your 15

20· ·patients were to, prior to reaching age of

21· ·majority, have treatment with an outside mental

22· ·health professional and begin to present as the

23· ·gender that matches their sex assigned at

24· ·birth, would you see that as a case study that

25· ·you no longer need to keep active?

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·1· · · · · ·A.· ·No.

·2· · · · · · · · LEFT:· Objection.

·3· · · · · · · · THE WITNESS:· No.· I would keep

·4· ·following the patient.

·5· ·BY MS. INGELHART:

·6· · · · · ·Q.· ·Okay.· Okay.· So you wouldn't --

·7· · · · · ·A.· ·Perhaps less frequently, because I

·8· ·would use the mental health provider as the

·9· ·sort of, if you will, monitor of how things are

10· ·going.

11· · · · · ·Q.· ·Okay.· Okay.· Oh, okay.· You said

12· ·you read a lot of articles.

13· · · · · ·A.· ·Yes.

14· · · · · ·Q.· ·Like a ton.· Can you recall

15· ·specifically a few that you've read recently?

16· · · · · ·A.· ·The most recent one was an article

17· ·in a publication called Quilette,

18· ·Q-u-i-l-e-t-t-e, and it's a very beautifully

19· ·written treatise about sort of gender and

20· ·gender behaviors and the spectrum thereof.

21· · · · · ·Q.· ·Okay.

22· · · · · ·A.· ·And it's sort of enlightening.

23· ·It's sort of written from the mental health

24· ·perspective and not really from the standpoint

25· ·of endocrinology specifically.

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·1· · · · · · · · I just read -- there are a number

·2· ·of what I call throwaway publications, in that

·3· ·they're not peer reviewed.· They're just

·4· ·invited people to come in and do opinions.

·5· ·Endocrine News, Pediatric News, and those come

·6· ·out sometimes twice a month or once a month.

·7· ·Monthly, they'll have synopses of lectures that

·8· ·are given, opinion pieces from people, and most

·9· ·often those things are all completely and

10· ·utterly gender affirming.

11· · · · · ·Q.· ·How do you subscribe to those?

12· ·How do you come up on those?

13· · · · · ·A.· ·They're sent to you until you tell

14· ·them no.· And even if you tell them no, they

15· ·still come.

16· · · · · ·Q.· ·I get that.· Thank you, Banana

17· ·Republic.· Hey.

18· · · · · · · · Who are the leader, in your

19· ·opinion, researchers in the area of gender

20· ·discordance?

21· · · · · ·A.· ·Kenneth Zucker.

22· · · · · ·Q.· ·Okay.

23· · · · · ·A.· ·Paul McHugh.

24· · · · · ·Q.· ·Can you spell McHugh for me,

25· ·please?

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·1· · · · · ·A.· ·M-c, Capital H-u-g-h.

·2· · · · · ·Q.· ·Okay.· Thank you.

·3· · · · · ·A.· ·David Pickup is a mental health

·4· ·professional in Texas who writes extensively in

·5· ·treats.· Peter Lee, who is a pediatric

·6· ·endocrinologist, emeritus retired faculty

·7· ·member at Hershey.· He does not write on the

·8· ·subject, but he talks on the subject.· It's

·9· ·interesting, because academic figures tend not

10· ·to express anything contrary publicly.

11· ·Contrary to affirmation publicly.

12· · · · · ·Q.· ·Okay.· Can you explain what you

13· ·mean?· I'm sorry.· I think you're trying to

14· ·pull out something.

15· · · · · ·A.· ·There is fear on the part of

16· ·academic pediatric endocrinologists to openly

17· ·state that affirmation is harmful.

18· · · · · ·Q.· ·Okay.· So did you mean that Lee

19· ·doesn't speak publicly, because he doesn't want

20· ·to share those affirmation type opinions

21· ·publicly?

22· · · · · ·A.· ·Yes.

23· · · · · ·Q.· ·Are Lee, Zucker, McHugh and Pickup

24· ·medical professionals who write or research or

25· ·print on affirmation type care?

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·1· · · · · ·A.· ·Yes.

·2· · · · · ·Q.· ·Okay.· As you would define

·3· ·affirmation?

·4· · · · · ·A.· ·Yes.

·5· · · · · ·Q.· ·Okay.· What's the best source for

·6· ·learning the standards of care on professional

·7· ·guidelines?

·8· · · · · · · · MR. BLAKE:· Objection.

·9· ·BY MS. INGELHART:

10· · · · · ·Q.· ·In your opinion?

11· · · · · ·A.· ·Well, standard of care and

12· ·guidelines are different.

13· · · · · ·Q.· ·Okay.

14· · · · · ·A.· ·So a standard of care from my

15· ·world view is something that is prepared

16· ·essentially to use as a legal document. I

17· ·mean, a statement -- you can be sued for

18· ·malpractice if you do something that is not a

19· ·standard of care, and there's an adverse

20· ·outcome.

21· · · · · ·Q.· ·Okay.

22· · · · · ·A.· ·A clinical guideline is just that.

23· ·It's a guideline.· You know, these ideas that

24· ·we think generally are appropriate.· We've got

25· ·literature that supports them or doesn't

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·1· ·support them, and we want you to know about

·2· ·them.· Because this is something that either is

·3· ·confusing or perhaps controversial, and so we

·4· ·want to be able to present what we think

·5· ·experts in the field would recommend that you

·6· ·do.

·7· · · · · · · · So the Endocrine Society does

·8· ·clinical guidelines for a number of things.

·9· ·Treatment of Cushing disease, for instance.· If

10· ·it's a very complex thing, it's a very

11· ·difficult diagnosis to make, there's a lot of

12· ·murkiness in terms of the studies that you use

13· ·to come up with a conclusion to intervene and

14· ·treat, and because of that they developed

15· ·clinical guidelines.· They just published the

16· ·clinical guidelines on congenital adrenal

17· ·hyperplasia.· It can be and most often is a

18· ·mild form of a differential sexual -- disorder

19· ·of sex differentiation.

20· · · · · · · · Treatment of Turner Syndrome.

21· ·These are things that are particularly in

22· ·pediatric endocrine purview.

23· · · · · ·Q.· ·And so there's guidelines?

24· · · · · ·A.· ·Right.· They are guidelines.· And

25· ·guidelines for treatment with adult males with

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·1· ·testosterone or post menopausal with hormonal

·2· ·replacement therapy.· So these are written not

·3· ·as standards of care but to say, you know,

·4· ·there are a lot of opinions on this.· What

·5· ·we've tried to do is to call the world's

·6· ·literature and show you the scientific basis,

·7· ·and the Endocrine Society guidelines are graded

·8· ·on a scale of 1 to 4.· 1 being no scientific

·9· ·evidence whatsoever, and 4 being very strong

10· ·scientific evidence.

11· · · · · ·Q.· ·Okay.

12· · · · · ·A.· ·And so every one of their

13· ·recommendations has --

14· · · · · ·Q.· ·I see.

15· · · · · ·A.· ·Yeah.· One or four checks or

16· ·circles filled in.· And so that gives you, if

17· ·you're sort of a critical reviewer, an idea

18· ·about is this scientifically based or not.

19· · · · · ·Q.· ·Okay.

20· · · · · ·A.· ·And so interestingly the endocrine

21· ·society guidelines for transgender care, the

22· ·majority of them have either no or very little

23· ·published science to back them up.

24· · · · · ·Q.· ·Okay.

25· · · · · ·A.· ·And that's alarming, but, you

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·1· ·know, as a practitioner, if something comes out

·2· ·as a clinical guideline and you are a busy

·3· ·practitioner who doesn't often see these

·4· ·things, and that's the case for most

·5· ·endocrinologists up until now, is that

·6· ·transgender patients were far and few between

·7· ·and particularly in pediatrics.· And so your

·8· ·professional society comes out and publishes a

·9· ·set of clinical guidelines, and you think,

10· ·okay, great, wow.· You go to the summary.· You

11· ·don't take the time necessarily to read through

12· ·it critically.· Okay?

13· · · · · ·Q.· ·Okay.

14· · · · · ·A.· ·If you are part-time academician,

15· ·part-time clinical practitioner, you read

16· ·everything in absolute and utter detail.· Okay?

17· ·And academic programs and their journal clubs

18· ·will very specifically take an article like

19· ·this, and they will literally take it totally

20· ·apart.· They'll go to every reference.· They'll

21· ·go back through.· They'll go out and research

22· ·things that, this paragraph says here, guess

23· ·what I found.· You know, a study in the journal

24· ·of whatever or whatever that's completely

25· ·against this.· Okay?

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·So that's not done by

·3· ·endocrinologists in general or by pediatric

·4· ·endocrinologists in general.· And in clinical

·5· ·practice, you know, I see patients four days a

·6· ·week and admin stuff sprinkled in.· Four full

·7· ·days, if you count all the hours up, and, you

·8· ·know, I haven't got time to do that unless I

·9· ·make an effort.

10· · · · · ·Q.· ·Right.

11· · · · · ·A.· ·So I tend to just pay a lot more

12· ·attention to the transgender stuff, because it

13· ·becomes for me a necessity that somebody's got

14· ·to do the job.

15· · · · · ·Q.· ·Okay.

16· · · · · ·A.· ·And I'm willing to take the time

17· ·to do that as best I can.· The person that

18· ·critiqued this article actually went through

19· ·from stem to stern and point by point by point.

20· ·Something I would love to have the time to do

21· ·but didn't, and it was sort of done for me by

22· ·somebody who was clearly -- he actually is a

23· ·very LGB activist psychologist.

24· · · · · ·Q.· ·LGB?

25· · · · · ·A.· ·LGB.· Yeah.· And he said, whoa,

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·1· ·whoa, whoa, whoa.· You know.· Let's look at

·2· ·this in-depth, because this is a

·3· ·misrepresentation of facts.

·4· · · · · ·Q.· ·And the doctor who did that kind

·5· ·of annotation and the new article, did you say

·6· ·that was Dr. Cox?

·7· · · · · ·A.· ·Cox.· C-o-x.· And I can actually

·8· ·get a copy of that to you.

·9· · · · · ·Q.· ·That would be great.

10· · · · · ·A.· ·I don't have it on my memory.· If

11· ·you'll remind me to provide that.

12· · · · · ·Q.· ·Thank you.· We would appreciate

13· ·that.· Okay.· And -- oh, shoot.· I lost my

14· ·train of thought.· Oh, okay.· So guidelines are

15· ·found in documents like what we're looking at.

16· ·They are often, I don't want to say always,

17· ·often created by professional associations in

18· ·that specific field, but they're not the same

19· ·-- they're not using the same weight in like a

20· ·legal malpractice proceeding?· They're just

21· ·guidelines?

22· · · · · ·A.· ·That's correct.

23· · · · · ·Q.· ·Where are standards of care found,

24· ·or how is that established?

25· · · · · ·A.· ·If somebody wants to establish a

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·1· ·set of things that this is what should be done

·2· ·and this is what's right and this is what's

·3· ·wrong, and they just create those, and they

·4· ·publish them.

·5· · · · · ·Q.· ·Who does that?

·6· · · · · ·A.· ·WPATH did that in this case. I

·7· ·don't know other standards of care,

·8· ·specifically, but I'm sure they do exist,

·9· ·because I have been asked in medical testimony

10· ·and depositions and stuff, are you aware of

11· ·standards of care versus clinical guidelines.

12· ·So I got most of my information about the

13· ·difference of those from attorneys in sort of

14· ·malpractice cases, particularly.

15· · · · · ·Q.· ·Okay.· Okay.· So what's the best

16· ·source for learning standards of care?

17· · · · · · · · MR. BLAKE:· Objection.

18· ·BY MS. INGELHART:

19· · · · · ·Q.· ·What do you use to learn or to

20· ·access standards of care?

21· · · · · ·A.· ·I don't often access standards of

22· ·care.

23· · · · · ·Q.· ·Okay.

24· · · · · ·A.· ·I look for clinical guidelines for

25· ·support.

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·1· · · · · ·Q.· ·All right.· Were you on faculty

·2· ·between -- anywhere between 1978 and 1980?

·3· · · · · ·A.· ·Yes.

·4· · · · · ·Q.· ·Where were you?

·5· · · · · ·A.· ·1978 to -- excuse me.· From 1976

·6· ·to '78, I was at LSU School of Medicine.· I was

·7· ·a fellow until -- 1980 to 1986 I was on

·8· ·clinical faculty at UC San Diego Medical

·9· ·School.· From 1986 to 1991 I was clinical

10· ·faculty at University of California San

11· ·Francisco School of Medicine.

12· · · · · ·Q.· ·Okay.

13· · · · · ·A.· ·And from that to Emory and

14· ·Morehouse.

15· · · · · ·Q.· ·And when did you leave the UC

16· ·system?

17· · · · · ·A.· ·I was transferred when I completed

18· ·my Navy career and moved to Atlanta.

19· · · · · ·Q.· ·Did the Navy transfer you to

20· ·Atlanta?

21· · · · · ·A.· ·No.· I finished my career, and

22· ·that was my final move after I -- they say,

23· ·goodbye, thanks, and move you to wherever

24· ·you're going to go.

25· · · · · ·Q.· ·Oh, they moved --

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·1· · · · · ·A.· ·They move you, yeah.

·2· · · · · ·Q.· ·So you choose where you want to

·3· ·go, and the government --

·4· · · · · ·A.· ·Yeah.· Yeah.

·5· · · · · ·Q.· ·-- as a nice gift says, we'll pay

·6· ·for that --

·7· · · · · ·A.· ·Right.

·8· · · · · ·Q.· ·-- expensive across country?

·9· · · · · ·A.· ·Right.

10· · · · · ·Q.· ·Got it.· Why did you choose

11· ·Atlanta?

12· · · · · ·A.· ·One of the job opportunities that

13· ·was available was in Southern Suburbs of

14· ·Atlanta, in Fayette County, Georgia.

15· · · · · ·Q.· ·One of the pediatricians in the

16· ·multi-specialty group was a resident that I had

17· ·trained with many, many years before.· He had

18· ·left the Navy after a very short period of

19· ·time, and he was done with his obligated

20· ·service and moved back to Georgia and then was

21· ·recruited from his home in Macon to come up to

22· ·Fayette County, Georgia to practice.· And they

23· ·were looking for a pediatrician, and he knew me

24· ·and he said, would you come look?

25· · · · · · · · And I said, Georgia?· I don't know

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·1· ·anything about Georgia.· We had no roots there,

·2· ·no family, no experience whatsoever.· And

·3· ·landed there and put our feet in red clay and

·4· ·probably will never leave.

·5· · · · · ·Q.· ·It's a great state.

·6· · · · · ·A.· ·Yeah.

·7· · · · · ·Q.· ·Well, thank you.· You've never

·8· ·worked as a mental health professional, right?

·9· · · · · · · · MR. BLAKE:· Objection.

10· · · · · · · · THE WITNESS:· Not as a certified

11· ·mental health professional, no.

12· ·BY MS. INGELHART:

13· · · · · ·Q.· ·You never worked as a

14· ·psychologist, correct?

15· · · · · ·A.· ·No.

16· · · · · ·Q.· ·Or as a psychiatrist?

17· · · · · ·A.· ·No.

18· · · · · ·Q.· ·You've never worked as a

19· ·geneticist either, correct?

20· · · · · ·A.· ·No.

21· · · · · ·Q.· ·What's the age range of your

22· ·patients?

23· · · · · ·A.· ·Birth to completion of first

24· ·undergraduate degree in college.· So it's 22,

25· ·23.· I have very few patients who are in their

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·1· ·late 20s who are neurologically compromised,

·2· ·and they're essentially children for all

·3· ·intents and purposes, an adult.· Endocrine

·4· ·folks don't like to take care of them.· So

·5· ·we're their home.

·6· · · · · ·Q.· ·Are those patients often patients

·7· ·you've treated over the course of their life?

·8· · · · · ·A.· ·Yes.· I don't often accept

·9· ·patients past 18, who have not been with me

10· ·before.

11· · · · · ·Q.· ·Okay.· Have you treated children

12· ·with intersex conditions?

13· · · · · ·A.· ·Yes.

14· · · · · ·Q.· ·Do you currently treat children

15· ·with intersex conditions?

16· · · · · ·A.· ·Yes.

17· · · · · ·Q.· ·How many do you currently treat?

18· · · · · ·A.· ·I think the number of active

19· ·patients I have now, perhaps 20 kids who have

20· ·adrenal hyperplasia, which is a very, very mild

21· ·form.

22· · · · · ·Q.· ·Okay.

23· · · · · ·A.· ·I have I think four patients with

24· ·complete androgen insensitivity.

25· · · · · ·Q.· ·Okay.

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·1· · · · · ·A.· ·I have one patient who is referred

·2· ·to as an XX male.· That's sort of a catch

·3· ·basket.· No one understands specifically what

·4· ·happened, but his karyotype is XX, and he had

·5· ·all male genitalia, produced testosterone.

·6· ·It's just one of those very rare -- super rare

·7· ·ones.

·8· · · · · · · · I have, gosh, two or three dozen

·9· ·Klinefelter's kids, but I don't consider them

10· ·DSDs at all.· That's an inappropriate use of

11· ·the term.

12· · · · · ·Q.· ·Why is that?

13· · · · · ·A.· ·Because it's not a sexual

14· ·differentiation issue.· They have an extra X

15· ·chromosome, but the only effect is it causes

16· ·infertility to them.· They have no anatomic

17· ·female organs anywhere, and there's no

18· ·ambiguity of genitalia whatsoever.· They just

19· ·have dysfunctional testes.

20· · · · · ·Q.· ·Okay.· So it affects their

21· ·reproduction.· What about the XX male?· It

22· ·sounds like they don't have --

23· · · · · ·A.· ·This particular one -- I've never

24· ·had anybody tell me they've ever treated one

25· ·before.· It was so rare that essentially it's

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·1· ·not even in endocrine textbooks really.· It's

·2· ·in genetics literature.· This is a boy who's

·3· ·autistic, who has male genitalia, and when they

·4· ·did the -- I can't remember specifically.· Oh,

·5· ·Mom had an -- she was older.· So they did in

·6· ·the pregnancy, sort of when you have a boy or

·7· ·girl or any Down syndrome or whatever, so she

·8· ·had an amniocentesis which said XX.· So they

·9· ·were all prepared for a girl.· This was

10· ·pre-ultrasound.· They weren't doing ultrasounds

11· ·routinely on every pregnancy that looked at

12· ·genitalia back then.· Ultrasound technology was

13· ·relatively crude, and they weren't thinking

14· ·they needed to do that.

15· · · · · · · · And so out comes a baby boy, and

16· ·they said, no, no, no, no.· What's wrong with

17· ·this?· Testicles descended.· No ambiguity of

18· ·genitalia whatsoever.· So they repeated the

19· ·chromosome analysis in the baby and came up

20· ·with XX.· A hundred percent XX.· So that

21· ·startled everybody, and that got me to go

22· ·searching, and I found the entity of XX male,

23· ·and that's what this child had.

24· · · · · ·Q.· ·Okay.· And that male has endocrine

25· ·medical needs?

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·1· · · · · ·A.· ·No.· Actually, did not.· There was

·2· ·a point in time where the testes sort of became

·3· ·retractile and very difficult to find, but they

·4· ·were there at birth.· I had documented they

·5· ·were there at birth, and then I kept following

·6· ·him just out of curiosity.· I mean I'm not

·7· ·going to need to do any medical treatment, but

·8· ·this is an educational experience for me.· And

·9· ·because of his autism and the fact that I was

10· ·also a general pediatrician in practice at that

11· ·time, I became that child's general

12· ·pediatrician and followed him along for routine

13· ·medical care.

14· · · · · · · · And then when I left my pediatric

15· ·practice behind in 2003 and did full-time

16· ·endocrine, the mom just came over to me and

17· ·said, can I continue to come to you even though

18· ·there's no really endocrine issues at all?

19· · · · · · · · I made sure that he went through

20· ·puberty appropriately, which he did.

21· ·Everything was smooth.· Hormone levels were

22· ·fine.· There was no evidence of any gonadal

23· ·damage, and the autism was the key.· The key

24· ·problem for him.

25· · · · · ·Q.· ·Okay.· Have you done any

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·1· ·scientific research related to the gender

·2· ·dysphoria?

·3· · · · · ·A.· ·I have not.

·4· · · · · ·Q.· ·Related generally to transgender

·5· ·people?

·6· · · · · ·A.· ·No.

·7· · · · · ·Q.· ·Anything related to any gender

·8· ·issues in scientific research?

·9· · · · · ·A.· ·No.

10· · · · · ·Q.· ·Okay.· Have you published any

11· ·books or articles addressing gender dysphoria?

12· · · · · ·A.· ·I have.

13· · · · · ·Q.· ·What are those?

14· · · · · ·A.· ·Most recently is actually an

15· ·article that will come out in October in Issues

16· ·in Law and Medicine, and it's a sort of

17· ·comparison of counseling treatment, so-called

18· ·watch and wait, versus affirmation, and the

19· ·pathways for each and the known outcomes for

20· ·each that are in published literature.

21· · · · · ·Q.· ·And just to be clear for the

22· ·record, watch and wait versus affirmation,

23· ·affirmation in this context means gender

24· ·affirming affirmation?

25· · · · · ·A.· ·That's correct.

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·1· · · · · ·Q.· ·Thank you.· Okay.· How does one

·2· ·get an article published in Issues in the Law?

·3· · · · · · · · MR. BLAKE:· Objection.

·4· ·BY MS. INGELHART:

·5· · · · · ·Q.· ·Oh.· And Medicine.· I'm sorry.

·6· · · · · ·A.· ·You're either invited to send it

·7· ·in for peer review, or you can volunteer and

·8· ·send it in for review.· Either way.

·9· · · · · ·Q.· ·So it's a peer review journal?

10· · · · · ·A.· ·It's a peer review journal.

11· · · · · ·Q.· ·Got it.

12· · · · · ·A.· ·I'm sorry.

13· · · · · ·Q.· ·I should have asked that more

14· ·artfully.· Okay.· Issues in Law and Medicine.

15· ·Will your article have both issues of law and

16· ·medicine discussed within it?

17· · · · · ·A.· ·No.

18· · · · · ·Q.· ·Will your articles just have

19· ·issues of medicine discussed with that?

20· · · · · ·A.· ·Yes.

21· · · · · ·Q.· ·Okay.· So then will your peer

22· ·reviewers also only be medical professionals?

23· · · · · ·A.· ·I think there are bioethic people

24· ·as well.· So it crosses over a bit into law.

25· · · · · ·Q.· ·Oh, okay.· Bioethics and an area

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·1· ·of law.

·2· · · · · ·A.· ·Yeah.

·3· · · · · ·Q.· ·Okay.· I understand.· So that's

·4· ·the most recent one, and have you published

·5· ·other articles or books -- or articles, I

·6· ·guess?

·7· · · · · ·A.· ·Let me think.· I mean we did the

·8· ·letter to the editor of Journal of Clinical

·9· ·Endocrinology Metabolism, which was published

10· ·in March of 2019.

11· · · · · ·Q.· ·Okay.

12· · · · · ·A.· ·And that was essentially a

13· ·critique of the 2017 guidelines.

14· · · · · ·Q.· ·And that was not a peer reviewed

15· ·article.· It was a letter to the editor?

16· · · · · ·A.· ·It was a letter to the editor,

17· ·yeah.· It's very difficult to get anything

18· ·published.

19· · · · · ·Q.· ·Agreed.· Okay.· You belong to

20· ·professional associations, correct?

21· · · · · ·A.· ·Yes.

22· · · · · ·Q.· ·Could you list that?· Do you know

23· ·them off the top of your head?

24· · · · · ·A.· ·The endocrine Society, which it

25· ·requires training in the field of

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·1· ·endocrinology.

·2· · · · · ·Q.· ·Okay.

·3· · · · · ·A.· ·I don't think board certification

·4· ·is required.· I belong to the Georgia Chapter

·5· ·of the American Academy of Pediatrics, but I

·6· ·left the membership with the National American

·7· ·Academy of Pediatrics five years ago.

·8· · · · · ·Q.· ·And why did you leave?

·9· · · · · ·A.· ·I just got tired of nonsense.

10· · · · · ·Q.· ·Okay.· What nonsense?

11· · · · · ·A.· ·Policy statements like this one

12· ·that are based on profound lack of valid

13· ·science.· Essentially, it became a social

14· ·political organization and not a medical

15· ·professional organization in my personal

16· ·opinion.· The Georgia Chapter maintains a

17· ·strong interest in legislative efforts in the

18· ·State of Georgia for the benefit and welfare of

19· ·children, which is most often devoid of social

20· ·activism.· If it's activism, it's activism in

21· ·general for the proven benefit of children.

22· ·Its concept is if it's good for children, then

23· ·Georgia Chapter generally will be supportive.

24· ·It's not completely, but it's way more than the

25· ·national organization, its parent organization.

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·1· · · · · · · · I belong to the American Diabetes

·2· ·Association, which is just dues paying.· You

·3· ·are a professional member or a nonprofessional

·4· ·member.

·5· · · · · · · · I belong to the Pediatric

·6· ·Endocrine Society, which is a national

·7· ·organization.· And I honestly don't know

·8· ·whether a degree is required, but the

·9· ·membership categories are if you're a

10· ·practicing and board certified endocrinologist,

11· ·you're sort of listed one way.· If you're an

12· ·affiliate, you're listed.· Or if you're from a

13· ·foreign country, you can be an affiliate.

14· · · · · ·Q.· ·Okay.

15· · · · · ·A.· ·I am a member of the American

16· ·College of Pediatricians.· Which is a

17· ·professional organization established in 2002,

18· ·I believe.

19· · · · · ·Q.· ·Okay.

20· · · · · ·A.· ·And it's an organization that

21· ·specifically looked at the American Academy of

22· ·Pediatrics as an organization politically

23· ·bound, and they wanted politics to be separate

24· ·from that, and so that they said, if we can't

25· ·make decisions that are based on valid science,

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·1· ·that the goal is specifically what is

·2· ·scientifically proven to be a clear benefit to

·3· ·children and recommended those policies.· And

·4· ·so we have some things in common with the

·5· ·American Academy of Pediatrics on a number of

·6· ·things.

·7· · · · · · · · We're a little easier to get up

·8· ·and run and make a statement about particular

·9· ·things, because our size is significantly

10· ·smaller, and we can access our membership

11· ·fairly quickly and get a read from the

12· ·membership and executive board and board

13· ·members to say, is this a concern that we

14· ·should address or not?· The American Academy of

15· ·Pediatrics says 67,000 members.· It's a

16· ·gigantic organization centered near Chicago.

17· ·It used to be a group that would listen to the

18· ·constituency, bring in input and sort of digest

19· ·it.· But over the past 30 years it's moved

20· ·completely away from that and is essentially

21· ·run by an executive committee of 12 members and

22· ·a, if you will, sort of a cadre of long-term

23· ·career people that are the bureaucrats within

24· ·the organization, who essentially run the

25· ·organization.

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·1· · · · · · · · And I maintained my membership in

·2· ·that organization as long as I could.· I was on

·3· ·their committee looking at guidelines and

·4· ·appropriate things for peer reviewed education

·5· ·opportunities and growth pubertal development.

·6· ·That was sort of easy to do, because there

·7· ·really wasn't any controversy.· There were

·8· ·things that were beginning to creep in that

·9· ·were inaccurate that I was able and I felt my

10· ·input was listened to and other people had

11· ·their opinion, and their educational material

12· ·then was guided back to a more essential and

13· ·scientifically based educational treatise.

14· · · · · · · · On the case of obesity they went

15· ·off the deep end, and it's very difficult for

16· ·me to read what they recommend and what they

17· ·say, because it turns out it doesn't work.· And

18· ·that's my own personal opinion.· I have an

19· ·enormous amount of clinical experience with

20· ·obese children, approaching it in a vastly

21· ·different way and coming out with a remarkably

22· ·successful treatment option that works.

23· ·Whereas, what they're recommending is just the

24· ·same thing it has been forever, and it's not

25· ·successful.· Ten percent success rate over

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·1· ·obesity.· I have about a 75 percent success

·2· ·rate.

·3· · · · · · · · And I gave input to that

·4· ·committee, and it was as if I weren't even in

·5· ·the room or on the telephone call.· And I

·6· ·decided, you know, I just -- I'm spinning my

·7· ·wheels, and I'm not getting anywhere.· It's

·8· ·just yet another reason why I really don't want

·9· ·to spend my time and effort at the American

10· ·Academy of Pediatrics.· So I left that

11· ·organization finally.

12· · · · · ·Q.· ·Why didn't they listen to your

13· ·opinions about the obesity?

14· · · · · ·A.· ·Because I'm a private practitioner

15· ·that doesn't do clinical research.

16· · · · · ·Q.· ·Okay.

17· · · · · ·A.· ·The American Academy of Pediatrics

18· ·began as an organization not of academicians

19· ·but of practicing physicians.

20· · · · · ·Q.· ·Okay.

21· · · · · ·A.· ·And actually the academic

22· ·pediatric community, their professional

23· ·organizations were the American Pediatric

24· ·Association and the Society for Pediatric

25· ·Research.· Very small cadre of academic

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·1· ·pediatricians who -- and I happen to be a

·2· ·member of the regional meetings for the Society

·3· ·for Pediatric Research and got to know a lot

·4· ·about how those organizations work and what

·5· ·their interests were, and it was a very snobby

·6· ·academic environment that looked down on the

·7· ·American Academy of Pediatrics as general

·8· ·practitioners who were just local yocals. I

·9· ·mean, honestly, what were used to be referred

10· ·to as LMDs.· Okay?· Local medical doctors.

11· · · · · ·Q.· ·Oh.

12· · · · · ·A.· ·People who were not in touch with

13· ·academia.

14· · · · · ·Q.· ·Okay.

15· · · · · ·A.· ·Okay.· The AAP as an organization

16· ·had tons of members, because it provided an

17· ·opportunity for CME.· Gave conferences dozens

18· ·of times a year regionally, nationally, twice a

19· ·year, worked hand-in-hand with the governing

20· ·boards of the certification societies and

21· ·whatnot, and the academic pediatricians saw

22· ·that as a need.· They needed to be involved in

23· ·that and stop looking down at them.· So they

24· ·basically came in and essentially took over the

25· ·organization.

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·1· · · · · · · · And it does not represent

·2· ·pediatricians.· It represents academic

·3· ·interests and social theory and politics.· And

·4· ·it's just like -- politics exist.· They're

·5· ·going to.· But when you start making policy

·6· ·statements like this and others that are an

·7· ·embarrassment in terms of lack of scientific

·8· ·validity, and they are not the opinion of the

·9· ·membership.· They are the opinion of a

10· ·committee.· Okay?· This paper does not

11· ·represent the opinion of pediatricians at all.

12· · · · · ·Q.· ·How do you know that?

13· · · · · ·A.· ·Because I've talked to

14· ·pediatricians.· All my referring pediatricians

15· ·that know me.· They were not asked.· This was

16· ·not put out for a review and your opinion.· The

17· ·American College, however, sends absolutely

18· ·every policy statement out to the full

19· ·membership and will not publish anything as a

20· ·policy statement unless it has approval of 75

21· ·percent of membership.

22· · · · · ·Q.· ·How big is the membership of the

23· ·college?

24· · · · · ·A.· ·It exceeds 500.

25· · · · · ·Q.· ·And how big is the membership of

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·1· ·the AAP?

·2· · · · · ·A.· ·67,000.

·3· · · · · ·Q.· ·Okay.· So you mentioned opinions,

·4· ·politics, et cetera, at the AAP that you

·5· ·disagreed with.· You also said there was

·6· ·conflict with your professional opinions about

·7· ·trans issues and OBC.· Were there any other

·8· ·areas of medicine?

·9· · · · · ·A.· ·Attention deficit disorder,

10· ·learning disabilities, in terms of the

11· ·evaluation, and that really kind of jelled in

12· ·with attention deficit disorder as an entity.

13· ·It's another entity for which there is no

14· ·diagnostic test.· Okay?· It's treated.· The

15· ·pharmacology industry has answers to

16· ·everything, and as a general pediatrician who

17· ·perks it from a different world view and was

18· ·much more successful in handling things and

19· ·actually getting to the root of the problems, I

20· ·had total disagreement with the guidelines and

21· ·representation there.

22· · · · · · · · There were some developmental

23· ·pediatrician -- developmental pediatrics

24· ·became, aside from neurology, a subspecialty

25· ·that was full of really strange people who were

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·1· ·not dealing with science at all and who were

·2· ·invited to speak and again were an

·3· ·embarrassment because of their clearly sort of

·4· ·anecdotal approach to everything.

·5· · · · · ·Q.· ·Were they doctors?

·6· · · · · ·A.· ·Yeah.

·7· · · · · ·Q.· ·Oh, okay.

·8· · · · · ·A.· ·They were pediatricians, actually.

·9· · · · · ·Q.· ·Okay.

10· · · · · ·A.· ·So medicine is full of things like

11· ·that.· Again, when there are battles to choose

12· ·that you think you can possibly make a

13· ·difference with and the scope of trying to

14· ·approach ASMA management, from my standpoint, I

15· ·was a tiny, tiny, tiny, tiny drop in an ocean,

16· ·and I knew that I wasn't going to get anywhere

17· ·trying to fight that battle.

18· · · · · · · · I just took care of my patients,

19· ·and I did well.· I did much better by then,

20· ·because of my methods of treatment.· Then those

21· ·that were recommended by the AAP and

22· ·guidelines, and so, you know, it's a situation

23· ·where always the focus is exactly what is best

24· ·for the children, what works, what creates the

25· ·least harm and what shows ongoing constant

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·1· ·compassion for the patient and why they came to

·2· ·see you.

·3· · · · · ·Q.· ·Okay.· Thank you.· So I understand

·4· ·your relationship with the American Academy of

·5· ·Pediatrics and the Georgia Chapter.· Are you a

·6· ·leader or an officer in the Pediatric Endocrine

·7· ·Society?

·8· · · · · ·A.· ·No, I'm not.

·9· · · · · ·Q.· ·Okay.· How many members are in

10· ·that group?· Do you know?

11· · · · · ·A.· ·I don't know.· I would guess about

12· ·a thousand.

13· · · · · ·Q.· ·Okay.· Do you know whether the

14· ·Pediatric Endocrine Society has a policy

15· ·statement on the treatment of trans or --

16· · · · · ·A.· ·They do.· They do.

17· · · · · ·Q.· ·Okay.· Are you familiar with that?

18· · · · · ·A.· ·I am.

19· · · · · · · · (Thereupon, Plaintiffs' Exhibit 2,

20· ·Statement on gender-affirmative approach to

21· ·care from the pediatric endocrine society

22· ·special interest group on transgender health,

23· ·was marked for identification purposes.)

24· ·BY MS. INGELHART:

25· · · · · ·Q.· ·Okay.· Plaintiffs' Exhibit 2.· So

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·1· ·do you recognize this document?

·2· · · · · ·A.· ·I do.

·3· · · · · ·Q.· ·And what is it?

·4· · · · · ·A.· ·It's a statement on

·5· ·gender-affirmative approach to care from the

·6· ·pediatric endocrine society special interest

·7· ·group on transgender health.

·8· · · · · ·Q.· ·Okay.· Could we turn to what is

·9· ·the second page, but it's called Page 476 here?

10· · · · · ·A.· ·Yes.

11· · · · · ·Q.· ·And look in the section on the

12· ·right-hand column called mental health care of

13· ·transgender youth.· Do you disagree with this

14· ·first paragraph statement here, there are no

15· ·data to support the use of reparative or

16· ·conversion therapy with the intention of

17· ·changing one's gender identity or sexual

18· ·orientation?· Furthermore, the American

19· ·Psychological Association, the American

20· ·Psychiatric Association and the American

21· ·Academy of Pediatrics, reject this form of

22· ·therapy and support a more trans-affirmative

23· ·model of care?

24· · · · · ·A.· ·I'm totally in opposition to that

25· ·statement.

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·1· · · · · ·Q.· ·Okay.· And why is that?

·2· · · · · ·A.· ·Because it has no scientific

·3· ·validity.

·4· · · · · ·Q.· ·Okay.· So you --

·5· · · · · ·A.· ·You know, the term -- and this is

·6· ·a common thing -- reparative or conversion

·7· ·therapy refers to essentially talk therapy.

·8· ·You know, there is no standard of care that has

·9· ·been practiced that anyone is aware of or can

10· ·prove has every actually happened, and there

11· ·are cases brought against them, litigation

12· ·against an individual, for electric shock and

13· ·rape and all the things that are constantly

14· ·brought up as what conversion therapy is or

15· ·aversive therapy.· Ice baths and things like

16· ·that.· Rubber band shocks and things like that.

17· ·That's not a standard of care, but it's always

18· ·referred to.

19· · · · · · · · So if they're talking about those

20· ·things, yes, but those are not ever recommended

21· ·by anybody who is a reputable practitioner in

22· ·mental health, who's trained, who has any

23· ·certification.· Are they done?· I have no idea,

24· ·but there are no case reports of them actually

25· ·having been done.

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·1· · · · · · · · There are anecdotal reports of

·2· ·this was done to me.· It's kind of like the

·3· ·movie Monty Python and the Holy Grail.· How do

·4· ·you know she's a witch?· Well, she turned me

·5· ·into a newt.· Are you familiar with that

·6· ·particular scene?

·7· · · · · ·Q.· ·No.· I don't think I understand

·8· ·that message.

·9· · · · · ·A.· ·And of course the man is not a

10· ·newt, and the people around him look at him and

11· ·say, what?· And he says, oh, but I got better.

12· · · · · ·Q.· ·Okay.

13· · · · · ·A.· ·So that is the validity.· An

14· ·anecdotal report without any scientific or

15· ·documented actual happening.· Just a statement

16· ·by somebody.· Okay?

17· · · · · ·Q.· ·Okay.

18· · · · · ·A.· ·So that to me immediately negates

19· ·the entire thing, because we're not talking

20· ·about conversion at all.· We're not talking

21· ·about reparative, unless you're trying to

22· ·repair mental health issues and repair

23· ·depression, anxiety, and in that case that is a

24· ·repair, if you will.· But that is meant as a

25· ·pejorative term as harm.· Okay?

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·1· · · · · · · · And so by stating that, I know

·2· ·already the entire bias.· I happen to know Dr.

·3· ·Rosenthal personally.· I've known him since he

·4· ·was in his fellowship training.

·5· · · · · ·Q.· ·Okay.

·6· · · · · ·A.· ·He is very agenda driven, and he's

·7· ·never left academia.· He's only been where he

·8· ·trained.· He's at UC San Francisco where he was

·9· ·a fellow, and he's never departed from there.

10· ·I often, knowing him as I do and having been

11· ·familiar with that training program that he

12· ·came from, his mentors in that training program

13· ·are all deceased at this point in time, but

14· ·they were notorious for ripping to shreds, even

15· ·ripping each other to shreds, over the lack of

16· ·scientific validity of things.· And if I have

17· ·an opportunity, without being -- not affronting

18· ·him in any way, I would like to say, Stephen,

19· ·none of this would hold up with your faculty

20· ·members.· They would have torn this to shreds,

21· ·because it's not based on science, and you know

22· ·it, and I know it.· Okay?

23· · · · · ·Q.· ·Okay.· So have you reviewed this

24· ·entire document?

25· · · · · ·A.· ·I have.· I have.· I can't quote

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·1· ·chapter and verse, but when it came out I read

·2· ·it.· I actually read the proposed version and

·3· ·sent in a critique of it.· It was invited,

·4· ·interestingly, by Stephen Rosenthal to

·5· ·specifically write critiques.· He specifically

·6· ·said after -- and this is how I know my letter

·7· ·to the Endocrine Society and my critique of

·8· ·their guidelines, because he was on that

·9· ·committee as well -- the things that I

10· ·critiqued about the Endocrine Society

11· ·guidelines he specifically in the invite to

12· ·critique these guidelines said, above all,

13· ·don't bring· up this, this and this.· Which

14· ·were the things that I brought up and others

15· ·had brought up.· So he was aware of the things

16· ·that they didn't want, and they didn't include

17· ·anything here in these guidelines, didn't

18· ·change anything.

19· · · · · ·Q.· ·What were those things?

20· · · · · ·A.· ·Just the lack of scientific

21· ·validity and the issues of harm done by what's

22· ·called talk therapy and avoidance.· You know,

23· ·statements like the undercurrent emotional

24· ·issues don't exist.· They're only reactive.

25· ·And it says it right in here.

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·1· · · · · ·Q.· ·Okay.· So is talk therapy

·2· ·conversion therapy?· I'm confused.

·3· · · · · ·A.· ·Talk therapy is called conversion

·4· ·therapy, yeah.· Talk therapy is essentially

·5· ·conversion therapy.· That's what they're

·6· ·referring to.

·7· · · · · ·Q.· ·And talk therapy is not the type

·8· ·of therapy you get when you watch and wait?

·9· · · · · ·A.· ·No.

10· · · · · ·Q.· ·Okay.· Okay.· Okay.· So you're

11· ·just saying that they're using terms that you

12· ·think represent something else here?

13· · · · · ·A.· ·Yes.

14· · · · · ·Q.· ·Okay.

15· · · · · ·A.· ·And the next paragraph, although

16· ·rates of depression are two to three times

17· ·higher in transgender youth versus non, it's

18· ·basically in response to societal rejection.

19· ·Okay?· Totally unvalidated.

20· · · · · ·Q.· ·What's unvalidated?· I'm sorry.

21· · · · · ·A.· ·That their suicide and depression

22· ·and anxiety is related to societal rejection

23· ·entirely.

24· · · · · ·Q.· ·So it's been unvalidated in

25· ·scientific data that societal pressures lead to

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·1· ·those mental health issues?

·2· · · · · ·A.· ·They are not the -- these kids

·3· ·have these issues beforehand.· It's been

·4· ·conservatively stated that 70 percent of

·5· ·transgender kids have undercurrent emotional

·6· ·issues.· In my clinical experience, it's a

·7· ·hundred percent.· So it depends on what you

·8· ·term psychological morbidity coming in.

·9· · · · · · · · But this paper says, essentially,

10· ·that all of that is entirely societal, and that

11· ·worrying about trying to do talk therapy to go

12· ·look at what's really in the basement and the

13· ·cobwebs is inappropriate and unnecessary.· And

14· ·that's what this statement said, as well.· So

15· ·it basically takes talk therapy and evaluation,

16· ·in-depth psychological evaluation and says

17· ·don't do it.

18· · · · · ·Q.· ·I see.· Oh, shoot.· If it comes to

19· ·me, I'll ask it later.

20· · · · · ·A.· ·Okay.

21· · · · · ·Q.· ·Okay.· So looking to the key

22· ·points section here on the same Page 2, at the

23· ·top, do you disagree with this first bullet

24· ·point that sex chromosomes and/or genitalia do

25· ·not determine one's gender identity?

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·1· · · · · ·A.· ·I would agree with that, yes.

·2· · · · · ·Q.· ·So sex chromosomes and genitalia

·3· ·do not determine one's gender identity?

·4· · · · · ·A.· ·They're not a definitive

·5· ·determination of gender identity, because

·6· ·gender identity is a fluid concept of a

·7· ·psychological basis.

·8· · · · · ·Q.· ·Okay.

·9· · · · · ·A.· ·So they are essentially many times

10· ·related, but they don't determine one's gender

11· ·identity entirely.· Because gender identity

12· ·disorder or gender dysphoria is caused by the

13· ·fact that there is a discordance between those

14· ·two.

15· · · · · ·Q.· ·Oh, that was my question.· So if

16· ·it's in your opinion that trans youths who

17· ·experience these mental health issues that are

18· ·concurrent with gender dysphoria and/or a

19· ·symptom in the criteria of gender dysphoria

20· ·aren't due to societal...

21· · · · · ·A.· ·Rejection?

22· · · · · ·Q.· ·Yes.· Societal factors,

23· ·environmental factors, from whence do you

24· ·believe those mental health issues come from?

25· · · · · · · · MR. BLAKE:· Objection.· Vague.

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·1· ·Misstates.

·2· · · · · · · · Go ahead.

·3· · · · · · · · THE WITNESS:· From adverse

·4· ·childhood events.

·5· ·BY MS. INGELHART:

·6· · · · · ·Q.· ·Okay.· Okay.· Is it possible that

·7· ·adverse childhood events could be related to

·8· ·somebody's gender non-congruity?

·9· · · · · · · · MR. BLAKE:· Objection.

10· ·Hypothetical.· Vague.

11· · · · · · · · Go ahead.

12· · · · · · · · THE WITNESS:· Down the pike later,

13· ·as the patient is rejected by family members or

14· ·peers, it could cause some secondary rejection

15· ·issues.

16· ·BY MS. INGELHART:

17· · · · · ·Q.· ·Okay.· Okay.· So do you believe

18· ·that talk therapy is the appropriate course of

19· ·treatment to get someone's gender identity to

20· ·realign with their birth assigned sex?

21· · · · · · · · MR. BLAKE:· Objection.

22· · · · · · · · THE WITNESS:· It is the most

23· ·effective, proven most effective means to

24· ·relieve gender dysphoria.

25· ·BY MS. INGELHART:

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·1· · · · · ·Q.· ·Okay.· We can set this aside for

·2· ·now.· We might come back to it.· I apologize.

·3· ·Can we take another break?· Is that okay?

·4· · · · · · · · THE COURT REPORTER:· Sure.

·5· · · · · · · · (Thereupon, a break was taken.)

·6· ·BY MS. INGELHART:

·7· · · · · ·Q.· ·Okay.· I think we left off talking

·8· ·about the Pediatric Endocrine Society; is that

·9· ·right?

10· · · · · ·A.· ·Right.

11· · · · · ·Q.· ·Okay.· And we were looking at that

12· ·document.· Actually, do you want to refer back

13· ·to it real quick?

14· · · · · · · · Here.· There's where I put mine.

15· ·Thank you.

16· · · · · · · · Okay.· I just wanted to quickly

17· ·look to the bottom of Page 476 here, where it

18· ·talks about desistance, I think.· So the author

19· ·notes it's important to note that not all young

20· ·gender-nonconforming children will persist as

21· ·such into adolescence, and that there might be

22· ·different paths of gender development and

23· ·degrees of complexity.· This has raised the

24· ·concern about supporting an early social

25· ·transition in young children who may not

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·1· ·persist into adolescence.· However, previous

·2· ·studies may have underestimated or

·3· ·misunderstood the likelihood of the long-term

·4· ·persistence.

·5· · · · · · · · And then it highlights, I think, a

·6· ·couple key issues that could explain, though

·7· ·the author does not assert that they do, in the

·8· ·left column.· A key issue is that criteria for

·9· ·gender identity disorder from early versions of

10· ·the DSM on which the studies were based

11· ·included diagnosis on the basis of gender

12· ·atypical expression alone, which may or may not

13· ·be independent of gender identity.· Some have

14· ·suggested that the proportion of persisters

15· ·would likely be higher by applying current

16· ·gender dysphoria criteria and, for example,

17· ·including individuals who continue to express a

18· ·desire to be of the opposite sex or to believe

19· ·that they were the opposite sex, regardless of

20· ·gender-stereotypical behaviors per se.

21· · · · · · · · I know that's a little wordy.· We

22· ·did talk about earlier that Dr. Zucker's study

23· ·was based on the gender identity disorder

24· ·criteria, right?

25· · · · · ·A.· ·The two were of the same actually,

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·1· ·So the name changed only because the -- and

·2· ·this is from Dr. Zucker's own personal

·3· ·statements and the people who understood the

·4· ·process.· The APA committee wanted to

·5· ·completely remove gender identity as any kind

·6· ·of pathology or any kind of morbidity

·7· ·whatsoever.· They wanted it stricken.· And so

·8· ·Dr. Zucker was profoundly against that.· He

·9· ·sort of held out and said, if you do that, then

10· ·all the patients that I've treated will have no

11· ·ability to have their care covered by

12· ·third-party payers.

13· · · · · · · · So I am willing to compromise and

14· ·call this a gender dysphoria, because that --

15· ·if it's a category you're willing to agree

16· ·exists, is a level that will allow then to have

17· ·a code, a DSM code, that we can put on and

18· ·match in payments for services.· DSM is all

19· ·about mental health being quantified and

20· ·interventions being quantified.· And without

21· ·that you can't say, I had an hour session with

22· ·a cranky, angry teenager.· Well, what's that

23· ·diagnosis?· Cranky?· No, that's not a

24· ·diagnosis.· Oh, but oppositional defiant

25· ·disorder is a diagnosis.· So we're going to put

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·1· ·a name to it.· We have to give it some sort of

·2· ·entity that we all are going to agree exists,

·3· ·so that there's coverage for your service.

·4· · · · · · · · So gender dysphoria in his mind

·5· ·encompassed everybody who had gender

·6· ·incongruence at all.

·7· · · · · ·Q.· ·Right.

·8· · · · · ·A.· ·Okay.· Anybody.· And so he took

·9· ·all those patients, and that's what he took.

10· ·His was actually a very concrete definable

11· ·entity.· And so he's been criticized that, oh,

12· ·well back then, the desisters really were not

13· ·gender dysphoric.· Therefore, you were over --

14· ·you know.· You know.· And the answer is that's

15· ·patent B.S.· It really is.· You're just

16· ·basically saying anything that was old and

17· ·previously published that we don't agree with

18· ·is counter to promoting affirmation only.

19· · · · · · · · And Zucker did not do that.

20· ·Zucker was all about talk therapy, all about

21· ·discovery, all about mental health issues as a

22· ·basis.· And here he was the world's leader in

23· ·literature, and the WPATH bibliography at the

24· ·time when he was running his clinic initially

25· ·quoted that he was a WPATH member.· He was on

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·1· ·their board.· I don't know that he ever assumed

·2· ·the office of presidency of that organization,

·3· ·but clearly a strong advocate for people who

·4· ·were transgender.· And subsequently the

·5· ·biography eliminated most of his references.

·6· · · · · · · · Here he was the person who was

·7· ·responsible for getting care for these kids and

·8· ·really working with them, and he was soundly

·9· ·rejected, and his clinic was shuttered by

10· ·activists who wanted him to basically go away.

11· · · · · ·Q.· ·Okay.· But are you saying that

12· ·there was no change in the criteria listed in

13· ·the DSM between the change from gender identity

14· ·disorder to gender dysphoria?

15· · · · · ·A.· ·It's all wording.· I mean it's the

16· ·same entity.· It's just his described -- and I

17· ·can't remember word for word what was in

18· ·DSM-III.· DSM-IV I haven't referred to

19· ·recently, because DSM-5 is sort of the new

20· ·entity that we have

21· ·to -- like it or not, it's what's in there.

22· ·And so I have read, you know, the DSM-5

23· ·criteria and more familiar with them than I am

24· ·the prior ones.

25· · · · · · · · But the idea is that it's -- you

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·1· ·know, it describes the same thing.· It's just

·2· ·named differently, so that it wasn't

·3· ·pathologic.· So that it was not a delusional

·4· ·disorder.· Zucker believed and stated that

·5· ·gender identity and gender incongruence is a

·6· ·delusional state.· Period.

·7· · · · · ·Q.· ·Do you agree with that?

·8· · · · · ·A.· ·Yes, I do.

·9· · · · · ·Q.· ·Okay.

10· · · · · ·A.· ·But it is not a delusional

11· ·disorder, and I didn't understand the

12· ·difference between the two of those things, but

13· ·he explained that sort of indirectly through a

14· ·third party that a delusional disorder is a

15· ·very specific psychiatric term and to say that

16· ·all kids with gender identity disorder are

17· ·delusional is incorrect.· The only people that

18· ·are delusional are the adults who persist in

19· ·their delusion, and that becomes a delusional

20· ·disorder.

21· · · · · · · · So all people who go through all

22· ·the counseling and therapy who do not lose that

23· ·delusional thought process then have a

24· ·delusional disorder.· Period.· End of sentence.

25· ·That's his -- he's the professional.· I am not.

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·1· ·He's the one who published and treated, and so

·2· ·I defer to experts in that field to use the

·3· ·terminology that they choose.· But making

·4· ·gender dysphoria the terms took it away from

·5· ·being a disorder, and that was the entire

·6· ·purpose of the APA committee that did that.

·7· · · · · · · · And there are people who are a

·8· ·party to the discussions that occurred both

·9· ·with Zucker in the room and with him out of the

10· ·room about how they were going to essentially

11· ·push him into dropping the disorder.

12· · · · · ·Q.· ·Okay.

13· · · · · ·A.· ·And he thought that would be a

14· ·disservice to the patients, that they would end

15· ·up on the streets with no --

16· · · · · ·Q.· ·Okay.· So just to be clear so I

17· ·understand Zucker.· Children lower than the age

18· ·of majority, who have what would be called now

19· ·gender dysphoria, then gender identity

20· ·disorder, have a term you used called the

21· ·delusional state, correct?

22· · · · · ·A.· ·Correct.

23· · · · · ·Q.· ·And do you agree with that?

24· · · · · ·A.· ·Delusional thought.· I want to

25· ·retract the word state.· Delusional thought.

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·1· · · · · ·Q.· ·Okay.· And then adult people over

·2· ·the age of majority or at the age of majority,

·3· ·who have gender dysphoria or gender identity

·4· ·disorder as it was formerly called and

·5· ·therefore persist with that have a delusional

·6· ·disorder?

·7· · · · · ·A.· ·Yes.· That was the original

·8· ·statement.

·9· · · · · ·Q.· ·Okay.

10· · · · · ·A.· ·But the word disorder was taken

11· ·away.

12· · · · · ·Q.· ·But do you agree with that?

13· · · · · ·A.· ·I do.· I agree with that.

14· · · · · ·Q.· ·Okay.· So this first critique here

15· ·says that the GID criteria were different in

16· ·kind in some ways than the gender dysphoria,

17· ·and that could explain some difference in prior

18· ·results from studies today.· And you disagree

19· ·with that?

20· · · · · · · · MR. BLAKE:· Objection.

21· · · · · · · · THE WITNESS:· I do.

22· ·BY MS. INGELHART:

23· · · · · ·Q.· ·Okay.· And then the second

24· ·criticism here is about follow-up after the

25· ·fact.· Do you happen to know Dr. Zucker's

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·1· ·methodology and how long after this study was

·2· ·completed that he did the follow-up?

·3· · · · · ·A.· ·He followed all the patients

·4· ·through adulthood.· He was not limited to just

·5· ·children.

·6· · · · · ·Q.· ·Okay.

·7· · · · · ·A.· ·His clinic was addiction medicine.

·8· ·That was the subdivision.· So he took care of

·9· ·primarily adults, but this was a very small

10· ·subset of patients who happened to be children.

11· · · · · ·Q.· ·Okay.· Do you know how far into

12· ·adulthood that he followed them?

13· · · · · ·A.· ·I don't.

14· · · · · ·Q.· ·All right.· I think we're going to

15· ·look at another exhibit, but just kind of

16· ·quickly.· So you can set this aside.

17· · · · · · · · (Thereupon, Plaintiffs' Exhibit 3,

18· ·a developmental, biopsychosocial model for the

19· ·Treatment of Children with Gender Identity

20· ·Disorder, was marked for identification

21· ·purposes.)

22· ·BY MS. INGELHART:

23· · · · · ·Q.· ·Okay.· So do you recognize this

24· ·document?

25· · · · · ·A.· ·I do.

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·1· · · · · ·Q.· ·What is it?

·2· · · · · ·A.· ·It's Kenneth Zucker's compendium

·3· ·of his experience with the patients in his

·4· ·clinic.

·5· · · · · ·Q.· ·Is this the study you were

·6· ·referring to when you were making references

·7· ·about rates of desistance among gender disorder

·8· ·children?

·9· · · · · ·A.· ·I can't remember if he

10· ·specifically looks at rates of desistance in

11· ·this article or it's a parallel publication,

12· ·but he looks at the methodology and the

13· ·undercurrent issues, the emotional issues and

14· ·how this happens, why it happens, and what one

15· ·can do.· And it has a lot of case studies in it

16· ·to kind of give examples of typical things,

17· ·and, you know, why it develops, when it

18· ·develops, how it goes through the child's life

19· ·and what his recommendations would be in terms

20· ·of helping these children to the best of his

21· ·ability.

22· · · · · ·Q.· ·Okay.· If you turn to Page 392,

23· ·it's a continuation of a section that starts

24· ·actually on 391, which is titled, is prevention

25· ·of adult transsexualism a reasonable treatment

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·1· ·goal, and given the low frequency with which

·2· ·GID persists into adulthood, how is it possible

·3· ·to determine the efficacy of treatment in

·4· ·attaining that goal?

·5· · · · · · · · So the bottom of Page 392, that's

·6· ·what is being discussed is the desistance.· Can

·7· ·you read out the last full paragraph at the

·8· ·bottom of 392?

·9· · · · · ·A.· ·The guest editors have made

10· ·reference to the low frequency with which GID

11· ·persists into adulthood and the implications of

12· ·this fact in the evaluation of treatment

13· ·efficacy.· Persistence rates have varied fairly

14· ·substantially in long-term follow-up studies.

15· ·For example, Green reported that only 1 of 44

16· ·previously feminine boys appeared to be gender

17· ·dysphoric at the time of follow-up. In

18· ·contrast, Wallien and Cohen-Kettenis reported

19· ·that 50 percent of 18 GID girls were persisters

20· ·at follow-up.· In our own follow-up studies, we

21· ·found a persistence rate of 12 percent for GID

22· ·girls and persistence rate of 13 for GID boys.

23· ·Thus, there is a fair bit of variation in

24· ·persistence rates.

25· · · · · ·Q.· ·Okay.· Could you read on to the

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·1· ·paragraph that tracks between the two pages

·2· ·there?

·3· · · · · ·A.· ·How can this variation be

·4· ·understood?· One possibility is sampling

·5· ·differences.· Another possibility pertains to

·6· ·the degree of GID in childhood.· Both Wallien

·7· ·and Cohen-Kettenis and Singh showed several

·8· ·metrics of GID severity in childhood predicted

·9· ·persistence at follow-up.· Other possibility is

10· ·to contextualize the natural history data.· Is

11· ·there really such a thing as natural history

12· ·for GID or does its developmental course vary

13· ·as a function of contextual factors?· If, as in

14· ·our clinic, treatment is recommended to reduce

15· ·the likelihood of GID persistence, perhaps the

16· ·data can only be interpreted in that context.

17· ·In any event, we require more comparative data

18· ·to draw conclusions about the natural history

19· ·of GID in children and its relation to

20· ·contextual factors.

21· · · · · ·Q.· ·Thank you.· So the first paragraph

22· ·you read on Page 392 referred to a few studies

23· ·with varying rates of reported desistance,

24· ·correct?

25· · · · · ·A.· ·Yes.

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·1· · · · · ·Q.· ·Okay.· So there is difference in

·2· ·studies about desistance rates?

·3· · · · · ·A.· ·There are, but the majority of

·4· ·them show a higher rate than the 50 percent in

·5· ·the one study of girls that Wallien and

·6· ·Cohen-Kettenis says.· Again, it looks as if --

·7· ·and I haven't asked him why he put this in this

·8· ·particular paper -- that he chose one that

·9· ·showed a relatively low, 50 percent, and then

10· ·his which showed 80 and essentially 90, 88

11· ·percent and 80 percent in his.

12· · · · · · · · The actual data that are in the

13· ·DSM-5 come from a coalescence of all the

14· ·studies.

15· · · · · ·Q.· ·Okay.

16· · · · · ·A.· ·Not just these two, what he

17· ·called, extremes.· He called his a high rate of

18· ·desistance and Wallien and Cohen-Kettenis a

19· ·relatively lower.· But still 50 percent is not

20· ·something to sneeze at, and he just chose those

21· ·two as ends.· In terms of what the DSM-5

22· ·criteria say, 98 percent of boys and 88 percent

23· ·of girls is the most that's been reported, not

24· ·by Zucker or that other person.

25· · · · · ·Q.· ·Okay.· And then, you know,

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·1· ·throughout the paragraphs we were reading it

·2· ·refers to GID, or gender identity disorder,

·3· ·right?

·4· · · · · ·A.· ·Right.

·5· · · · · ·Q.· ·Okay.· And if we turn to the very

·6· ·first page, just the front cover, yours looks

·7· ·different than mine.· Does it have the

·8· ·publication date?· It does.· What is that

·9· ·publication date?

10· · · · · ·A.· ·That says 2012, I think.· Yes. I

11· ·believe it's -- all right.· Yeah.· March 2012.

12· · · · · ·Q.· ·Great.· Okay.· And when was the

13· ·DSM-5 first published?

14· · · · · ·A.· ·I don't know.· I'm guessing 2014.

15· ·I think that's about right.

16· · · · · ·Q.· ·I think that's close.· So it was

17· ·after this?

18· · · · · ·A.· ·Yes.

19· · · · · ·Q.· ·So that's why they referred to

20· ·GID?

21· · · · · ·A.· ·Yeah.

22· · · · · ·Q.· ·Okay.· All right.· Thank you.

23· ·You're also a member of the Endocrine Society,

24· ·you said?

25· · · · · ·A.· ·Yes.

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·1· · · · · ·Q.· ·Okay.· Are you aware of whether

·2· ·they have a position statement about the

·3· ·treatment of transgender folks?

·4· · · · · ·A.· ·They did their clinical

·5· ·guidelines.

·6· · · · · ·Q.· ·Okay.

·7· · · · · ·A.· ·In 2009 and then the revision in

·8· ·2017.

·9· · · · · ·Q.· ·Okay.· Then you said that was a

10· ·society that's selective in such a way that it

11· ·requires training in the field of pediatrics?

12· · · · · ·A.· ·You know, I'd have to say you pay

13· ·dues, and you're in a category depending on

14· ·your degree.

15· · · · · ·Q.· ·Okay.· So let's look at that

16· ·position statement too.

17· · · · · · · · (Thereupon, Plaintiffs' Exhibit 4,

18· ·transgender health, was marked for

19· ·identification purposes.)

20· ·BY MS. INGELHART:

21· · · · · ·Q.· ·Okay.· Have you seen this before?

22· · · · · ·A.· ·Yes.

23· · · · · ·Q.· ·And what is it again?

24· · · · · ·A.· ·This is the Endocrine Society

25· ·guidelines.· It's a position statement, and I

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·1· ·don't know whether or not this is the 2000 --

·2· ·yeah, it's the 2017.· So it's the second

·3· ·attenuation of this guideline.

·4· · · · · ·Q.· ·Okay.· And looking at the second

·5· ·paragraph on the first page, the first

·6· ·paragraph under the word background, do you see

·7· ·the last full sentence of that paragraph which

·8· ·begins with the word considerable?

·9· · · · · ·A.· ·Okay.· Do you want me to read that

10· ·to you?

11· · · · · ·Q.· ·Sure.

12· · · · · ·A.· ·I'll just read it, okay.

13· · · · · ·Q.· ·Do you disagree with that

14· ·statement?

15· · · · · ·A.· ·Considerable scientific evidence

16· ·has emerged demonstrating a durable biologic

17· ·element.· I totally disagree with that.

18· · · · · ·Q.· ·Okay.· And on what basis do you

19· ·disagree with that?

20· · · · · ·A.· ·There is no scientific basis for

21· ·that whatsoever.

22· · · · · ·Q.· ·Okay.

23· · · · · ·A.· ·And it's so stated in the DSM

24· ·criteria and the APA handbook.

25· · · · · ·Q.· ·Okay.· Yes.· I think you said

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·1· ·that.· So in both of those documents they

·2· ·state, according to you, that there's no

·3· ·biological basis, correct?

·4· · · · · ·A.· ·That's correct.

·5· · · · · ·Q.· ·Okay.· So can you see the I guess

·6· ·second half of that sentence, or maybe it's a

·7· ·whole new sentence, individuals may make

·8· ·choices?

·9· · · · · ·A.· ·Individuals make choices due to

10· ·other factors in their lives, but there do not

11· ·seem to be external forces that genuinely cause

12· ·individuals to change gender identity.

13· · · · · · · · That's also totally not factual.

14· · · · · ·Q.· ·And on what basis do you say that?

15· · · · · ·A.· ·On the basis that 70 percent of

16· ·kids are reported to have -- no.· Excuse me.

17· ·40 percent of kids are reported to have

18· ·undercurrent psychological morbidity.

19· · · · · ·Q.· ·Okay.· So I do want to make a

20· ·distinction.· So you're a pediatric

21· ·endocrinologist, right?

22· · · · · ·A.· ·Yes.

23· · · · · ·Q.· ·And Dr. Zucker's also a pediatric

24· ·endocrinologist, correct?

25· · · · · ·A.· ·No.· He's a clinical psychologist.

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·1· · · · · ·Q.· ·He's not a pediatric

·2· ·endocrinologist?

·3· · · · · ·A.· ·No, he is not.

·4· · · · · ·Q.· ·Okay.· We'll come back to that.

·5· ·We'll just have to come back to that.· Okay.

·6· ·And then if we flip this over, it looks at

·7· ·positions.· Do you see the second bullet point

·8· ·under positions?

·9· · · · · ·A.· ·Medical intervention for

10· ·transgender individuals, including both hormone

11· ·therapy and medically indicated surgery is

12· ·effective, relatively safe, and has been

13· ·established as the standard of care.

14· · · · · ·Q.· ·Do you disagree with that

15· ·statement?

16· · · · · ·A.· ·Yes, I disagree with that. I

17· ·would say established as standard of care is

18· ·this document establishes a guideline but not a

19· ·standard of care.· The WPATH is the standard of

20· ·care.

21· · · · · ·Q.· ·Okay.

22· · · · · ·A.· ·And I would argue that they are --

23· ·that (A), it is not relatively safe at all, and

24· ·has been established as the standard of care.

25· ·That's the WPATH's standard of care.· It's a

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·1· ·self-serving social advocacy organization of

·2· ·people who believe that's correct, and they all

·3· ·believe it.

·4· · · · · ·Q.· ·What makes WPATH a self-serving

·5· ·social advocacy organization?

·6· · · · · ·A.· ·It has no requirement for

·7· ·education, certification or training.

·8· · · · · ·Q.· ·Would it surprise you to know that

·9· ·they do have a certification for training?

10· · · · · ·A.· ·Oh, they will do a certification,

11· ·if you attend a conference.· But it's not

12· ·required for membership.· Membership requires

13· ·paying dues.· That's it.

14· · · · · ·Q.· ·What is required of membership for

15· ·the American College of Pediatrics?

16· · · · · ·A.· ·Board certification in pediatrics.

17· · · · · ·Q.· ·And WPATH doesn't require any type

18· ·of board certification?

19· · · · · ·A.· ·Does not require it.· It is people

20· ·who are interested in the field of transgender

21· ·health.

22· · · · · ·Q.· ·Okay.

23· · · · · ·A.· ·And if I applied, they might

24· ·recognize my name and say, no, I can't become a

25· ·member.· They are evidently trying to -- well,

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·1· ·I won't go into that.

·2· · · · · ·Q.· ·What about the American Diabetes

·3· ·Association?

·4· · · · · ·A.· ·They're a professional section.

·5· ·You have to have a degree certification.

·6· · · · · ·Q.· ·Do you need a degree certification

·7· ·for the professional part of WPATH?

·8· · · · · ·A.· ·I didn't realize there was a

·9· ·subsection that was professional only.

10· · · · · ·Q.· ·Okay.· Okay.

11· · · · · ·A.· ·So I went to their website and

12· ·said, if I want to become a member, what

13· ·information do I have to provide?· And degree

14· ·certification was absolutely not part of it.

15· · · · · ·Q.· ·Okay.· Well, very good.· Let's put

16· ·this aside.

17· · · · · · · · Okay.· So are you a member of the

18· ·American College of Pediatrics?

19· · · · · ·A.· ·American College of Pediatricians.

20· · · · · ·Q.· ·Pediatricians.

21· · · · · ·A.· ·Yes.

22· · · · · ·Q.· ·I'm sorry.

23· · · · · ·A.· ·Mm-hmm.

24· · · · · ·Q.· ·Are you a leader within that

25· ·organization?

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·1· · · · · ·A.· ·I'm currently the president.

·2· · · · · ·Q.· ·Okay.· How long have you been a

·3· ·member?

·4· · · · · ·A.· ·Since 2007.

·5· · · · · ·Q.· ·How long have you been the

·6· ·president?

·7· · · · · ·A.· ·I assumed the position 13 months

·8· ·ago.

·9· · · · · ·Q.· ·Okay.· When was the American

10· ·College of Pediatricians formed?

11· · · · · ·A.· ·I believe, 2002.

12· · · · · ·Q.· ·Okay.· Were you a part of that

13· ·formation?

14· · · · · ·A.· ·No.

15· · · · · ·Q.· ·Do you know what motivated the

16· ·founding group, founding members to formally

17· ·organize?

18· · · · · ·A.· ·The American Academy of Pediatrics

19· ·produced a statement on the effects and

20· ·benefits of same sex adoption.· In that policy

21· ·statement they essentially said there was

22· ·absolutely no adverse effect whatsoever of same

23· ·sex couples adopting children and that the

24· ·outcome of these children was as good, and

25· ·without statistically significant findings,

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·1· ·perhaps even better, based on anecdotal

·2· ·reporting of welfare of the families that they

·3· ·surveyed that these kids were maybe even

·4· ·perhaps better cared for.· But we can't prove

·5· ·that scientifically, but certainly there is no

·6· ·provable downside to same sex adoption.

·7· · · · · ·Q.· ·Okay.

·8· · · · · ·A.· ·And adoption is a very complex and

·9· ·critical issue, and these members said, okay,

10· ·let's look at the scientific background.· And

11· ·then Dr. Sharon Quick, who's a pediatric

12· ·intensivist, took the time and went through

13· ·point by point of all the technical paper that

14· ·supported and said, these are not valid

15· ·scientific studies.· These are anecdotal

16· ·reports.· These are things that were basically

17· ·a survey from the LGB community.· Have you

18· ·adopted?· How happy are your children?· Okay?

19· · · · · · · · And so it wasn't done

20· ·independently and professionally.· These were

21· ·just report after report after report, and they

22· ·were trying to, therefore, ergo, these kids are

23· ·very happy and very functional and without any

24· ·difference whatsoever and anecdotally maybe

25· ·even better, because they were, you know --

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·1· ·just a better environment in their opinion.

·2· · · · · · · · And so they took issue with that,

·3· ·and they tried to speak within the academy. A

·4· ·former president of the American Academy

·5· ·himself, Joe Zanga, took strong issue as a

·6· ·member of the executive committee of past

·7· ·presidents and an invited person, and he

·8· ·realized where this came from.

·9· · · · · ·Q.· ·Okay.

10· · · · · ·A.· ·And he knew the inside workings of

11· ·the academy, of the committee that generated

12· ·this report and said it's unethical what they

13· ·did, and this is not the American Academy of

14· ·Pediatrics that it's supposed to be.· We are

15· ·off the track.· They've gone off the wheels

16· ·here.· We need to speak with what is

17· ·scientifically valid for children.

18· · · · · · · · And it was at that point that he

19· ·and a couple of other members at a meeting of

20· ·the AAP actually gathered together in a sidebar

21· ·meeting room and said, what can we do about

22· ·this?· And Joe specifically said there is no

23· ·way for us to change this position statement.

24· ·He knew how the position statement was put

25· ·together.· He knew that it did not represent a

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·1· ·vote as a membership, that it was not with any

·2· ·input from the vote of the majority of the

·3· ·membership, that it was done by a committee.

·4· ·And he knew those members individually, and he

·5· ·said they are agenda oriented people.· They are

·6· ·misstating science, and the American Academy

·7· ·can't tolerate this.· He was told, sorry,

·8· ·Charlie.· You know, you don't like it, tough.

·9· · · · · · · · He did not leave them.· He to this

10· ·day has not left the American Academy of

11· ·Pediatrics.· He's a stalwart that says, if

12· ·we're going to bring about change and rescue

13· ·the AAP, we have to stay within it and work

14· ·within it.· Okay?

15· · · · · ·Q.· ·Mm-hmm.

16· · · · · ·A.· ·But he has made no headway

17· ·whatsoever in that regard.· He encouraged me

18· ·all the way through to stay a member of the AAP

19· ·for the same purpose.· He said if everyone who

20· ·disagrees and is really disgusted with the AAP

21· ·leaves, the AAP will get more and more down

22· ·that pathway, and children will be harmed,

23· ·because everybody looks to the AAP.· It's

24· ·giant.· It's huge.· It was essentially the only

25· ·general pediatric, you know, advocacy group.

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·1· · · · · · · · And so he stuck with it, but a

·2· ·number of individuals said no, and he was one

·3· ·of the founding members of the American College

·4· ·for that specific purpose.· Not casting

·5· ·aspersions and name calling and hating and

·6· ·being bigoted and awful, but basically saying

·7· ·kids are who we're supposed to represent here.

·8· ·What's happened is that we have left the

·9· ·benefit for children, and we've gone off for

10· ·the wants and needs of the adults.

11· · · · · ·Q.· ·Okay.

12· · · · · ·A.· ·And that's how it was started.

13· · · · · ·Q.· ·Okay.· So let's look at another

14· ·exhibit.

15· · · · · · · · (Thereupon, Plaintiffs' Exhibit 5,

16· ·Pro-Life Pediatric Group Stands Contrary to

17· ·Established American Academy of Pediatrics, was

18· ·marked for identification purposes.)

19· ·BY MS. INGELHART:

20· · · · · ·Q.· ·What I just had marked as

21· ·Plaintiffs' Exhibit No. 5 is an article from

22· ·the publication called the Catholic Exchange.

23· ·It's about the founding of the American College

24· ·of Pediatricians.· On the second page, Zanga,

25· ·Dr. Zanga, as you were speaking of before, is

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·1· ·quoted as describing his organization -- or not

·2· ·quoted.· He's referenced as describing his

·3· ·organization as one with Judeo-Christian,

·4· ·traditional values that's open to pediatric

·5· ·medical professionals of all religions who hold

·6· ·true to the group's core beliefs, that life

·7· ·begins at conception and that the traditional

·8· ·family unit, headed by an opposite-sex couple,

·9· ·poses fewer risk factors in the adoption and

10· ·raising of children.· Is that accurate?

11· · · · · ·A.· ·That's Dr. Zanga's opinion, okay?

12· ·In terms of Judeo.· It happens that

13· ·Judeo-Christian concepts happen to jibe with

14· ·the concept of what is best for children and

15· ·keeping politics out of that.· You know,

16· ·focusing on truly a core value that is ethical

17· ·and based on science.· And so life begins at

18· ·conception is a scientifically valid opinion.

19· ·It's proven in any number of ways, but people

20· ·have opposite opinions.· Okay?· So that happens

21· ·to jibe with Judeo-Christian, and in this case

22· ·Catholic theology.· So they report on that as

23· ·if that's the core, and this is a religious

24· ·based organization.

25· · · · · · · · There is absolutely no requirement

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·1· ·to be of any particular religious faith at all

·2· ·in membership.· It's not asked for.· It is

·3· ·discussed among members collegially, if they

·4· ·wish to share that information, but the

·5· ·organization is completely devoid of a

·6· ·religious basis.· There is nowhere in the

·7· ·application -- no one is excluded for being an

·8· ·atheist or any religion other than

·9· ·Judeo-Christian religions.

10· · · · · ·Q.· ·Okay.· Why did you join ACP?

11· · · · · ·A.· ·Because I knew Joe Zanga

12· ·personally, and he asked me if I knew about the

13· ·organization and he said, would you become a

14· ·member?· Because he knew of my advocacy with

15· ·the Georgia Chapter.· He was in Columbus,

16· ·Georgia at the time and head of Columbus

17· ·Regional Medical Center's Pediatric Department,

18· ·and so he invited me down for CME.

19· · · · · · · · I knew him from medical school

20· ·days.· He was a resident a couple years ahead

21· ·of me in the -- a medical student a couple

22· ·years ahead of me and in the residency program

23· ·at Medical College Virginia.· He also happened

24· ·to intersect with my wife and my brother, who's

25· ·an emergency room specialist in New Orleans,

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·1· ·and Joe was in New Orleans at the Children's

·2· ·Hospital there as head of pediatrics for a

·3· ·while and ran into my brother and said, do you

·4· ·know -- not a very common last name.

·5· · · · · · · · And so our paths kept crossing,

·6· ·and so he took the time to write me and said,

·7· ·would you look into what our organization is?

·8· ·And I did, and I thought this makes a lot of

·9· ·sense, and it's exactly why I'm frustrated with

10· ·the direction the AAP is going, why I love the

11· ·Georgia Chapter, because they are far more

12· ·tuned into helping children and avoiding

13· ·political traps and working across the aisle

14· ·and getting state legislatures to understand

15· ·true science and benefit for children.· So I

16· ·joined.

17· · · · · ·Q.· ·Okay.· Thank you.· I'd like to

18· ·talk a little bit more about the group.· I'm

19· ·going to enter another exhibit.· I'm definitely

20· ·going to lose count.

21· · · · · · · · THE COURT REPORTER:· This is No.

22· ·6.

23· · · · · · · · MS. INGELHART:· Thank you.

24· · · · · · · · (Thereupon, Plaintiffs' Exhibit 6,

25· ·About Us, American College of Pediatrics, was

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·1· ·marked for identification purposes.)

·2· ·BY MS. INGELHART:

·3· · · · · ·Q.· ·Do you recognize this document,

·4· ·this webpage?

·5· · · · · ·A.· ·I do.

·6· · · · · ·Q.· ·Can you tell me what it is?

·7· · · · · ·A.· ·It's sort of the mission statement

·8· ·explanation of what the college is about.· It's

·9· ·from the website.

10· · · · · ·Q.· ·Okay.· So I want to start looking

11· ·at the core values portion, the heading that

12· ·falls at the bottom of the first page, but the

13· ·text is actually if we flip over to the second

14· ·page.· No. 2, under core values says -- I

15· ·assume the subject would be the American

16· ·College of Pediatricians -- recognizes that

17· ·good medical science cannot exist in a moral

18· ·vacuum and pledges to promote such science.

19· ·What does that mean?

20· · · · · ·A.· ·It means that ethics and a code of

21· ·behavior, of ethical behavior, which is the

22· ·basis of a civil society, has to be part of

23· ·that or we are in a vacuum that basically

24· ·allows for an anarchy of ideas, and that's what

25· ·it's about.

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·1· · · · · ·Q.· ·Okay.· So to your knowledge, is

·2· ·there a reason that ethics wasn't used here

·3· ·instead of referencing a moral vacuum?

·4· · · · · ·A.· ·I think they tried to use a term

·5· ·that people would understand, and ethics is

·6· ·perhaps not -- I didn't write this particular

·7· ·thing.· I read that, and I see ethics.

·8· · · · · ·Q.· ·Okay.· The next one, No. 3,

·9· ·recognizes the fundamental mother-father family

10· ·unit, within the context of marriage, to be the

11· ·optimal setting for the development and

12· ·nurturing of children and pledges to promote

13· ·this unit.

14· · · · · ·A.· ·Yes.

15· · · · · ·Q.· ·So this is a core value of the

16· ·ACP?

17· · · · · ·A.· ·Yes.

18· · · · · ·Q.· ·Okay.· So when you say that

19· ·science can exist in a moral vacuum, is the

20· ·belief about the optimal setting for the

21· ·development of children based on a moral

22· ·principle?

23· · · · · ·A.· ·No.· It's based on sociology

24· ·research.

25· · · · · ·Q.· ·Okay.· And --

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·1· · · · · ·A.· ·That's the science part.

·2· · · · · ·Q.· ·Okay.· If science research showed

·3· ·that children actually developed better with

·4· ·two mothers, would that cause ACP to alter its

·5· ·position?

·6· · · · · · · · MR. BLAKE:· objection.

·7· ·Hypothetical.

·8· · · · · · · · THE WITNESS:· No.

·9· ·BY MS. INGELHART:

10· · · · · ·Q.· ·Why not?

11· · · · · ·A.· ·Because if it's scientifically

12· ·valid, that's what the college is based on.

13· · · · · ·Q.· ·Okay.· So it would change its

14· ·position?· I'm sorry.· I think you --

15· · · · · ·A.· ·Yeah.· It would say that that was

16· ·not a critical part of welfare of children.· If

17· ·a sociologic study, cross-sectional, not

18· ·picking volunteer people to say that I'm a same

19· ·sex couple and what do I think about my

20· ·children.· If it was a total survey as the

21· ·sociologic studies that support the

22· ·mother-father intact unit family, if it's the

23· ·same quality and it comes up and says there is

24· ·no difference, then we would remove that

25· ·objection.

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·1· · · · · ·Q.· ·I see.· Okay.· Do you agree with

·2· ·this statement at No. 3, with the core value to

·3· ·promote the unit of the mother-father family

·4· ·unit?

·5· · · · · ·A.· ·Yes.

·6· · · · · ·Q.· ·Do you also agree with the No. 2

·7· ·statement about medical science shouldn't exist

·8· ·in a moral vacuum?

·9· · · · · ·A.· ·And when I refer to moral vacuum

10· ·as an ethicless vacuum, yes.

11· · · · · ·Q.· ·Okay.· So history section of this

12· ·webpage begins at the bottom of the page that

13· ·we're on.· It says that ACP was founded --

14· ·let's see if I can find it.· In Sentence 2

15· ·under history, it says that ACP was founded by

16· ·a group of concerned physicians who saw the

17· ·need for a pediatric organization that would

18· ·not be influenced by politically driven

19· ·pronouncements of the day.

20· · · · · ·A.· ·Yes.

21· · · · · ·Q.· ·Can you explain again what that's

22· ·referring to?

23· · · · · ·A.· ·Yes.· That was the statement on

24· ·same sex adoption.· That's the document that

25· ·they were concerned about.

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·1· · · · · ·Q.· ·Okay.· But did you say in a prior

·2· ·statement that same sex adoption isn't harmful,

·3· ·it turns out?· Is that what you said before?

·4· · · · · ·A.· ·No.· That it was not as

·5· ·beneficial.· That the most beneficial is a

·6· ·heterosexual, married, intact, functional

·7· ·family.

·8· · · · · ·Q.· ·All right.· Thank you.· Okay.· The

·9· ·third sentence says, the college bases its

10· ·policies and positions upon scientific truth

11· ·within a framework of ethical absolutes.· Not

12· ·to belabor, but can you explain what that

13· ·means?

14· · · · · ·A.· ·It looks at sort of ethics as an

15· ·issue.· It does not separate out ethics,

16· ·bioethics, and so you have issues of life and

17· ·death that you have to consider in terms of

18· ·interventions and policies and look at the

19· ·clinical research.· And it's through that lens.

20· ·So for that reason, very naturally, it's going

21· ·to look at life at the beginning and life at

22· ·the end.· And life at the end for pediatric

23· ·practice is situations where a terminal illness

24· ·is occurring, and what kind of support would

25· ·you give?· Would you withdraw support?· Is that

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·1· ·ethical?

·2· · · · · · · · And it takes a stand of ethics on

·3· ·the side of, you know, life is precious, and

·4· ·you really need to totally examine the ethical

·5· ·issues with somebody independent, in the field

·6· ·of bioethics, if necessary.· And we have

·7· ·consultants in those fields to look at and

·8· ·critically review policy statements and through

·9· ·their eyes.

10· · · · · ·Q.· ·Okay.· Thank you.· Could you

11· ·define specifically what ethical absolutes

12· ·mean?· Maybe you have, but I just...

13· · · · · ·A.· ·I mean I didn't choose those

14· ·words.· Okay?· This is crafted by other people

15· ·who edit, but I think it's talking about you

16· ·can't ignore ethical issues, that you have to

17· ·take -- there is a limit which needs to be

18· ·established of what is ethical, and that if you

19· ·don't do that you could take science to a

20· ·harmful end.

21· · · · · ·Q.· ·Okay.

22· · · · · ·A.· ·Experimentation on children.· You

23· ·know.· Yeah.

24· · · · · ·Q.· ·That's an ethical absolute no?

25· · · · · ·A.· ·Yeah.· I mean if you're going

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·1· ·to -- let's do something and see what happens.

·2· · · · · ·Q.· ·Okay.

·3· · · · · ·A.· ·You know, without true informed

·4· ·consent and knowledge of -- it's what guides

·5· ·clinical research to this day.· We were all

·6· ·trained repeatedly and endlessly on good

·7· ·clinical practices, and so all the clinical

·8· ·research studies I do I have to have

·9· ·certification.· I didn't mention that, but I'm

10· ·certified in good clinical practices for

11· ·clinical research.· So we have to know about

12· ·informed consent assent, that balanced

13· ·presentations, stopping criteria, independent

14· ·reviews, safety and all that.· All those have

15· ·to be understood.· We have to know who

16· ·regulates those things and why they're

17· ·important.· So that's where that comes from.

18· · · · · ·Q.· ·Okay.· So I guess if -- I'm just

19· ·trying to understand these terms.· If there was

20· ·a conflict between one of these ethical

21· ·absolutes and what the scientific research

22· ·would show, then would the ethical absolute

23· ·take precedent?

24· · · · · · · · MR. BLAKE:· Objection.

25· ·Hypothetical.

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·1· · · · · · · · THE WITNESS:· I'll give you an

·2· ·example.· Let's just say that the science said

·3· ·that if you poisoned children, a hundred

·4· ·percent of them come to harm, that would be an

·5· ·ethical issue that we'd say, no, you can't do

·6· ·that study.· Yes, it's a conclusion that might

·7· ·be valid based on a scientific study that you

·8· ·poisoned a hundred children and a hundred

·9· ·children had very adverse -- and the majority

10· ·of them, 90 percent, died.· Okay?· That's valid

11· ·science.

12· ·BY MS. INGELHART:

13· · · · · ·Q.· ·Okay.

14· · · · · ·A.· ·Okay.· It's not ethical.

15· · · · · ·Q.· ·Got it.· Okay.· Another exhibit to

16· ·be introduced.

17· · · · · · · · (Thereupon, Plaintiffs' Exhibit 7,

18· ·Gender Ideology Harms Children, was marked for

19· ·identification purposes.)

20· ·BY MS. INGELHART:

21· · · · · ·Q.· ·So this is Plaintiffs' Exhibit No.

22· ·7.· Do you recognize this document?

23· · · · · ·A.· ·I do.

24· · · · · ·Q.· ·Could you tell me what it is?

25· · · · · ·A.· ·It's a statement by the college in

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·1· ·regard to the gender ideology, referring to the

·2· ·sort of societal push to promote affirmation of

·3· ·incongruent genders.

·4· · · · · ·Q.· ·Okay.· The first sentence here

·5· ·under the updated date, do you agree with that

·6· ·statement there?

·7· · · · · ·A.· ·Yes, I do.

·8· · · · · ·Q.· ·Okay.· Would you read it?

·9· · · · · ·A.· ·The American College of

10· ·Pediatricians urges healthcare professionals,

11· ·educators and legislators to reject all

12· ·policies that condition children to accept as

13· ·normal a life of chemical and surgical

14· ·impersonation of the opposite sex.

15· · · · · ·Q.· ·What does impersonation of the

16· ·opposite sex mean?

17· · · · · ·A.· ·It means the physical appearance

18· ·and -- the physical appearance, primarily, and

19· ·living as if they were the biologic opposite

20· ·sex.

21· · · · · ·Q.· ·But specifically the word

22· ·impersonation, like what's that word doing?

23· · · · · ·A.· ·That means that they are

24· ·pretending to be the opposite sex, when they

25· ·cannot be the opposite sex.

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·1· · · · · ·Q.· ·Okay.· Thank you.· Turning over to

·2· ·paragraph numbered 8, could you read the bold

·3· ·sentence?

·4· · · · · ·A.· ·Conditioning children into

·5· ·believing a lifetime of chemical and surgical

·6· ·impersonation of the opposite sex is normal and

·7· ·healthful is child abuse.

·8· · · · · ·Q.· ·And do you agree with that?

·9· · · · · ·A.· ·I thoroughly agree with that.

10· · · · · ·Q.· ·And then there's a paragraph

11· ·called bottom line, which starts at the bottom

12· ·of the second page and continues over onto the

13· ·third page.· So looking at the third page, the

14· ·last sentence says, the college maintains it's

15· ·abusive to promote this ideology, first and

16· ·foremost for the well-being of the gender

17· ·dysphoric children themselves, and secondly,

18· ·for all of their non-gender-discordant peers,

19· ·many of whom will subsequently question their

20· ·own gender identity, and face violations of

21· ·their right to bodily privacy and safety.· Do

22· ·you agree with that statement?

23· · · · · ·A.· ·Yes.

24· · · · · ·Q.· ·Okay.· What does it mean that

25· ·non-gender-discordant peers would subsequently

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·1· ·question their own gender identity in the

·2· ·presence of gender dysphoric children

·3· ·expressing --

·4· · · · · ·A.· ·Well, the precepts of childhood

·5· ·development from Ericson and others who are

·6· ·experts in that field, and all I know is what

·7· ·we learned as pediatricians about how children

·8· ·develop and what their concept is of abstract

·9· ·principles and what their brains can figure

10· ·out, is a six-year-old, in general, who sees a

11· ·boy go leave the room and come back in with a

12· ·wig, makeup, eye lashes, a dress, and Mary

13· ·Janes, believe that it's possible that that

14· ·child changed from one sex to the other.· Okay?

15· ·And that's concrete thinking.· Okay?· They

16· ·don't look at it as if it is a costume that

17· ·they're wearing.· It's that that person

18· ·changed.· And that's sort of the mindset of a

19· ·six-year-old.· A nine or ten-year-old has a

20· ·little bit of a different world view than a

21· ·16-year-old and a 20-year-old.

22· · · · · · · · And so that if you are in a school

23· ·environment, in kindergarten, and anxiety

24· ·develops when there is conflict in reality and

25· ·fantasy.· You know, the scary stories and the

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·1· ·boogeyman in the closet and the monsters, et

·2· ·cetera, et cetera, all come from a crossover

·3· ·between not knowing what's real and not knowing

·4· ·what's fantasy.· And unless the child knows

·5· ·real and fantasy, they begin to internalize

·6· ·this concept and become anxious, and it

·7· ·develops into an anxiety disorder as a result

·8· ·of that.

·9· · · · · · · · So it's very important for

10· ·children to be taught concrete facts and to say

11· ·this is the pretend over here, and this is the

12· ·real over here.· And when a kindergartner, a

13· ·five or six-year-old child, has a person in

14· ·their class suddenly turn into somebody of the

15· ·opposite sex, their fear is that will happen to

16· ·me.· And there are any number of case reports

17· ·of that happening to children and them seeking

18· ·mental healthcare as a result of anxiety,

19· ·because they felt what I thought was real is

20· ·not real, where is reality, where is fantasy,

21· ·and is that going to happen to me?· And so they

22· ·suffer, okay, as a result of that happening to

23· ·them.

24· · · · · ·Q.· ·Are those case studies published?

25· · · · · ·A.· ·Yes.

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·1· · · · · ·Q.· ·Could I look at them?

·2· · · · · ·A.· ·Yes.

·3· · · · · ·Q.· ·Do you know who --

·4· · · · · ·A.· ·I don't know who published them,

·5· ·but I know they have been.· I've been referred

·6· ·to.· I actually am involved in a case in

·7· ·England where two boys suffered emotionally

·8· ·from anxiety disorder as a result of that and

·9· ·required treatment.

10· · · · · ·Q.· ·What's that case in England?

11· · · · · ·A.· ·Salley and Nigel Rowe Versus

12· ·whatever.· City of Isle of White or something.

13· · · · · ·Q.· ·Is that because I think I read in

14· ·England they've banded what's so-called

15· ·conversion therapy?· Is it a related matter to

16· ·that new policy?

17· · · · · ·A.· ·No.· It was just a school policy

18· ·that said acceptance of transgender students

19· ·will happen, and that it's going to happen.

20· · · · · ·Q.· ·Got it.

21· · · · · ·A.· ·Yeah.

22· · · · · ·Q.· ·Okay.· The questioning of their

23· ·own gender identity of -- just gender

24· ·identified or nontransgendered children, as a

25· ·result of seeing other children transition, is

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·1· ·that an example of that social contagion

·2· ·principle we were talking about before?

·3· · · · · ·A.· ·No.

·4· · · · · ·Q.· ·Oh, okay.· Can you explain the

·5· ·difference then?

·6· · · · · ·A.· ·So social contagion is sort of a

·7· ·person who has anxiety and depression, who

·8· ·talks to friends, goes to a meeting of issues

·9· ·related to transgender and same sex attraction,

10· ·is introduced to the concept or is told by a

11· ·teacher, as is the cases in British Columbia,

12· ·that they are transgender.· They don't

13· ·understand what transgender is.· They go to the

14· ·internet, and they see, and it's like a

15· ·checklist.

16· · · · · · · · I always say it's like the ADD

17· ·checklist on the front of Good Housekeeping

18· ·magazine at the grocery store.· If I go down

19· ·that list, I have severe ADD based on just

20· ·checking off a list of things that says this is

21· ·how you establish the diagnosis.· When in truth

22· ·that's not valid at all.

23· · · · · ·Q.· ·Okay.

24· · · · · ·A.· ·So these kids don't have that

25· ·level of sophistication, and when they're

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·1· ·troubled and they go to the internet and

·2· ·someone has told them, go here and look here, I

·3· ·think that's what you have, they'll go down a

·4· ·checklist.· And by gosh they match the

·5· ·criteria; therefore, that is me.· And then they

·6· ·start communicating online with others, and

·7· ·they say, yes.· Those people say, come on over.

·8· ·This is exactly what you have.· You need to.

·9· ·This is the answer to your prayers.· And that's

10· ·the recruitment of those kids.

11· · · · · ·Q.· ·Okay.

12· · · · · ·A.· ·It's different than being affected

13· ·by -- you know, and having anxiety as a

14· ·young -- and these are young children.· You

15· ·know, a 12 or a 13-year-old knows better. I

16· ·mean this is a child who's suffering.· You

17· ·know, I want to have compassion for them.· My

18· ·school tells me we should have compassion.· We

19· ·should not bully them.· It's wrong to say

20· ·anything negative to them or to harm them

21· ·emotionally in any way, which is totally valid,

22· ·totally compassionate, totally supported by our

23· ·organization or my professional opinion.· But,

24· ·you know, those kids know that this is that

25· ·child, and this is not me.· I will not fear

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·1· ·that that is going to happen to me.

·2· · · · · ·Q.· ·That's what you mean by know

·3· ·better?

·4· · · · · ·A.· ·Yes.

·5· · · · · ·Q.· ·Okay.· And so the comments in this

·6· ·most recent exhibit about children questioning

·7· ·their gender identity is about young children?

·8· · · · · ·A.· ·About young children.

·9· · · · · ·Q.· ·With different cognitive abilities

10· ·than the type of people who are susceptible to

11· ·the social contagion pressures?

12· · · · · ·A.· ·That's correct.

13· · · · · ·Q.· ·Got it.· Thanks.

14· · · · · · · · MS. INGELHART:· I have just this

15· ·many more, but we could pause if people are

16· ·hungry.

17· · · · · · · · THE WITNESS:· I'm fine.

18· · · · · · · · MR. BLAKE:· Let's finish this --

19· · · · · · · · THE WITNESS:· Let's get through.

20· · · · · · · · MR. BLAKE:· -- module.

21· · · · · · · · (Thereupon, Plaintiffs' Exhibit 8,

22· ·On the Promotion of Homosexuality in the

23· ·Schools, was marked for identification

24· ·purposes.)

25· ·BY MS. INGELHART:

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·1· · · · · ·Q.· ·I just placed in front you, or had

·2· ·placed in front of you, Plaintiffs' Exhibit No.

·3· ·8.· Do you recognize this documents?

·4· · · · · ·A.· ·I do.

·5· · · · · ·Q.· ·What is it?

·6· · · · · ·A.· ·This is a statement by the college

·7· ·in August of 2008 that was produced after the

·8· ·letter to superintendents of schools by the

·9· ·Obama administration, which promoted the

10· ·concept that there was absolutely no negativity

11· ·whatsoever to the homosexual lifestyle and

12· ·conditions that are medical conditions

13· ·associated with that particular diagnostic

14· ·criteria or lifestyle.

15· · · · · ·Q.· ·Okay.· Thank you.· That's helpful

16· ·context.· The checklist on the right column,

17· ·the fourth one down that says homosexual

18· ·lifestyle carries grave health risks.

19· · · · · · · · MR. BLAKE:· I'm just going to

20· ·object to this entire exhibit as entirely

21· ·irrelevant.· It's not related to transgender

22· ·folks at all.· It's not a document which he's

23· ·said he's relied on to form his opinion, but if

24· ·you want to waste your time and ask more

25· ·questions about this --

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·1· · · · · · · · THE WITNESS:· Well, I mean I don't

·2· ·see what it has to do with transgenderism.· So

·3· ·but if I could just say that.

·4· ·BY MS. INGELHART:

·5· · · · · ·Q.· ·Okay.· I guess I appreciate that.

·6· ·I'm just going to ask a couple of questions.

·7· ·So these two checkmarks here, the fourth and

·8· ·the fifth, do you disagree with those

·9· ·statements?

10· · · · · · · · MR. BLAKE:· Objection.

11· · · · · · · · THE WITNESS:· The scientific

12· ·evidence that I know of indicates that those

13· ·are issues, and then actually Dr. McHugh and

14· ·Mayer's treatise on this subject, it's

15· ·documented as such.

16· ·BY MS. INGELHART:

17· · · · · ·Q.· ·Okay.· Does the mainstream medical

18· ·establishment agree that the sexual

19· ·reorientation therapy mentioned here is

20· ·effective?

21· · · · · · · · MR. BLAKE:· Objection.· Vague.

22· · · · · · · · THE WITNESS:· It depends on -- the

23· ·sexual reorganization therapy I think is not

24· ·something that is supported.· What is called

25· ·integrative therapy or talk therapy for anxiety

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·1· ·and depression is supported.· Okay?

·2· ·BY MS. INGELHART:

·3· · · · · ·Q.· ·Is that distinction similar to

·4· ·what we made before about how conversion

·5· ·therapy for some is -- that people have

·6· ·different meanings for the word conversion

·7· ·therapy?

·8· · · · · ·A.· ·Absolutely.

·9· · · · · ·Q.· ·Okay.· So some might read the word

10· ·sexual orientation and imagine something

11· ·extreme?

12· · · · · ·A.· ·That's correct.

13· · · · · ·Q.· ·Involving like physical

14· ·interaction?

15· · · · · ·A.· ·Correct.

16· · · · · ·Q.· ·And some may read it as talk

17· ·therapy?

18· · · · · ·A.· ·That's correct.

19· · · · · ·Q.· ·Okay.· Thanks.· That's all on that

20· ·one.· And then I'm going to switch forward to

21· ·this one.

22· · · · · · · · While we're looking for that, do

23· ·you believe that talk therapy can have similar

24· ·effects for people who have same sex attraction

25· ·as people who are gender dysphoric?

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·1· · · · · · · · MR. BLAKE:· Objection.· Relevance.

·2· · · · · · · · THE WITNESS:· The talk therapy is

·3· ·all aimed at the undercurrent anxiety,

·4· ·depression, related to ACEC, adverse childhood

·5· ·events.· And so there's a common thread that

·6· ·when that is the core issue that talk therapy

·7· ·works in both instances.

·8· ·BY MS. INGELHART:

·9· · · · · ·Q.· ·Okay.· So in the case of same sex

10· ·attraction it works to address underlying

11· ·concerns and therefore change sexual behavior?

12· · · · · · · · MR. BLAKE:· Objection.· Relevant.

13· · · · · · · · THE WITNESS:· The goal is not to

14· ·change sexual behavior.· It's to basically

15· ·address the undercurrent anxiety and

16· ·depression, so that you don't have suicide and

17· ·debilitating depression ongoing, because it's

18· ·not going to be paid attention to.

19· ·BY MS. INGELHART:

20· · · · · ·Q.· ·Okay.· So we have a new exhibit

21· ·here.

22· · · · · · · · (Thereupon, Plaintiffs' Exhibit 9,

23· ·American College of Pediatricians, The Best for

24· ·Children, was marked for identification

25· ·purposes.)

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·1· ·BY MS. INGELHART:

·2· · · · · ·Q.· ·Do you recognize this document?

·3· · · · · ·A.· ·I do.

·4· · · · · ·Q.· ·To whom was it addressed?

·5· · · · · ·A.· ·To school superintendents.

·6· · · · · ·Q.· ·Is it similarly broadly addressed

·7· ·to the Obama letter where this was sent to more

·8· ·than one or could be sent to more than one

·9· ·school district?

10· · · · · ·A.· ·Yes.

11· · · · · ·Q.· ·Okay.· Does this document

12· ·reflect, specifically turning over to the

13· ·second and third paragraphs here -- okay.

14· ·Let's be more specific here.· Looking past the

15· ·colon in the second paragraph to (1)

16· ·individuals with unwanted same sex attraction

17· ·often can be successfully treated, does ACPs

18· ·agree with that statement?

19· · · · · · · · MR. BLAKE:· Objection.· Relevance

20· ·again.· This is another document that at least

21· ·in part deals solely with same sex issues and

22· ·doesn't relate to transgender issues or Dr. Van

23· ·Meter's opinion.

24· · · · · · · · Go ahead.· You can answer.

25· · · · · · · · THE WITNESS:· The concept here is

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·1· ·that if an individual is suffering, that to

·2· ·deny them therapy that could be beneficial is

·3· ·harmful.

·4· ·BY MS. INGELHART:

·5· · · · · ·Q.· ·And how are you characterizing a

·6· ·denial of treatment?

·7· · · · · ·A.· ·By law.

·8· · · · · ·Q.· ·And what laws?· I'm sorry.

·9· · · · · ·A.· ·State laws, in California. I

10· ·think there are 14 states and the District of

11· ·Columbia which outlaw any therapy for people

12· ·who have unwanted same sex attraction that are

13· ·seeking counseling.

14· · · · · ·Q.· ·Okay.· Seeking counseling to what

15· ·end?

16· · · · · ·A.· ·To try to figure out why they're

17· ·unhappy with their sexual attraction, and they

18· ·would like to be relieved of that.

19· · · · · ·Q.· ·Okay.· And those are the same laws

20· ·that discuss similar treatment for people who

21· ·are gender dysphoric, right?

22· · · · · ·A.· ·That's correct.· It is now an

23· ·umbrella.

24· · · · · ·Q.· ·Got it.· Which is why these are

25· ·relevant.· So are you familiar with those laws?

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·1· ·Those banned laws?

·2· · · · · · · · MR. BLAKE:· Objection.· Relevance,

·3· ·again.· I know you think this is relevant

·4· ·because the same laws are involved, but these

·5· ·laws are not part of this case or --

·6· · · · · · · · MS. INGELHART:· I appreciate it --

·7· · · · · · · · MR. BLAKE:· -- or.

·8· · · · · · · · MS. INGELHART:· You can --

·9· · · · · · · · MR. BLAKE:· Hold on please.· Or

10· ·his opinion.· I mean you've gone on now for

11· ·three or four hours.· I guess it's only been --

12· ·well, it's almost four hours.· About a lot of

13· ·things that tangentially relates to his

14· ·understanding of transgender issues and

15· ·potentially bias, but his opinion -- none of

16· ·his conclusions and his opinion have been

17· ·addressed once so far.

18· · · · · · · · Go ahead.· You can answer.

19· · · · · · · · THE WITNESS:· You probably need to

20· ·restate the question now.

21· · · · · · · · MS. INGELHART:· Yeah.· Yeah.

22· · · · · · · · MR. BLAKE:· Same objection.

23· · · · · · · · MS. INGELHART:· And I appreciate

24· ·it.· And so we can have that standing

25· ·objection, because I think I understand

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·1· ·counsel's position, and we're going to try to

·2· ·move efficiently in the speaking objections.

·3· ·If we can just have it as a standing

·4· ·objections.· If we can just have it as a

·5· ·standing objection, we'll let it go faster.

·6· ·BY MS. INGELHART:

·7· · · · · ·Q.· ·This first -- next to No. 1 --

·8· ·individuals with unwanted same sex attraction

·9· ·can often be successfully treated.· That

10· ·implies that people with unwanted same sex

11· ·sexual attraction can often be treated and

12· ·therefore not have that same sexual attraction

13· ·anymore, correct?

14· · · · · · · · MR. BLAKE:· Objection.

15· · · · · · · · THE WITNESS:· It basically says

16· ·they can be treated for their undercurrent

17· ·depression and anxiety.

18· ·BY MS. INGELHART:

19· · · · · ·Q.· ·Then why doesn't it say that?

20· · · · · · · · MR. BLAKE:· Objection.

21· · · · · · · · MS. INGELHART:· He's the president

22· ·of this organization.· Presumably --

23· · · · · · · · MR. BLAKE:· Not in 2010.

24· · · · · · · · THE WITNESS:· I wasn't.

25· ·BY MS. INGELHART:

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·1· · · · · ·Q.· ·This is still a position statement

·2· ·that is on your website and accessible.

·3· · · · · ·A.· ·It is a letter to -- it was a

·4· ·response to the Obama adminstration's treatise,

·5· ·point by point.

·6· · · · · ·Q.· ·So do you no longer agree with

·7· ·this statement?

·8· · · · · ·A.· ·We are in the process of revising

·9· ·policy statements to be more germane and to

10· ·better express the intent, and so we are open

11· ·to critique of everything we've said.· So that

12· ·it does not get misconstrued as to what our

13· ·intent was.

14· · · · · ·Q.· ·Okay.· But you previously

15· ·testified that you didn't disagree with this,

16· ·right?

17· · · · · ·A.· ·Yes, I did.

18· · · · · ·Q.· ·Okay.· And this is still available

19· ·on your website?

20· · · · · ·A.· ·Yes, it is.

21· · · · · ·Q.· ·Okay.· All right.· Okay.· The last

22· ·question.· How many policy statements, about,

23· ·does the American College for Pediatricians

24· ·have?

25· · · · · · · · MR. BLAKE:· Objection.· Relevance.

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·1· · · · · · · · THE WITNESS:· I would have to

·2· ·guess.· I don't know.

·3· ·BY MS. INGELHART:

·4· · · · · ·Q.· ·Could you round for me?

·5· · · · · ·A.· ·40.

·6· · · · · ·Q.· ·Okay.· Do you know what proportion

·7· ·reference LGBT related issues?

·8· · · · · ·A.· ·Probably, 50 percent.

·9· · · · · · · · MS. INGELHART:· Okay.· We can go

10· ·off the record and break for lunch.

11· · · · · · · · (Thereupon, a break was taken.)

12· · · · · · · · MS. INGELHART:· Okay.· We'll go

13· ·back on the record.

14· ·BY MS. INGELHART:

15· · · · · ·Q.· ·Do you know whether transgender

16· ·people experience higher rates of

17· ·discrimination than the general population?

18· · · · · · · · MR. BLAKE:· Objection.· Relevance.

19· · · · · · · · Answer if you know.

20· · · · · · · · THE WITNESS:· No.· I do not know.

21· ·BY MS. INGELHART:

22· · · · · ·Q.· ·Do you know whether transgender

23· ·people experience higher rates of harassment

24· ·than the general population?

25· · · · · · · · MR. BLAKE:· Objection.· Basis

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·1· ·foundation.

·2· ·BY MS. INGELHART:

·3· · · · · ·Q.· ·Okay.· Do you know whether

·4· ·transgender people experience higher rates of

·5· ·violence than the general population?

·6· · · · · · · · MR. BLAKE:· Objection.

·7· · · · · · · · THE WITNESS:· I do not.· No.

·8· ·BY MS. INGELHART:

·9· · · · · ·Q.· ·Do you know whether transgender

10· ·people may be exposed to immediate negative

11· ·outcomes, if they have to use identity

12· ·documents that reveal their transgender status?

13· · · · · ·A.· ·I do not.

14· · · · · · · · MR. BLAKE:· Objection.

15· ·Foundation.

16· ·BY MS. INGELHART:

17· · · · · ·Q.· ·What determines gender identity?

18· · · · · ·A.· ·The individual.

19· · · · · ·Q.· ·Can you explain?

20· · · · · ·A.· ·Gender, as it was brought into

21· ·medical terminology by John Money, meant it's

22· ·sort of an internal sense of your sexual

23· ·identity.

24· · · · · ·Q.· ·Okay.· Okay.· Are there any

25· ·components of gender identity, or how do you

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·1· ·know someone's gender identity.

·2· · · · · · · · MR. BLAKE:· Objection.· Vague.

·3· · · · · · · · THE WITNESS:· You ask them.

·4· · · · · · · · MS. BONHAM:· Is this all one

·5· ·exhibit?

·6· · · · · · · · MS. INGELHART:· It should be, but

·7· ·we can triple check.

·8· · · · · · · · (Thereupon, Plaintiffs' Exhibit

·9· ·10, letter, CV, and rebuttal expert report from

10· ·Dr. Van Meter, was marked for identification

11· ·purposes.)

12· ·BY MS. INGELHART:

13· · · · · ·Q.· ·All right.· What we've just

14· ·presented is Plaintiffs' Exhibit 10.· For ease

15· ·of reference and flipping back and forth, we

16· ·have put your first report with your rebuttal.

17· ·So the order of the documents here is your

18· ·initial report, followed by your CV, followed

19· ·by your rebuttal report.

20· · · · · ·A.· ·Okay.

21· · · · · ·Q.· ·Thank you.· So do you recognize

22· ·this document?

23· · · · · ·A.· ·I do.

24· · · · · ·Q.· ·Okay.· And did you create this

25· ·document?

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·1· · · · · ·A.· ·I did.

·2· · · · · ·Q.· ·Okay.· And you reviewed it in

·3· ·advance of today, correct?

·4· · · · · ·A.· ·Yes, I did.

·5· · · · · ·Q.· ·Okay.

·6· · · · · ·A.· ·Whether I reviewed this copy of my

·7· ·CV, I can't tell you.· It depends on the date

·8· ·of it.

·9· · · · · ·Q.· ·Okay.· So I want to turn to the

10· ·rebuttal report at the back, which Paragraph 11

11· ·of it is the second to last page of this pile

12· ·of papers.

13· · · · · ·A.· ·Paragraph 11.· Okay.

14· · · · · ·Q.· ·Can you read Paragraph 11?

15· · · · · ·A.· ·Yes.· Dr. Ettner states elsewhere,

16· ·in Paragraph 20, that gender identity is

17· ·determined merely by the statement of the

18· ·adolescent or adult.· Mere statements by the

19· ·individual, obviously, do not indicate a

20· ·biologic basis for gender identity.· Nor do

21· ·such statements indicate that gender identity

22· ·is immutable.

23· · · · · ·Q.· ·Okay.· Did you just testify that

24· ·you determined somebody's gender identity by

25· ·asking them?

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·1· · · · · ·A.· ·Gender identity, yes.

·2· · · · · ·Q.· ·Okay.· So this Paragraph 11 here,

·3· ·you're saying that you disagree with Dr. Ettner

·4· ·as to substance in your second two sentences,

·5· ·not the first?

·6· · · · · ·A.· ·I'm not sure I understand your

·7· ·question.

·8· · · · · ·Q.· ·Sure.· Okay.· So in Paragraph 11

·9· ·you state that -- you reference back to Dr.

10· ·Ettner's report where she says to you,

11· ·according to you, that gender identity is

12· ·determined merely by the statement of the

13· ·adolescent or adult?

14· · · · · ·A.· ·That's correct.· So I don't

15· ·disagree with that.

16· · · · · ·Q.· ·Okay.· So you're highlighting your

17· ·divergence from her opinion in the second two

18· ·sentences, correct?

19· · · · · ·A.· ·That's correct.

20· · · · · ·Q.· ·Okay.· And what is your basis that

21· ·there's no biological basis for -- what's your

22· ·basis for the assertion that there's no

23· ·biological basis for gender identity?

24· · · · · ·A.· ·Because there is no valid

25· ·scientific study that indicates such.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·There are attempts to look at

·3· ·brain MRI studies to look at exon deletions or

·4· ·couplings and pairs.· The numbers are extremely

·5· ·small.· The interpretation that is presented

·6· ·has been challenged by authorities in the

·7· ·fields of neuroimaging and in molecular

·8· ·genetics to say that the conclusions that were

·9· ·reached in each case that are not valid.

10· · · · · ·Q.· ·Thank you.· In your view, a

11· ·person's sex does not include their gender

12· ·identity, correct?

13· · · · · ·A.· ·That's correct.

14· · · · · ·Q.· ·In your professional expert

15· ·opinion, is a gender identity something that is

16· ·fixed?

17· · · · · ·A.· ·No, I do not believe it's fixed.

18· · · · · ·Q.· ·Okay.

19· · · · · ·A.· ·But it may be persistent, but it

20· ·is not so that it cannot be changed.

21· · · · · ·Q.· ·In your opinion, does gender

22· ·identity crystallize for individuals at a

23· ·certain point in time?

24· · · · · ·A.· ·I do not know.

25· · · · · ·Q.· ·Okay.· Great.· We'll put this

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·1· ·aside.· We will certainly come back to it.

·2· · · · · ·A.· ·Okay.

·3· · · · · ·Q.· ·I'm going to introduce another

·4· ·exhibit.· Exhibit 11.

·5· · · · · · · · (Thereupon, Plaintiffs' Exhibit

·6· ·11, Certification of Birth of Stacie Marie Ray,

·7· ·was marked for identification purposes.)

·8· ·BY MS. INGELHART:

·9· · · · · ·Q.· ·Plaintiffs' Exhibit 11 has just

10· ·been handed to you.· Do you know what this

11· ·document is?

12· · · · · ·A.· ·It says it's a certification of

13· ·birth

14· · · · · ·Q.· ·From the State of Ohio, right?

15· · · · · ·A.· ·From the State of Ohio.

16· · · · · ·Q.· ·Do you happen to recognize the

17· ·name on this birth certificate?

18· · · · · ·A.· ·Yes, I do.

19· · · · · ·Q.· ·Do you know who it is?

20· · · · · ·A.· ·It's one of the plaintiffs, I

21· ·believe.

22· · · · · ·Q.· ·Okay.· Great.· Thank you.· Looking

23· ·at the right-hand side of the birth certificate

24· ·where there's a field that says sex, does it

25· ·say biological sex or sex?

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·1· · · · · · · · MR. BLAKE:· Objection.

·2· · · · · · · · THE WITNESS:· It says sex, because

·3· ·biological sex is sort of a redundancy.· Sex is

·4· ·sex, and it is biologic.· So you don't have to.

·5· ·It's like saying it's a green color.· Okay?

·6· ·Sex is biologic.· So to say biologic sex is to

·7· ·try to separate it from the construction of

·8· ·gender identity.· So it has no biologic basis.

·9· ·Sex and gender are often interchangeably used

10· ·on documents.

11· · · · · · · · My Georgia driver's license has

12· ·sex.· My Delta frequent flyer card has gender.

13· ·The reason for that I can only, in conjecture,

14· ·say is because the word sex has so many

15· ·connotations in terms of a verb, you know, it's

16· ·a potentially adult word of some kind, but

17· ·gender is so squeaky clean that it's an easier

18· ·way to say what you really mean, which is the

19· ·sex of the patient.

20· ·BY MS. INGELHART:

21· · · · · ·Q.· ·Okay.· So --

22· · · · · ·A.· ·That's just --

23· · · · · ·Q.· ·No, no.

24· · · · · ·A.· ·I'm trying to figure it out.· Why

25· ·in the world would you ever use gender on a

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·1· ·document if you're applying for something, when

·2· ·what you're really trying to say what is your

·3· ·sex?

·4· · · · · ·Q.· ·Okay.· So do you think that

·5· ·government issued identity documents should

·6· ·just list sex assigned at birth instead of a

·7· ·marker for gender?

·8· · · · · ·A.· ·No, I think it should just say

·9· ·sex.· Sex assigned at birth is kind of another

10· ·inaccuracy.· Okay?· Sex is determined at

11· ·conception.

12· · · · · ·Q.· ·Okay.

13· · · · · ·A.· ·Calling it assigned is sort of a

14· ·judgmental kind of a thing, as if it were an

15· ·opinion.· It is something that is recognized at

16· ·birth by anatomy, or if there's confusion it's

17· ·recognized that there's confusion.· We do not

18· ·let a baby boy, that we think is a baby boy,

19· ·whose testicles are not in the scrotum -- both

20· ·of them or one or both of them in the

21· ·scrotum -- we do not let that baby leave the

22· ·nursery identified as a male or female until we

23· ·essentially determine whether or not the sex of

24· ·that baby is male or female.

25· · · · · ·Q.· ·Okay.· So did you say that

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·1· ·government issued any documents should have the

·2· ·word sex, right?

·3· · · · · ·A.· ·It should in that if they're

·4· ·collecting data, which is what government

·5· ·documents are supposed to do, and you are

·6· ·looking at epidemiologist things such as the

·7· ·things that are different from male sex to

·8· ·female sex, and then you're going to need to

·9· ·keep records of those things.· And for instance

10· ·a trans female who comes in -- excuse me. A

11· ·trans male who comes into the emergency room

12· ·with abdominal cramping, it's important for the

13· ·medical diagnosis that it be obvious to

14· ·everyone that that person is a -- the sex they

15· ·were born, because their internal anatomy

16· ·likely in the case of the pregnancy that

17· ·essentially was a miscarriage, that was because

18· ·there was no recognition of sex, there was

19· ·recognition instead of gender.· So that's an

20· ·actual -- and it's rare.· I fully admit that

21· ·made a lot of news because it was splashy, but

22· ·it was an event which just illustrated the

23· ·point that you need to know sex differences,

24· ·not gender differences in terms of medicine and

25· ·outcomes.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·The FDA recognizes sex as

·3· ·important, because they make sure that drugs

·4· ·are tested in males and they are tested in

·5· ·females, before they can say they're safe and

·6· ·effective.· Because the human body as a male

·7· ·reacts differently than the human female body

·8· ·does.· No matter what the gender is perceived

·9· ·to be, the important thing is the sex.

10· · · · · ·Q.· ·So on like identity documents and

11· ·forms, just to be clear, you think that the sex

12· ·marked on a birth certificate, the original

13· ·birth certificate, should be what's on those

14· ·documents?

15· · · · · ·A.· ·The purpose is to collect data on

16· ·births to look at population, okay, to

17· ·establish an anchor of identity, but more

18· ·important to look at sex.· Say percentage of

19· ·males, percentage of females.· Accidents

20· ·involving -- epidemiologist studies involving

21· ·males and females.· If that's changed, then you

22· ·skew the data, and you all the sudden lose the

23· ·biologic proportion of male-to-females, and if

24· ·you're looking at laws and discrimination, et

25· ·cetera, et cetera, you're going to lose all the

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·1· ·benefit of being able to quantify your

·2· ·population.· And this is a government document

·3· ·establishing biologic population.

·4· · · · · ·Q.· ·Okay.· So just to be clear,

·5· ·though, you think it would be better if

·6· ·documents required a person to list sex that

·7· ·was originally on their birth certificate

·8· ·whenever identifying sex or gender?

·9· · · · · · · · MR. BLAKE:· Objection.· Misstates.

10· ·Relevance.

11· · · · · · · · THE WITNESS:· I'm saying that in a

12· ·birth record.· Birth record.

13· ·BY MS. INGELHART:

14· · · · · ·Q.· ·Okay.· So not generally identity

15· ·documents?

16· · · · · ·A.· ·You know, everything else is more

17· ·of a social construct.· So if you on your

18· ·driver's license say, I have blond hair and

19· ·blue eyes, and what you really have is brown

20· ·hair that you have bleached, and you're wearing

21· ·blue contacts, okay, the reason that the

22· ·driver's license says blond hair and blue eyes

23· ·is because if you are recognized in an event

24· ·where they have to have some kind of identity

25· ·that's right there and immediate, they have it,

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·1· ·and it matches.· Okay?

·2· · · · · · · · Instead of saying you see someone

·3· ·who's blond and blue eyed and on their driver's

·4· ·license it says black hair and black eyes,

·5· ·you're thinking, wait a minute.· This doesn't

·6· ·represent what this is, where I need to know

·7· ·right at this very second.· This is not a

·8· ·document like that.· This is a health record of

·9· ·demographics.

10· · · · · ·Q.· ·Okay.· But like in the

11· ·hypothetical that you introduced with the trans

12· ·man presenting at a hospital with abdominal

13· ·pain, you said that it's important that he on a

14· ·form would list female, right?

15· · · · · · · · MR. BLAKE:· Objection.

16· · · · · · · · THE WITNESS:· If there's not a

17· ·form, at least inform immediately all the

18· ·medical personnel, I need to tell you something

19· ·in private.· This is all HIPPA compliant.· You

20· ·know, you are my physician.· I'm sharing with

21· ·you the fact that I am actually a female in

22· ·terms of my sex, but my gender is male.

23· ·BY MS. INGELHART:

24· · · · · ·Q.· ·Okay.

25· · · · · ·A.· ·I'm concerned, therefore, that I

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·1· ·might be pregnant.· You know.

·2· · · · · ·Q.· ·Yeah.· Okay.

·3· · · · · ·A.· ·Yeah.

·4· · · · · · · · (Thereupon, Plaintiffs' Exhibit

·5· ·12, Transgender, a state of mind in search of

·6· ·biology by Dr. Van Meter, PowerPoint photos,

·7· ·was marked for identification purposes.)

·8· ·BY MS. INGELHART:

·9· · · · · ·Q.· ·Quickly, I'd like to introduce

10· ·another exhibit, Exhibit 12.· What I have just

11· ·had placed before you is Plaintiffs' Exhibit

12· ·12.· Do you recognize this document?

13· · · · · ·A.· ·I do.

14· · · · · ·Q.· ·What is it?

15· · · · · ·A.· ·It's a printout of a PowerPoint

16· ·presentation.

17· · · · · ·Q.· ·Is it a PowerPoint presentation of

18· ·your own?

19· · · · · ·A.· ·Yes.

20· · · · · ·Q.· ·Do you know when this PowerPoint

21· ·presentation was used?

22· · · · · ·A.· ·This I believe was what I

23· ·presented at the meeting of the Southern

24· ·Pediatric Endocrine Society meeting, in

25· ·Atlanta.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·In I think it was 2014.

·3· · · · · ·Q.· ·Thank you.· Okay.· That's helpful.

·4· ·So if you could turn -- unfortunately there's

·5· ·not Bates numbers -- to the second to last

·6· ·piece of paper that is titled, recapturing the

·7· ·language, did you create this Power Point?

·8· · · · · ·A.· ·I did.

·9· · · · · ·Q.· ·So this third bullet point here

10· ·says, remove gender and replace with sex on all

11· ·government and business documents.

12· · · · · · · · MR. BLAKE:· Objection.· That's not

13· ·what it says.

14· · · · · · · · MS. INGELHART:· I literally just

15· ·read it.

16· · · · · · · · MR. BLAKE:· You literally read it

17· ·wrong.

18· · · · · · · · MS. INGELHART:· Remove gender and

19· ·replace with sex on all government and business

20· ·documents.

21· · · · · · · · MR. BLAKE:· You read it again

22· ·wrong.· You're inserting the word all.

23· · · · · · · · MS. INGELHART:· I'm saying on.

24· · · · · · · · MR. BLAKE:· You said on all.

25· · · · · · · · MS. BONHAM:· Why don't we read it

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·1· ·one more time for the record?

·2· · · · · · · · MR. BLAKE:· Thank you.

·3· ·BY MS. INGELHART:

·4· · · · · ·Q.· ·Okay.· Remove gender and replace

·5· ·with sex on government and business documents?

·6· · · · · ·A.· ·Yes, I wrote that.

·7· · · · · ·Q.· ·Okay.· Thank you.· This is

·8· ·inconsistent with your prior statement,

·9· ·correct?

10· · · · · · · · MR. BLAKE:· Objection.

11· · · · · · · · THE WITNESS:· This is a statement

12· ·of what if I were in charge and what I thought

13· ·made sense and what would be honest is what

14· ·should happen, but that's different than what I

15· ·previously stated.

16· · · · · · · · Okay.· Thank you.· That's all.

17· · · · · · · · MS. INGELHART:· For the record, I

18· ·wasn't trying to intentionally misread.

19· · · · · · · · MR. BLAKE:· I know you weren't.

20· · · · · · · · MS. INGELHART:· Okay.· Thank you.

21· ·BY MS. INGELHART:

22· · · · · ·Q.· ·What is gender dysphoria?

23· · · · · ·A.· ·It is a term that was created by

24· ·the APA committee in creation of DSM-5 to

25· ·replace the term gender identity disorder to

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·1· ·describe the emotional discomfort created by

·2· ·having an incongruent gender and sex.

·3· · · · · ·Q.· ·Okay.· And it replaced the term

·4· ·gender identity disorder, correct?

·5· · · · · ·A.· ·Essentially, in the DSM.· Yes, it

·6· ·did.

·7· · · · · ·Q.· ·Okay.· Is that why in your report

·8· ·you sometimes use gender identity disorder

·9· ·versus the term gender dysphoria?

10· · · · · ·A.· ·It's almost interchangeable with

11· ·gender incongruence and gender identity

12· ·disorder and gender dysphoria, because for me

13· ·they are all essentially the same thing with

14· ·just different names put to them.

15· · · · · ·Q.· ·Okay.· And can you clarify for me

16· ·what gender incongruence is?· I think I

17· ·understand but...

18· · · · · ·A.· ·It is when there's a mismatch

19· ·between the gender and the sex.

20· · · · · ·Q.· ·Okay.· Thank you.· Do you believe

21· ·it's ever appropriate for a transgender person

22· ·to undertake gender transition?

23· · · · · ·A.· ·Yeah.· I don't think there's any

24· ·appropriate time or age.

25· · · · · ·Q.· ·Thank you.· Is that the view

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·1· ·generally accepted within your field?

·2· · · · · ·A.· ·Among nonprofessional societies,

·3· ·among colleagues, absolutely.

·4· · · · · ·Q.· ·Among all of your colleagues, all

·5· ·pediatric endocrinologists in the U.S.?

·6· · · · · ·A.· ·The majority of pediatric

·7· ·endocrinologist colleagues.· When I give

·8· ·presentations and take assessment of their

·9· ·response and what they come up to me afterwards

10· ·and say, it's 75 percent.

11· · · · · ·Q.· ·Okay.· Are the people who attend

12· ·your panels and presentations representative of

13· ·the entire population of pediatric

14· ·endocrinologists?

15· · · · · · · · MR. BLAKE:· Objection.

16· · · · · · · · THE WITNESS:· I can't state that,

17· ·but they are representative of the people who

18· ·come to CME meetings.

19· ·BY MS. INGELHART:

20· · · · · ·Q.· ·Okay.· Thank you.· Have you ever

21· ·taken any steps to facilitate someone's gender

22· ·transition?

23· · · · · ·A.· ·Yes, I did.· In 1994, when I gave

24· ·that boy some estrogen.

25· · · · · ·Q.· ·Okay.· Any other time?

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·1· · · · · ·A.· ·No.

·2· · · · · ·Q.· ·Okay.· And on what basis did you

·3· ·do that?

·4· · · · · ·A.· ·There was no precedent set in

·5· ·children, and everyone who could advise me said

·6· ·we don't know, but if you're going to do it,

·7· ·this is how you should.

·8· · · · · ·Q.· ·Okay.· And I'm sorry.· Who did you

·9· ·consult with on that?

10· · · · · ·A.· ·Peter Lee, Claude Migeon, Mel

11· ·Grumbach, Gail Richards in Seattle.

12· · · · · ·Q.· ·And are they all also --

13· · · · · ·A.· ·They were all pediatric

14· ·endocrinologists, yeah.

15· · · · · ·Q.· ·Okay.· Thank you.· Thank you so

16· ·much.· Do you agree that individuals with

17· ·gender dysphoria, if not treated, often suffer

18· ·clinical significant emotional distress?

19· · · · · ·A.· ·Absolutely.

20· · · · · ·Q.· ·Including depression and suicidal

21· ·thoughts?

22· · · · · ·A.· ·Yes.

23· · · · · ·Q.· ·Okay.· And that it can impair the

24· ·functioning in their daily lives?

25· · · · · ·A.· ·It does.

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·1· · · · · ·Q.· ·Thank you.

·2· · · · · ·A.· ·It's by definition.· That's what

·3· ·gender dysphoria is.· It's a description of

·4· ·that impairment.

·5· · · · · ·Q.· ·Okay.· And again, without proper

·6· ·treatment, do you agree that a significant

·7· ·portion, like 30 to 40 percent, develop

·8· ·suicidal ideation thoughts or attempt suicide?

·9· · · · · ·A.· ·It's actually closer to about 20

10· ·percent, and the study's done at the Williams

11· ·Institute, where they looked at actual suicide

12· ·attempts.· It is equal to, I believe, autism

13· ·and just general anxiety and depression.

14· · · · · ·Q.· ·Okay.· Do you believe that

15· ·generally speaking transgender adults can

16· ·voluntarily change their gender identity?

17· · · · · ·A.· ·I don't know, because I don't

18· ·treat those.· I think at that end of the

19· ·spectrum it is far more difficult.· That would

20· ·be my experience of listening to the -- to Ken

21· ·Zucker and knowing what he's written is by the

22· ·time you get to adulthood, that if you have not

23· ·desisted, the desistance rate gets narrower and

24· ·narrower to that point in time.· But the point

25· ·is they need lifelong emotional support.

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·1· ·Lifelong psychiatric intervention or

·2· ·psychological intervention.· And if you make

·3· ·the assumption that they're done and you've

·4· ·fixed them and let them go, that that's a grave

·5· ·disservice.· His point was if they get to

·6· ·adulthood and they choose to transition

·7· ·medically and surgically, they need to be your

·8· ·patients until the end of their life, and if

·9· ·you let them go, they will be in grave danger

10· ·of harming themselves.

11· · · · · ·Q.· ·Okay.· On the in perpetuity,

12· ·danger of harming one's self if they're not in

13· ·care, what's the basis for that?

14· · · · · ·A.· ·His personal experience, and then,

15· ·you know, the Dhejne study talks about just the

16· ·suicide rate being 20 fold greater.

17· · · · · ·Q.· ·Like the Swedish study?

18· · · · · ·A.· ·Yeah.

19· · · · · ·Q.· ·Okay.· And also Zucker's research,

20· ·as well?

21· · · · · ·A.· ·Right.

22· · · · · ·Q.· ·Okay.· Thank you.· Do you agree

23· ·whether a trait is biological and whether a

24· ·trait can be changed are two different things?

25· · · · · · · · MR. BLAKE:· Objection.· Vague.

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·1· · · · · · · · THE WITNESS:· Biological seems to

·2· ·be that there is a genetic programming that,

·3· ·again, I would say that biological means it

·4· ·can't be successfully changed.· You can make

·5· ·attempts to do so, but you will not succeed.

·6· ·BY MS. INGELHART:

·7· · · · · ·Q.· ·Is it your opinion that there's no

·8· ·genetic component to gender identity?

·9· · · · · ·A.· ·That's correct.

10· · · · · ·Q.· ·Okay.· Is it your opinion that

11· ·there's, therefore, no relationship to

12· ·transgender identity and inheritability?

13· · · · · ·A.· ·Correct.

14· · · · · ·Q.· ·I think we touched on this before,

15· ·but do you believe that the removal of gender

16· ·identity disorder from the DSM and its

17· ·replacement with gender dysphoria was a

18· ·disservice to patients?

19· · · · · · · · MR. BLAKE:· Objection.· Vague.

20· · · · · · · · THE WITNESS:· Yes.

21· ·BY MS. INGELHART:

22· · · · · ·Q.· ·Thank you.· Is it your opinion

23· ·that sex reassignment surgery and treatment for

24· ·gender dysphoria is a form of mutilation?

25· · · · · ·A.· ·Yes.

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·1· · · · · ·Q.· ·Okay.· For the record, let's turn

·2· ·back to your report.· In the initial part of

·3· ·it, Paragraph 24, which is on Page 5 of the

·4· ·initial, so it is the third paper in that file.

·5· · · · · ·A.· ·Okay.

·6· · · · · ·Q.· ·I think this is what we talked

·7· ·about earlier on the record or off.· I'd just

·8· ·like to put it on the record.· This statement

·9· ·here, do you hold firm that that's accurate?

10· · · · · ·A.· ·No.· I mean those numbers have

11· ·been modified considerably, depending on how

12· ·the question is asked in the population.· It is

13· ·now estimated in a study of high school

14· ·students of Oregon that it's 24 percent of the

15· ·population that says issues with gender

16· ·identity.

17· · · · · ·Q.· ·Okay.

18· · · · · ·A.· ·I mean that's the extreme on one

19· ·side, and somewhere in the middle, the actual

20· ·standard up until sort of the increase of the

21· ·adolescence female.· I talked about the strange

22· ·rush in gender incongruence.· Two to one

23· ·female-to-males.· Prior to that it was .06.· It

24· ·was 6 out of 100,000 males and 3 out of 100,000

25· ·females.· So that was a respected figure from

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·1· ·Europe.· Those were the WPATH statistics at the

·2· ·time.· It has been modified considerably since

·3· ·then, and I think that's the concern is the

·4· ·repetity of the modification to a hundred fold.

·5· ·You know, going from 200 cases a year to 2,400

·6· ·cases a year in the UK, over a span of 10 years

·7· ·made them sit up and say, what's going on?

·8· ·Let's pause.· Let's go and examine exactly what

·9· ·this phenomenon is, because that cannot be

10· ·explained by social acceptance.

11· · · · · ·Q.· ·Okay.· Can I just quickly ask you

12· ·the terminology here?· You used the term

13· ·biological females and biological males.

14· · · · · ·A.· ·It's redundant.

15· · · · · ·Q.· ·Okay.· Thank you.

16· · · · · ·A.· ·Well, actually, no.· Biological

17· ·females, yeah.· I mean what that is is the sex

18· ·is male or female is what that intent was.· To

19· ·use the word biologic sex, as I said, is sort

20· ·of a redundancy.

21· · · · · ·Q.· ·I see.· Okay.· Thank you.

22· · · · · ·A.· ·So the biological female refers to

23· ·female sex.· Biological male, male sex.

24· · · · · ·Q.· ·Got it.· Not to be confused with

25· ·female gender?

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·1· · · · · ·A.· ·Right.

·2· · · · · ·Q.· ·Thank you.· And you cited to the

·3· ·Endocrine News source for this?

·4· · · · · ·A.· ·Yes.· And I went back, and I went

·5· ·to see where I found that, and I will have to

·6· ·go back and find out, because I've got a stack

·7· ·in a folder exactly what I used, and somehow

·8· ·inadvertently misstated that that came from

·9· ·that source.· And I reread that, because I

10· ·could look it up, and I said, well, that's an

11· ·interesting criticism and I want to make sure

12· ·that I point by point go through.· And it's an

13· ·valid criticism.· So I fully say that did not

14· ·come from that source.

15· · · · · ·Q.· ·Mistakes in footnotes happen.

16· · · · · ·A.· ·I get concerned, because I signed

17· ·this.

18· · · · · ·Q.· ·Fair.· So but generally is the

19· ·Endocrine News a reputable source?

20· · · · · ·A.· ·No.· It's one of the throwaways.

21· · · · · ·Q.· ·Okay.· Before I said I wanted to

22· ·come back to this, and so quickly tie up a lose

23· ·end.· Can we refer back to the Zucker exhibit.

24· ·What's the number?

25· · · · · ·A.· ·It is 3.

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·1· · · · · ·Q.· ·Thank you.· Can we go back to

·2· ·Exhibit 3 really quickly.· Just back to the

·3· ·same place we were before, Page No. 392.

·4· ·Apologies.· Can we look at Page 369, the very

·5· ·first page?

·6· · · · · ·A.· ·Okay.

·7· · · · · ·Q.· ·In the first non-italicized

·8· ·paragraph, this study is indicated to be 590

·9· ·children.· Is that how you read that as well?

10· · · · · ·A.· ·Yes.· And I may have misstated 560

11· ·previously, but it's 590.

12· · · · · ·Q.· ·But this is the study you cite to

13· ·for rate of desistance and --

14· · · · · · · · MR. BLAKE:· Objection.

15· ·BY MS. INGELHART:

16· · · · · ·Q.· ·And is that accurate?· Is this the

17· ·study that you cite to for rate of desistance?

18· · · · · ·A.· ·No.· DSM is what I also cited to

19· ·in that.

20· · · · · ·Q.· ·Okay.· But this is one of them?

21· · · · · ·A.· ·Yeah.· This is one of them.

22· · · · · ·Q.· ·Okay.· Thank you.· Thank you for

23· ·the clarification.· So this is one of the

24· ·documents that you cite to for rate of

25· ·desistance, but this document is just a study

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·1· ·of children, correct?

·2· · · · · ·A.· ·That's correct.

·3· · · · · ·Q.· ·And as we discussed before, rate

·4· ·of desistance among children is higher than

·5· ·rates of desistance amongst adults?

·6· · · · · ·A.· ·That's correct.

·7· · · · · ·Q.· ·Okay.· Okay.· Back to your report.

·8· ·Sorry for all the jumping around.· We're going

·9· ·to look at the rebuttal portion.· So we can

10· ·flip to the very last page of this stack of

11· ·papers and to Paragraph 15.· Can you refresh

12· ·your recollection?· Do you know what we're

13· ·talking about?

14· · · · · ·A.· ·Yes.· This is the Dhejne study.

15· · · · · ·Q.· ·Okay.· And that's the one where

16· ·you cited for what assertion again?

17· · · · · ·A.· ·That there was nearly 20 times

18· ·increase of suicide -- completed suicides, not

19· ·attempts, in patients who had completed the

20· ·entire gender affirmation process.· Social,

21· ·medical and surgical.

22· · · · · ·Q.· ·Okay.· Great.· Thank you.

23· · · · · · · · (Thereupon, Plaintiffs' Exhibit

24· ·13, Long-Term Follow-Up of Transsexual Persons

25· ·Undergoing Sex Reassignment Surgery:· Cohort

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·1· ·Study in Sweden, was marked for identification

·2· ·purposes.)

·3· ·BY MS. INGELHART:

·4· · · · · ·Q.· ·I'm going to introduce another

·5· ·exhibit.· This is Plaintiffs' Exhibit 13.· If

·6· ·you want to take a look at it.· Do you

·7· ·recognize this document?

·8· · · · · ·A.· ·I have not combed through it.

·9· ·It's the second or a follow-up study by Cecilia

10· ·Dhejne.· So I'm aware of it, yes.

11· · · · · ·Q.· ·And I apologize, but looking back

12· ·to the last page here, Paragraph 15 of your

13· ·rebuttal -- oh, I'm sorry.· The other one

14· ·there.· This is where -- I'll wait until you

15· ·get there.

16· · · · · ·A.· ·Okay.

17· · · · · ·Q.· ·Okay.· So it shows on 19-fold

18· ·increase in completed suicides, and you don't

19· ·have a footnote here, but is this the study I

20· ·just introduced?· Is that the one that you're

21· ·referring to?

22· · · · · ·A.· ·No, it's not.

23· · · · · ·Q.· ·It's not?

24· · · · · ·A.· ·No.· It's a -- hang on.· Hang on.

25· ·Wait a minute.· I can tell you.

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·1· · · · · ·Q.· ·Yeah.· No problem.

·2· · · · · ·A.· ·And this is 2000 -- what's the

·3· ·date?· No, it is this one.

·4· · · · · ·Q.· ·Okay.

·5· · · · · ·A.· ·I'm sorry.· Yes.

·6· · · · · ·Q.· ·Okay.· Thank you.

·7· · · · · ·A.· ·Yes, yes, yes.

·8· · · · · ·Q.· ·Thank you.

·9· · · · · ·A.· ·Okay.

10· · · · · ·Q.· ·Okay.· So can you explain to me

11· ·what a 19-fold increase means?

12· · · · · ·A.· ·Well, 19 times the amount of

13· ·suicides compared to the general populations of

14· ·Sweden's.

15· · · · · ·Q.· ·Okay.· So it's 19 times greater.

16· ·It wasn't an increase from some other previous

17· ·measure?

18· · · · · ·A.· ·No.

19· · · · · ·Q.· ·Thank you.· Okay.· And then in

20· ·your second sentence here it says -- sorry.

21· ·I'll let you get there.· It says these studies

22· ·indicate that gender incongruent patients who

23· ·undergo appropriate treatment and return to

24· ·identification with their biologic sex are at

25· ·far less risk for suicide.· What do you mean by

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·1· ·this study indicates?

·2· · · · · ·A.· ·These being --

·3· · · · · ·Q.· ·Oh, these.· Yes.

·4· · · · · ·A.· ·-- a conglomerate of all prior --

·5· ·the studies that are mentioned in the paper.

·6· ·It's not the Dhejne study specifically.

·7· · · · · ·Q.· ·Oh, okay.· I misunderstood the

·8· ·paragraph.· Thank you.

·9· · · · · ·A.· ·Okay.

10· · · · · ·Q.· ·Okay.· We can set aside your

11· ·report and then look back to the Dhejne study.

12· ·Thank you for teaching me how to pronounce the

13· ·name.· We discussed earlier issues with control

14· ·groups in these studies.

15· · · · · ·A.· ·Right.

16· · · · · ·Q.· ·If you look on the very first

17· ·page, there's a quick section that's called

18· ·participants.· In the gray box --

19· · · · · ·A.· ·In the gray box.· Okay.· Right.

20· · · · · ·Q.· ·-- there's participant.· So what

21· ·are the two comparative groups here?

22· · · · · ·A.· ·Random population controls and the

23· ·trans male-to-females and female-to-males.

24· · · · · ·Q.· ·Okay.· And by general population

25· ·control, what is that specifically?

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·1· · · · · ·A.· ·That is the population of Sweden,

·2· ·and a sample of the population to look at

·3· ·incidence of suicide.

·4· · · · · ·Q.· ·Okay.· Thank you.· So the

·5· ·non-control group were transgender people,

·6· ·correct?

·7· · · · · ·A.· ·That's correct.

·8· · · · · ·Q.· ·Who had undergone medical gender

·9· ·affirmation?

10· · · · · ·A.· ·Social, medical and surgical.

11· · · · · ·Q.· ·Thank you.· And the control group

12· ·was generally representative of non-transgender

13· ·people?

14· · · · · ·A.· ·That's correct.

15· · · · · ·Q.· ·Okay.· Can we turn to what in

16· ·my -- oh, I'm going to try to compare -- to the

17· ·results section.· Whatever that --

18· · · · · ·A.· ·I've got it.

19· · · · · ·Q.· ·Okay.· And there's a comment that

20· ·says, Table 1.

21· · · · · ·A.· ·Yes.

22· · · · · ·Q.· ·That's commenting upon Table 1. I

23· ·apologize.· Could we go off the record really

24· ·quick?

25· · · · · · · · THE COURT REPORTER:· Sure.

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·1· · · · · · · · (Thereupon, the deposition briefly

·2· ·went off the record.)

·3· ·BY MS. INGELHART:

·4· · · · · ·Q.· ·So on Page 4 of the document that

·5· ·you're looking at in the results section,

·6· ·subsection characteristics prior to sex

·7· ·reassignment, there's a paragraph that starts

·8· ·with the words Table 1.· The second sentence

·9· ·says there were no substantial differences

10· ·between female-to-males and male-to-females

11· ·regarding measured baseline characteristics.

12· ·Immigrant status was twice as common among

13· ·transsexual individuals compared to controls,

14· ·living in an urban area somewhat more common,

15· ·and higher education about equally prevalent.

16· ·Transsexual individuals had been hospitalized

17· ·for psychiatric morbidity other than gender

18· ·identity disorder prior to sex reassignment

19· ·about four times more than the controls.

20· · · · · · · · Really it's that last sentence

21· ·that's operative.· Do you understand what that

22· ·sentence says?

23· · · · · ·A.· ·Yeah.· Mm-hmm.

24· · · · · ·Q.· ·Okay.· The conclusion -- sorry.

25· ·There's so much jumping around.· In your

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·1· ·report, do you cite to the study to say that

·2· ·transition can lead to higher rates of

·3· ·suicidality?

·4· · · · · ·A.· ·If you look at a four-fold

·5· ·increase in psychiatric hospitalization versus

·6· ·the 20-fold increase in completed suicides,

·7· ·there is obviously a correlation that there is

·8· ·psychiatric morbidity occurring, okay?· We

·9· ·would say, in the trans population.· Which is,

10· ·as far as I'm concerned, indigenous to the

11· ·disorder or the dysphoria.· Okay?

12· · · · · ·Q.· ·Okay.

13· · · · · ·A.· ·So it's not surprising to see that

14· ·those patients are troubled, but despite that,

15· ·if it's four times the amount of psychiatric

16· ·admissions but 20-fold amount of completed

17· ·suicides, that in my mind, if you look at that,

18· ·that's a five-fold increase in suicidality, if

19· ·you will, or completed suicides perhaps. I

20· ·mean it's an inference that this doesn't state,

21· ·but it says, we have troubled people to begin

22· ·with.· And what was done for them increased

23· ·their suicide rate far more than it would be

24· ·expected.· You might have a four-fold increase.

25· ·If their four-fold's emotionally sick or going

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·1· ·in, then that suicide completion would then be

·2· ·maybe four times as much, but it was 20 times

·3· ·as much as the general population.· So you've

·4· ·got population that's in the hospital for

·5· ·mental disorder is four times more than the

·6· ·general population and kills themselves 20

·7· ·times more often.· That's a multiple factor

·8· ·that indicates that the affirmation was not a

·9· ·successful concept in those patients.· The

10· ·affirmation had a higher risk.

11· · · · · ·Q.· ·So, Doctor, is your inference

12· ·based on an assumption that there's a direct

13· ·relationship between rate of hospitalization

14· ·and rate of suicide?

15· · · · · ·A.· ·No.· No.

16· · · · · ·Q.· ·Can you explain then what your

17· ·basis for saying the transition after these

18· ·hospitalizations is what caused suicide?

19· · · · · ·A.· ·Well, there was an increase.· And

20· ·so it's just a matter of -- it's an assumption.

21· · · · · ·Q.· ·And what is the increase, though?

22· ·From what to what?

23· · · · · ·A.· ·Four to twenty.

24· · · · · ·Q.· ·But the four represents the

25· ·number -- four times as likely represents the

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·1· ·number of hospitalizations, correct?

·2· · · · · ·A.· ·Right.

·3· · · · · ·Q.· ·And 20 represents the number of

·4· ·completed suicides, correct?

·5· · · · · ·A.· ·Right.

·6· · · · · ·Q.· ·So you're saying an increase from

·7· ·hospitalization to -- you're saying that a

·8· ·change in number value of a hospitalization

·9· ·rate to a rate of completed suicide is

10· ·something you could describe as an increase?

11· · · · · ·A.· ·It appears to me just on a cursory

12· ·analysis, and the problem is that there's

13· ·missing all of the explanations for the

14· ·hospitalizations and what had prompted them.

15· ·Was it a suicide attempt?· Was it something

16· ·else that was just an actual depression?· What

17· ·was the grade?· You know, why they were

18· ·hospitalized.

19· · · · · · · · So all that's missing.· So if you

20· ·look at it as a comparative, it makes you think

21· ·these are troubled people, and the affirmation

22· ·seemed not to help at all and perhaps multiply

23· ·it.

24· · · · · ·Q.· ·Okay.

25· · · · · ·A.· ·And again I'm just looking at this

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·1· ·from the information that I can glean from that

·2· ·statement.

·3· · · · · ·Q.· ·Right.· Can you look to the

·4· ·section, continuing on, morbidity, that says

·5· ·Table 2 at the top of the paragraph.· It's just

·6· ·below where we were before.

·7· · · · · ·A.· ·Hang on.· Table 2.· Okay.

·8· · · · · ·Q.· ·The second sentence that begins

·9· ·with the hyphenated word sex-reassigned.

10· · · · · ·A.· ·Yes.· Okay.

11· · · · · ·Q.· ·Sex-reassigned transsexual persons

12· ·of both genders had approximately a three times

13· ·higher --

14· · · · · ·A.· ·I'm missing -- I'm sorry.

15· · · · · ·Q.· ·It's okay.

16· · · · · ·A.· ·It's under which?

17· · · · · ·Q.· ·It's on Page 4 of the document

18· ·you're looking at.

19· · · · · ·A.· ·Okay.

20· · · · · ·Q.· ·Under the right-hand column term

21· ·morbidity.

22· · · · · ·A.· ·I've got that's mortality actually

23· ·is what it says.

24· · · · · ·Q.· ·You're right.· You're right.

25· · · · · ·A.· ·Okay.

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·1· · · · · ·Q.· ·I'm having some reading trouble

·2· ·today.

·3· · · · · ·A.· ·That's okay.· That's all right.

·4· · · · · ·Q.· ·Sex-reassigned transsexual persons

·5· ·of both genders had approximately a three times

·6· ·higher risk of all-cause mortality than

·7· ·controls, also after adjustment for covariates.

·8· · · · · ·A.· ·Okay.

·9· · · · · ·Q.· ·Do you understand what that

10· ·sentence says?

11· · · · · ·A.· ·And I'm not sure I understand it.

12· · · · · ·Q.· ·Okay.· Could you tell me what your

13· ·understanding of it is?

14· · · · · ·A.· ·Actually I mean it sounds to me

15· ·like there was a three-fold increase of

16· ·mortality for any reason at all.

17· · · · · ·Q.· ·And you're using the word increase

18· ·to explain the difference between the

19· ·controller's measure --

20· · · · · ·A.· ·And control.· Right, right.

21· · · · · ·Q.· ·Okay.· So can you restate that

22· ·again?· What's your understanding of the

23· ·sentence?

24· · · · · ·A.· ·It says sex-reassigned transsexual

25· ·persons of both genders.· Meaning that there

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·1· ·was not any difference between male-to-female,

·2· ·female-to-male.· Had an approximately

·3· ·three-time higher risk of all-cause mortality.

·4· ·Not suicide, but all causes.

·5· · · · · ·Q.· ·Okay.· Do you think that their

·6· ·transition is the cause of higher rates?

·7· · · · · ·A.· ·That would be sheer conjecture.

·8· · · · · ·Q.· ·Okay.· How is it then not

·9· ·conjecture in the other inference?

10· · · · · ·A.· ·Well, it's a higher statistical

11· ·difference.· Okay?· Twenty versus three.· Three

12· ·times is possibly due to other confounding, and

13· ·this is any mortality, meaning that they could

14· ·have died of heart disease.· They could have

15· ·died by any other causes.· They could have been

16· ·hit by, you know, a trolley or whatever.

17· · · · · ·Q.· ·Okay.

18· · · · · ·A.· ·Suicide to me means an intended

19· ·death.

20· · · · · ·Q.· ·I understand.

21· · · · · ·A.· ·Okay.

22· · · · · ·Q.· ·Thank you.· We can set aside

23· ·the -- I already forgot how to say her name.

24· · · · · ·A.· ·Dhejne.

25· · · · · ·Q.· ·Dhejne -- thank you -- study.· But

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·1· ·one quick question.· Is in-patient care at a

·2· ·psychiatric facility always a precursor for a

·3· ·completed suicide?

·4· · · · · ·A.· ·No.

·5· · · · · ·Q.· ·Okay.· Thank you.· Do you agree

·6· ·that transgender adults are at greater risk of

·7· ·death by suicide than the general population?

·8· · · · · ·A.· ·Yes.

·9· · · · · ·Q.· ·What's the impotence of people

10· ·born with, as you call it, DSDs?

11· · · · · ·A.· ·For the ones that are what we

12· ·would call ambiguous to the point where

13· ·identification is not possible by appearance of

14· ·external anatomy, about 1 in 4,500.

15· · · · · ·Q.· ·Okay.· Let's turn to Page 3 of

16· ·your initial report.· So just 3 of that

17· ·document there.· Paragraph 16 here says, for

18· ·reasons most often occurring as random events,

19· ·there are malfunctions of the normal

20· ·differentiation.· These aberrations of normal

21· ·development are responsible for what we

22· ·classify as disorders of sexual

23· ·differentiation, or DSD, and they represent a

24· ·very small fraction of the human population.

25· ·The incidence of such circumstances occurs 1 in

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·1· ·4,500 to 1 in 5,500 births.

·2· · · · · ·A.· ·Right.

·3· · · · · ·Q.· ·Okay.· Does this refer to all

·4· ·DSDs, as the sentence says?

·5· · · · · · · · MR. BLAKE:· Objection.

·6· · · · · · · · THE WITNESS:· It refers to DSDs in

·7· ·the classic sense.· You know, ambiguitive

·8· ·genitalia.

·9· ·BY MS. INGELHART:

10· · · · · ·Q.· ·Okay.

11· · · · · ·A.· ·Not the Klinefelter's, not the

12· ·Turner's syndrome, not to people with

13· ·hypospadias.

14· · · · · ·Q.· ·Paragraph 14 above here.· You want

15· ·to review it very quick?

16· · · · · ·A.· ·Do you want me to read it out

17· ·loud?

18· · · · · ·Q.· ·No.· You can just read it to

19· ·yourself.

20· · · · · ·A.· ·Okay.

21· · · · · ·Q.· ·I'm thinking of the wrong one.· Is

22· ·it possible, as we discussed earlier today, for

23· ·a newborn with XX chromosomes to present

24· ·phenotypically with a penis and a scrotum at

25· ·birth?

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·1· · · · · ·A.· ·Yes.

·2· · · · · ·Q.· ·Okay.· Would that be a DSD?

·3· · · · · ·A.· ·That would be a DSD.

·4· · · · · ·Q.· ·Okay.· So does that fit into the

·5· ·general definition of DSD, as you said before?

·6· ·Atypical genitalia?

·7· · · · · ·A.· ·Well, it's one that will be

·8· ·discovered accidentally, most likely.· Like the

·9· ·one case of the XX male that I had, and that is

10· ·far rarer than the 1 in 5,000.· I can't quote

11· ·the statistic, but it's exceedingly -- I think

12· ·I'm the only person in my community in Atlanta

13· ·who's seen an XX male.

14· · · · · ·Q.· ·Okay.· Thank you.· And let's just

15· ·turn the page to Paragraph 17, and you can just

16· ·read it to yourself again.

17· · · · · ·A.· ·Okay.

18· · · · · ·Q.· ·In that paragraph, you referred to

19· ·the Intersex Society of North America consensus

20· ·statement and update, right?

21· · · · · ·A.· ·Right.

22· · · · · ·Q.· ·Okay.· That group presented the

23· ·ideas in their consensus statement that you

24· ·cite to to support your argument, right?

25· · · · · ·A.· ·Yes.

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·1· · · · · ·Q.· ·Okay.· All right.· Let's pull up

·2· ·those two.

·3· · · · · · · · (Thereupon, Plaintiffs' Exhibit

·4· ·14, Consensus statement on management of

·5· ·intersex disorders, and Plaintiffs' Exhibit 15,

·6· ·Global Disorders of Sex Development Update

·7· ·since 2006:· Perceptions, Approach and Care,

·8· ·were marked for identification purposes.)

·9· ·BY MS. INGELHART:

10· · · · · ·Q.· ·I'm going to introduce two

11· ·exhibits at one time.· Do you recognize these

12· ·two documents?

13· · · · · ·A.· ·I do.

14· · · · · ·Q.· ·Are they what you refer to in the

15· ·third sentence of Paragraph 17 in your report?

16· · · · · ·A.· ·Yeah.· Both are Dr. Lee's

17· ·references, yes.

18· · · · · ·Q.· ·Okay.· Thank you.· Could you show

19· ·me in these reports where this consensus

20· ·statement is attributed to the Intersex Society

21· ·of North America?

22· · · · · ·A.· ·It's actually a term that was used

23· ·as a colloquial term.· I mean it was an

24· ·interest group, the Intersex Society.· It has a

25· ·different name and a professional name.· The

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·1· ·ones that actually ended up publishing.· They

·2· ·went through a whole change of nomenclature.

·3· ·Originally, it was called the Intersex Society

·4· ·of North America -- I think, of North America.

·5· ·And then they got together as a consortium and

·6· ·decided on a better name.

·7· · · · · ·Q.· ·Okay.

·8· · · · · ·A.· ·But it's a colloquialism.

·9· · · · · ·Q.· ·Okay.· Let's pull up just that

10· ·last one really quick.

11· · · · · ·A.· ·So just to show you.· LWPES is

12· ·actually the Pediatric Endocrine Society, and

13· ·ESPE is the European.· So that -- sort of if

14· ·you want to have it as a special interest group

15· ·called the Intersex Society came together to

16· ·these two organizations, and then they decided

17· ·we were going to publish guidelines under an

18· ·auspice of a new -- of sort of the general term

19· ·of PES and ESP.

20· · · · · ·Q.· ·And is that on the 2016 update or

21· ·the original?

22· · · · · ·A.· ·This is the updated.· I mean this

23· ·is the original, and this is the update.

24· · · · · ·Q.· ·Okay.· We're going to enter the

25· ·one-third exhibit for this line of questions.

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·1· · · · · · · · (Thereupon, Plaintiffs' Exhibit

·2· ·16, Dear ISNA Friends and Supporters, was

·3· ·marked for identification purposes.)

·4· ·BY MS. INGELHART:

·5· · · · · ·Q.· ·Plaintiffs' Exhibit 16.· Do you

·6· ·recognize just the title at the top?

·7· · · · · ·A.· ·Yes.

·8· · · · · ·Q.· ·Okay.· This you can see at the

·9· ·bottom corner of the page where it came from,

10· ·isna.org?

11· · · · · ·A.· ·Yes.

12· · · · · ·Q.· ·From the Intersex Society of North

13· ·America's website.· The second bullet point on

14· ·the page, can you read that?

15· · · · · ·A.· ·More cautious approach to surgery.

16· · · · · ·Q.· ·I'm sorry.· No.

17· · · · · ·A.· ·In August 2006?

18· · · · · ·Q.· ·Correct.

19· · · · · ·A.· ·Okay.· A new standard of care was

20· ·published in Pediatrics.· The consensus

21· ·statement on management of intersex disorders

22· ·is an important inroad to resolving this

23· ·crisis.· It incorporates many of the concepts

24· ·and changes long advocated by ISNA.

25· · · · · · · · So that is, again, the

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·1· ·organization morphed into something that was a

·2· ·bit more scientifically based, that was

·3· ·broader.· It involved the professional

·4· ·societies, because that group, ISNA, was a very

·5· ·small nucleus of people, and they wanted again

·6· ·to get to all pediatric endocrinologists and

·7· ·develop a consensus policy.

·8· · · · · ·Q.· ·Okay.· But the consensus statement

·9· ·was not actually from --

10· · · · · ·A.· ·No.

11· · · · · ·Q.· ·Okay.· How do you know that the

12· ·consensus statement was conceived in the manner

13· ·you described?

14· · · · · ·A.· ·By talking to Dr. Lee.· He's a

15· ·personal friend and a mentor.

16· · · · · ·Q.· ·Okay.· Thank you.· You can set all

17· ·three of these exhibits aside.

18· · · · · · · · Turning back to your report

19· ·document to Paragraph 19 in the original

20· ·report, which is on Page No. 4, can you just

21· ·read it and refresh your recollection to

22· ·yourself?

23· · · · · ·A.· ·DSD patients are not transgender.

24· ·They have objective, physical, medically

25· ·verifiable, physiologic conditions.

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·1· ·Transgender people generally do not have

·2· ·intersex conditions -- yeah, generally, you

·3· ·don't have -- or any other verifiable physical

·4· ·anomaly.· People who identify feeling like the

·5· ·opposite sex or somewhere in between do not

·6· ·comprise a third sex.· They remain biological

·7· ·men or biological women as determined by their

·8· ·chromosomes and sex at birth.

·9· · · · · ·Q.· ·Okay.· So would you agree that

10· ·transgender identity and intersex identity are

11· ·not necessarily mutually exclusive?

12· · · · · ·A.· ·There are obviously cases that --

13· ·I believe Dr. Gordon said he had had some cases

14· ·in his experience where there were kids with

15· ·DSDs, and it depends again on what are you

16· ·calling a DSD.· So if you have a patient who

17· ·has Klinefelter's, I would not consider that a

18· ·DSD.· All right?· If you have a Turner's girl,

19· ·that's not a DSD.· And he did not say which of

20· ·the DSDs he was talking about.

21· · · · · ·Q.· ·Okay.· So they can co-exist with

22· ·some definitions?

23· · · · · ·A.· ·Yeah.· But they're not -- they're

24· ·not -- it's sort of -- again, the concept of

25· ·having ambiguous, okay?· Or having gonads of

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·1· ·one sex and having the physical appearance of

·2· ·the other does not essentially -- that's not an

·3· ·issue of gender identity.

·4· · · · · ·Q.· ·Okay.· Are you aware of whether

·5· ·there's documentation of transgender people

·6· ·having a different rate of karyotype

·7· ·abnormalities as compared to the general

·8· ·population?

·9· · · · · ·A.· ·I'm aware that it's stated, but

10· ·again it would be a population study.· And if

11· ·you had took all transgenders, and the problem

12· ·is you can't find all transgenders, and looked

13· ·at chromosome analysis to see whether or not

14· ·there were anything.· It depends on who

15· ·presented to you, and also what is -- I guess

16· ·much like you did in Sweden, take a sample of

17· ·population and say, .5 percent has a chromosome

18· ·anomaly.

19· · · · · ·Q.· ·Okay.

20· · · · · ·A.· ·The problem is it's selection

21· ·bias.· We don't know how to find all

22· ·transgender people.· So if you have transgender

23· ·patients come in that volunteer to have a --

24· ·and we don't do karyotypes on transgender

25· ·people.· It's not part of the workup.· Again,

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·1· ·it has no -- the reason to do that is if they

·2· ·had some concern about being an intersex

·3· ·condition, you could verify that.

·4· · · · · ·Q.· ·Okay.· Okay.· Just to the next

·5· ·paragraph on Page 4.· In some DSDs there exists

·6· ·more than one set of chromosomes.· Can you just

·7· ·clarify for me?· What do you mean by more than

·8· ·one set?

·9· · · · · ·A.· ·Each cell contains a set of

10· ·chromosomes.· So the gonads can have one set of

11· ·chromosomes, and the rest of the body can be

12· ·entirely different.· It's called mosaicism.

13· ·Okay?· Skin cells can be -- particularly in

14· ·kids that have remarkably unusual pigmentation

15· ·of the skin and stripes and swirls, you can

16· ·take a biopsy of the one color skin and take a

17· ·biopsy of another color skin and find genetic

18· ·differences between the two of those.· So that

19· ·is a mosaicism.· It's called a mosaicism.· So

20· ·you can have differences in karyotype from

21· ·tissue to tissue.

22· · · · · ·Q.· ·So just for my science nerd

23· ·skills, there's different kinds of ways of

24· ·having more than one set of chromosomes?· It

25· ·can present in some people like with different

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·1· ·skin tones across your body?

·2· · · · · ·A.· ·Right.· Mosaicism in skin.· The

·3· ·most commonly thought of ones is the mosaicism

·4· ·of like a gonadal dysgenesis, which is Turner's

·5· ·syndrome, can have XY, XO karyotype.· Both are

·6· ·like 30 percent of the cells are XY.· 70

·7· ·percent of the cells are XO.· Meaning there's

·8· ·no second X.· The patient typically is a girl

·9· ·with Turner syndrome has no functioning gonadal

10· ·functioning that's testicular, but nonetheless

11· ·those girls are at risk of having a malignancy

12· ·develop in their gonad.

13· · · · · ·Q.· ·Okay.

14· · · · · ·A.· ·Their gonads are already damaged

15· ·by the process of atrophy as part of Turner

16· ·syndrome, but the standard of care is to go in

17· ·and take out any residual gonadal tissue or

18· ·scar to prevent -- if there's any possibility

19· ·that there was a Y chromosome in those cells,

20· ·it needs to be eliminated because it has a

21· ·higher potential for malignancy.

22· · · · · ·Q.· ·So in those instances, the XY

23· ·cells versus the ones that are XO, so like X

24· ·missing a sex chromosome, those can be

25· ·localized, generally?

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·1· · · · · ·A.· ·They generally are most throughout

·2· ·the body one particular type, but in the gonads

·3· ·you can have -- that's what true hermaphrodism

·4· ·is is presence of both gonadal functioning,

·5· ·gonadal tissue, that you find on laproscopic

·6· ·exam.

·7· · · · · ·Q.· ·I understand.· Thank you.· Okay.

·8· ·Is it your opinion that biological sex is

·9· ·binary?

10· · · · · ·A.· ·Yes.

11· · · · · ·Q.· ·Does the existence of people with

12· ·DSDs illustrate that not everyone falls within

13· ·the two binaries of sex?

14· · · · · ·A.· ·The true so-called, previously

15· ·called, true hermaphrodites had both cell

16· ·lines.· Okay?· So the predominant cell line is

17· ·the one that ends up taking over, programming

18· ·the body, creating the hormones, or making the

19· ·hormones absent to make a body male or a

20· ·female.· So in a case of -- you're either of

21· ·them.· A biologic man -- yeah, a biologic male.

22· ·You're either male sex or female sex, depending

23· ·on the predominant cell type and the functional

24· ·anatomy that goes along with that and the

25· ·hormones that have been produced.· So that's

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·1· ·all binary.

·2· · · · · ·Q.· ·So inartfully, so correct me, I'm

·3· ·not trying to ask you to assent to my

·4· ·misunderstanding, if one has a chromosomal DSD

·5· ·that would place them somewhere between a

·6· ·typical male or a typical female, you would

·7· ·still designate them on the binary based on

·8· ·like if the majority of their secondary sex

·9· ·characteristics look a certain way?

10· · · · · · · · MR. BLAKE:· Objection.

11· · · · · · · · THE WITNESS:· If their body

12· ·function and response to hormones is one way,

13· ·you assign it.· That's the sex.

14· ·BY MS. INGELHART:

15· · · · · ·Q.· ·Okay.· So folks with DSDs --

16· · · · · ·A.· ·The complete androgen insensitive

17· ·male is female.

18· · · · · ·Q.· ·Okay.

19· · · · · ·A.· ·Okay.· And determined to be.

20· · · · · ·Q.· ·Thank you.· That clarifies it for

21· ·me.· Okay.· On Paragraph 14, just the page

22· ·before, you state in the first sentence, a

23· ·fetus is determined to be either a male, XY, or

24· ·female, XX.· That's correct.· Yes?

25· · · · · ·A.· ·That's correct.

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·1· · · · · ·Q.· ·Are fetus chromosomes karyotyped

·2· ·generally?

·3· · · · · ·A.· ·No.

·4· · · · · ·Q.· ·Okay.· Do you agree that without

·5· ·photographic or very detailed writing at the

·6· ·time of birth, describing the genitals, you

·7· ·cannot be certain that a person with an M on a

·8· ·birth certificate had typical genitals compared

·9· ·to most people marked with an M at birth?

10· · · · · · · · MR. BLAKE:· Objection.

11· · · · · · · · THE WITNESS:· I'm not sure I

12· ·understand your question.

13· ·BY MS. INGELHART:

14· · · · · ·Q.· ·Sure.· Do you agree that without

15· ·like a photo of a baby's genitals or somebody

16· ·really writing up what those characteristics

17· ·look like, that we can't be certain that

18· ·somebody with an M on a birth certificate had

19· ·typical genitals of an average male?

20· · · · · · · · MR. BLAKE:· Objection.· Vague.

21· · · · · · · · THE WITNESS:· So the exam of a

22· ·newborn, okay, the first thing is a quick

23· ·impression.· The second thing is before the

24· ·birth certificate is ever completed is the

25· ·complete head to toe exam by a physician or a

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·1· ·second level provider who pays very detailed

·2· ·attention to the genitalia.· So if there is

·3· ·virilization of the female, it's noted.

·4· · · · · · · · If there is an absence of

·5· ·testicles in the scrotum but everything else

·6· ·looks fine, again, that is so important.· It's

·7· ·not just looking.· It's actually hands on.· You

·8· ·pull the testicles down in the scrotum, and at

·9· ·that point of time in a term baby the testicles

10· ·are easily found in the scrotum.· They're not

11· ·retractile, because the baby has testosterone

12· ·levels very typical of an early pubertal male

13· ·at that point in time, at the end of the third

14· ·trimester.

15· · · · · · · · If you just look across the room

16· ·and you don't touch the scrotum and you don't

17· ·find each testicle down, that's an incomplete

18· ·exam.· That would be called a cursory exam, and

19· ·there should be nothing cursory about an exam

20· ·of a newborn.· It needs to be head to toe,

21· ·totally detailed.· Heart, lungs, fingers, toes,

22· ·scalp hair patterns, presence of cataracts,

23· ·missing digits, dimples, sinus tracks,

24· ·everything.· Everything has to be looked at.

25· · · · · · · · So if it's cursory, it's an

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·1· ·inappropriate exam, and it's inefficient and

·2· ·inappropriate.· So determining that has a very

·3· ·significant -- although it seems mundane.

·4· ·Like, yeah, I can tell from here to there that

·5· ·that's a baby boy across the room in the

·6· ·bassinet, you don't know that until you've

·7· ·actually examined the patient completely.

·8· ·BY MS. INGELHART:

·9· · · · · ·Q.· ·So two questions.· Is that a

10· ·standard of care?

11· · · · · ·A.· ·Yes, it is.

12· · · · · ·Q.· ·Okay.· And where did you learn

13· ·that information?

14· · · · · ·A.· ·From the first days of medical

15· ·school, and then really re-enforced in

16· ·pediatric rotations in medical school and then

17· ·in pediatric residency and certainly in

18· ·fellowship.

19· · · · · ·Q.· ·Does it ever happen that intersex

20· ·babies who have atypical genitals are still

21· ·marked with an M or an F, just based on an

22· ·exam?

23· · · · · · · · MR. BLAKE:· Objection.

24· · · · · · · · THE WITNESS:· Yes.· That has

25· ·happened, and it's a tragedy when it comes down

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·1· ·the pike as finally discovered to be

·2· ·inappropriate, and it happens.

·3· ·BY MS. INGELHART:

·4· · · · · ·Q.· ·Without a karyotype, we can't be

·5· ·certain what a person's sex chromosomes are,

·6· ·right?

·7· · · · · · · · MR. BLAKE:· Objection.

·8· · · · · · · · THE WITNESS:· Yes.· By definition.

·9· ·BY MS. INGELHART:

10· · · · · ·Q.· ·But in your report at Paragraphs

11· ·31 -- initial report, Page 5, Paragraphs 31 to

12· ·34 on Page 6, you conclude for each of the four

13· ·plaintiffs that you know what their sex

14· ·chromosomes are, correct?

15· · · · · ·A.· ·It's a conclusion based on

16· ·information provided, without a physical exam.

17· ·So I mean, totally inclusive, I've never

18· ·examined any of the patients.· So I cannot

19· ·state emphatically.· It is just the evidence

20· ·presented, done by other people, who I assume

21· ·did an exceptionally appropriate job, but

22· ·that's what was reported to me.· And by

23· ·information in their statements.

24· · · · · ·Q.· ·Okay.· But it is an assumption?

25· · · · · ·A.· ·It's an assumption.

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·1· · · · · · · · MR. BLAKE:· And I'll say we're

·2· ·willing to withdraw those conclusions if you

·3· ·guys will submit for karyotypes.· I mean is

·4· ·that what we're doing with these questions?· If

·5· ·they want to submit for a karyotype, we'll

·6· ·withdraw the conclusions.

·7· · · · · · · · MS. INGELHART:· No, thank you.

·8· · · · · · · · MR. BLAKE:· Okay.

·9· ·BY MS. INGELHART:

10· · · · · ·Q.· ·What's the appropriate gender

11· ·pronoun for a transgender person who's

12· ·transitioned?

13· · · · · ·A.· ·I am told in order to be sensitive

14· ·and not offensive that you chose the pronoun

15· ·that they ask you.· So you ask a patient what

16· ·they wish to be called, and that's what you

17· ·call them.

18· · · · · ·Q.· ·And in general is that your course

19· ·of practice?

20· · · · · ·A.· ·That's my course of a practice,

21· ·and, you know, I sometimes stumble

22· ·accidentally, and I will apologize in that case

23· ·if I use a wrong name or a wrong pronoun.

24· · · · · ·Q.· ·Thank you.· Okay.· Do you think

25· ·that civil rights should be based only on

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·1· ·immutable biology?

·2· · · · · · · · MR. BLAKE:· Objection.· Relevance.

·3· · · · · · · · Answer, if you know.

·4· · · · · · · · THE WITNESS:· I don't have an

·5· ·opinion, but I'm -- I can say I have experience

·6· ·to say.

·7· · · · · · · · (Thereupon, Plaintiffs' Exhibit

·8· ·17, Breitbart, Doctors' Political Group Places

·9· ·Gender Ideology Above Biology, was marked for

10· ·identification purposes.)

11· ·BY MS. INGELHART:

12· · · · · ·Q.· ·What's being placed before you is

13· ·Plaintiffs' Exhibit 17.

14· · · · · ·A.· ·Mm-hmm.

15· · · · · ·Q.· ·Can you turn to the last

16· ·paragraph?· It starts with a quote, it is high

17· ·time?

18· · · · · ·A.· ·What page?

19· · · · · ·Q.· ·Oh, I'm sorry.· It should be the

20· ·third page of the, you know, the double-sided.

21· ·I think we have all of the comment sections in

22· ·there.

23· · · · · ·A.· ·It's high time that governmental

24· ·agencies at the national and local levels

25· ·return to valid science, which reveals that

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·1· ·there are two biologic sexes, and the only two,

·2· ·male and female.· Gender identity is a social

·3· ·construct, not a biologic one, and

·4· ·gender-specific rights have no place in

·5· ·regulation of law.

·6· · · · · ·Q.· ·So would you like to answer their

·7· ·question again?

·8· · · · · ·A.· ·Surely.· I mean that's my specific

·9· ·opinion, that gender specific rights are not

10· ·biologically based.· And to me race and sex are

11· ·biologic, and that's a fact.· And therefore,

12· ·rights are appropriate for the individuals, and

13· ·discrimination against the individuals based on

14· ·a biologic precept -- the patient has no

15· ·control, and there is no changing that.· You

16· ·don't change your race by wishing.· You don't

17· ·change your sex by wishing.· Okay?· So gender,

18· ·since it's a wish, is exactly that, and

19· ·therefore I can't imagine a civil right or a

20· ·law that would protect my wishes.

21· · · · · ·Q.· ·Is that a medical opinion?

22· · · · · ·A.· ·It's a personal opinion.

23· · · · · ·Q.· ·Do your professional opinions and

24· ·decisions generally concur with those of the

25· ·American College of Pediatricians?

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·1· · · · · ·A.· ·Generally.

·2· · · · · ·Q.· ·Okay.· I think we can set aside

·3· ·this Breitbart exhibit.

·4· · · · · · · · (Thereupon, Plaintiffs' Exhibit

·5· ·18, Gender Identity Issues in Children and

·6· ·Adolescents, was marked for identification

·7· ·purposes.)

·8· ·BY MS. INGELHART:

·9· · · · · ·Q.· ·We just presented you with

10· ·Plaintiffs' Exhibit No. 18.· Do you recognize

11· ·this document?

12· · · · · ·A.· ·This was a document produced from

13· ·a presentation that I gave at the American

14· ·College of Pediatricians' meeting.· A CME

15· ·meeting.· I believe it was in Houston.

16· · · · · ·Q.· ·Okay.

17· · · · · ·A.· ·So it was basically a distillation

18· ·from my PowerPoint presentation.

19· · · · · ·Q.· ·The one that we looked at before?

20· · · · · ·A.· ·No.· A different one.

21· · · · · ·Q.· ·Oh, I'm sorry.

22· · · · · ·A.· ·Yeah.· A different one.

23· · · · · ·Q.· ·Okay.· Thank you.· Okay.· Can we

24· ·turn to Page 3, under the sub heading, the role

25· ·of psychotherapy?· Let me know when you're

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·1· ·there.

·2· · · · · ·A.· ·I'm there.

·3· · · · · ·Q.· ·Okay.· Could you read the third

·4· ·sentence right after the Page No. 238?

·5· · · · · ·A.· ·Yes.· There is clearly an

·6· ·opportunity to recruit the gender change option

·7· ·in the pre-adolescent if the therapist has such

·8· ·an agenda.

·9· · · · · ·Q.· ·Can you explain what you mean

10· ·there?

11· · · · · ·A.· ·Yes.· People who advertise that

12· ·their practice is gender dysphoria specialty or

13· ·gender identity specialty basically recruit

14· ·patients, and the one in Atlanta that claimed

15· ·her 37 years experience, I asked her

16· ·specifically, how many of your patients that

17· ·came to you of any age at any point in time

18· ·that walked in your door returned and desisted?

19· ·And it was like a deer in a headlight.· She had

20· ·never done that.· Not a single patient.

21· · · · · · · · Now, that flies in the face of all

22· ·published studies, and she is labeled as a

23· ·transgender specialist psychologist in Atlanta.

24· ·Okay?· So that was the reference to that kind

25· ·of behavior in the therapist.· The Queer Med

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·1· ·office that basically refers to specific

·2· ·psychologists that when you walk in the door

·3· ·you are as if somebody sent on the transgender

·4· ·pathway.

·5· · · · · · · · Emory University.· One of the

·6· ·patients that the mother came to me for a

·7· ·second opinion.· There was never any discussion

·8· ·about psychological evaluation of the patient,

·9· ·of the family, of the background, but puberty

10· ·blockers were offered because this patient was

11· ·starting to develop breasts or they thought was

12· ·starting to develop breasts and had some pubic

13· ·hair.· And so that patient was scheduled to be

14· ·put on puberty blockers, but first the person

15· ·who was running the clinic, the physician in

16· ·charge, ordered some lab work just to verify

17· ·that this was puberty.· As it turned out, it

18· ·wasn't puberty.

19· · · · · · · · When I saw this patient, she was

20· ·not pubertal at all.· It was things that looked

21· ·like puberty.· She had chest fat, but no breast

22· ·tissue, no estrogen effect anywhere.· Her pubic

23· ·hair growth was what we call premature

24· ·adrenarche.· It's not puberty, but it's the

25· ·adrenal gland component of future puberty that

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·1· ·starts body odor, acne and hair growth, and

·2· ·that's what she had.· She did not have puberty.

·3· ·The lab test came back showing she wasn't in

·4· ·puberty, and only for that reason did this

·5· ·physician not start her on puberty blockers.

·6· · · · · ·Q.· ·Okay.

·7· · · · · ·A.· ·The mother, I questioned her. I

·8· ·said, well, who from the staff?· She said, I've

·9· ·never met any of the staff.· This is her father

10· ·who took her over to this clinic.· The father

11· ·and the father's girlfriend took her to this,

12· ·and that was at the recommendation of the

13· ·counselor that they see.· I've never been

14· ·interviewed by the counselor.· I've never had

15· ·anything to do with that.· I just heard she was

16· ·going over to get puberty blockers.· This is

17· ·the biologic mother of the child, and this

18· ·biologic mother had custody of this child

19· ·because of the abuse, physical abuse, by the

20· ·father and emotional abuse by the father.· The

21· ·mother acquiesced and let the girl live with

22· ·her father and gave permission to the court so

23· ·that she could live there, because her older

24· ·sister insisted, and her older sister wanted to

25· ·live with Dad, because Dad gave the girl

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·1· ·anything she wanted.· Phone privileges, access

·2· ·to the internet 24/7, and Mom would not let

·3· ·that happen.

·4· · · · · · · · So Mom said, fine.· You know, I'm

·5· ·sick and tired of fighting.· I'll let this

·6· ·happen.· You know, I'm going to be watching

·7· ·what's going on.· And when she found out that

·8· ·the child had been sent to Emory and was going

·9· ·to be transitioned, she came to me and said,

10· ·what's going on here?· Can you help me?

11· · · · · · · · So this is a case typical of

12· ·transgender clinics, unfortunately, where these

13· ·kids essentially walk in the door, and there

14· ·are no questions asked.· There is no evaluation

15· ·psychologically.· They are immediately transed,

16· ·and that's called the transgender experts, and

17· ·to me it's an abomination.· And it doesn't go

18· ·along with the Endocrine Society guidelines,

19· ·which say you need to be evaluated thoroughly

20· ·by a competent mental health care professional.

21· · · · · ·Q.· ·Okay.

22· · · · · ·A.· ·All right.

23· · · · · ·Q.· ·And you just stated that this

24· ·happens often?

25· · · · · ·A.· ·Yes.

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·1· · · · · ·Q.· ·On what basis do you know the

·2· ·frequency of it?

·3· · · · · ·A.· ·So there are endocrinologists and

·4· ·pediatricians who have made their way

·5· ·physically into transgender clinics to observe.

·6· ·The one case in Colorado, and the woman

·7· ·specifically said, I'm not going to tell you

·8· ·where it happened, because it's client

·9· ·privilege and stuff, but she said I walked in

10· ·and I was a guest and I was held peripherally

11· ·so I was not allowed to hear deliberation of

12· ·the faculty at all, but the patient came in and

13· ·essentially the staff told her that everyone

14· ·that comes in is transitioned.· Everyone that

15· ·comes in is transitioned.

16· · · · · · · · The woman who runs the clinic in

17· ·Cincinnati admitted everyone that comes in is

18· ·transitioned.· So if you ask a question of

19· ·three of four different transgender clinics and

20· ·you always get the same answer, I'm

21· ·extrapolating that that's more common than it

22· ·is uncommon.

23· · · · · ·Q.· ·Okay.· Thank you.· Are the gender

24· ·transition experts, people who hold themselves

25· ·out as experts, are they specialists?

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·1· · · · · ·A.· ·Not always.· The clinic in

·2· ·Cincinnati is run by a nurse practitioner.

·3· · · · · ·Q.· ·Okay.

·4· · · · · ·A.· ·The clinic in San Francisco is run

·5· ·by a clinical psychologist.

·6· · · · · ·Q.· ·Okay.

·7· · · · · ·A.· ·Emory's clinic is run by a

·8· ·pediatric endocrinologist.· So I don't think

·9· ·that's a requirement, and from the

10· ·publications, again, in the throwaway things,

11· ·where there are these repeated statements and

12· ·articles about affirmation being the way to go

13· ·and what you do and these are the guidelines,

14· ·they are often written by directors of clinics

15· ·who are not physicians and not medical

16· ·subspecialists.

17· · · · · ·Q.· ·Okay.· Do you know whether most

18· ·folks who arrive at one of these gender clinics

19· ·or to the offices of one of these experts like

20· ·the woman in Atlanta, if they're referred to

21· ·those offices?

22· · · · · ·A.· ·They are often referred by mental

23· ·health practitioners.

24· · · · · ·Q.· ·Okay.

25· · · · · ·A.· ·Or more commonly now the kids come

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·1· ·from the internet and say, this is what I want.

·2· ·Or the schools will refer them.

·3· · · · · ·Q.· ·Okay.

·4· · · · · ·A.· ·A lot of the information comes

·5· ·from the schools.

·6· · · · · ·Q.· ·Okay.· So mental health treatment

·7· ·that you've identified today as a part of the

·8· ·wait and watch sort of treatment path, that

·9· ·involves counseling, correct?

10· · · · · ·A.· ·That's correct.

11· · · · · ·Q.· ·Okay.· Do you know whether gender

12· ·affirmation type treatment that these

13· ·colleagues of the gender clinics provide

14· ·involve mental health treatment?

15· · · · · ·A.· ·I'm told that it does, but it's

16· ·aimed at the family for learning how to accept

17· ·or not be negative in any way.

18· · · · · ·Q.· ·You don't know whether it is aimed

19· ·at the individual patient?

20· · · · · ·A.· ·It is specifically stated not

21· ·aimed, in the Seattle clinic.· It's not aimed

22· ·at the patient specifically.· It's aimed at the

23· ·family.

24· · · · · ·Q.· ·Okay.· So I'm still looking at

25· ·this reduction of your PowerPoint to the ACP

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·1· ·here.· I want to turn the page to Page 4 and

·2· ·look at the top of it.

·3· · · · · ·A.· ·Okay.

·4· · · · · ·Q.· ·You know what.· It might be

·5· ·helpful actually, if you start reading the

·6· ·paragraph at the bottom of Page 3.· I don't

·7· ·want us to read out of context.· Could you

·8· ·start the sentence that starts --

·9· · · · · ·A.· ·All right.· The transgender

10· ·community has a worldwide organization, WPATH,

11· ·which promulgates the idea that humans are born

12· ·transgender and that these transgendered people

13· ·have civil rights as a class of individuals.

14· ·WPATH holds conferences internationally,

15· ·nationally and regionally to promote its

16· ·ideology.· WPATH maintains a bibliography for

17· ·use by its members to help provide testimony

18· ·for legal battles.· It developed standards of

19· ·care for transgender medical treatment.· It

20· ·provides expert opinion for the mainstream

21· ·medical societies which are so focused on

22· ·political correctness that they accept these

23· ·opinions without any credible scientific

24· ·scrutiny.· These networking efforts then

25· ·encourage the professional societies to write

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·1· ·policy guidelines which are sent to educators,

·2· ·government agencies and to physicians.· Their

·3· ·dogma is that gender must be taught to children

·4· ·as a spectrum, not as male or female and that

·5· ·this education should begin in kindergarten, if

·6· ·not pre-school.· They promote early

·7· ·cross-dressing, and are the major behind the

·8· ·scenes pushers of anti-bullying campaigns.

·9· ·People who question the validity of innate

10· ·transgenderism are labeled as racists, and the

11· ·transgendered are coddled as victims.

12· · · · · ·Q.· ·Okay.· I just have a few questions

13· ·about a term definition.

14· · · · · ·A.· ·Sure.

15· · · · · ·Q.· ·What do you mean by the word

16· ·dogma?

17· · · · · ·A.· ·A fact that's just a statement

18· ·that cannot be denied.· It is a core value that

19· ·no one can question.

20· · · · · ·Q.· ·Okay.· Is the dogma necessarily

21· ·not credible?· I'm just trying to understand

22· ·the connotation.

23· · · · · ·A.· ·A dogma can be credible.

24· · · · · ·Q.· ·Okay.

25· · · · · ·A.· ·Okay.· But dogma is often used in

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·1· ·terms of religion.· Okay?

·2· · · · · ·Q.· ·Okay.

·3· · · · · ·A.· ·So this is a profound belief which

·4· ·is not to be questioned.

·5· · · · · ·Q.· ·Okay.

·6· · · · · ·A.· ·I mean you can answer it but

·7· ·sorry, Charlie, it's not going to change.

·8· · · · · ·Q.· ·Okay.· And then the anti-bullying

·9· ·campaigns referenced there.· To what were you

10· ·referring?

11· · · · · ·A.· ·Bullying has been going on

12· ·forever.· It has only recently become an issue

13· ·when it had to do with same sex attracted kids

14· ·and transgender kids.· Okay?· No one cared a

15· ·whip or had any guidelines or protected bullied

16· ·kids when it was just a mean bully picking on a

17· ·kid who was, you know, victimized in fourth

18· ·grade because he had a pencil bag that was the

19· ·wrong color or jealousy or whatever it was.

20· · · · · · · · So I look at bullying as a

21· ·two-part process.· We have a bullier who is

22· ·troubled, a very troubled person, and that

23· ·bully needs a lot of attention, not

24· ·condemnation.· But understanding, what happened

25· ·to you that makes you have to put somebody else

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·1· ·down physically or emotionally to bring

·2· ·yourself up?

·3· · · · · · · · So if we just go for the victim

·4· ·and hold that victim and coddle them and say,

·5· ·I'm sorry, the world is a terrible place,

·6· ·you're going to be okay, and leave it at that,

·7· ·we're not going to change the world at all.· So

·8· ·that's been there since time and memorial.· It

·9· ·only became a real hot button issue when it

10· ·involved the gay and transgender community.· It

11· ·should have been a hot button issue all along.

12· ·I mean it needed to be understood, and it was

13· ·just swept under the carpet until it had to do

14· ·with people who were of a class of, I mean, and

15· ·honest to goodness, victims.· There is no

16· ·question.· And so it's all about compassion,

17· ·but it all of the sudden became important, when

18· ·it should have been important forever.

19· · · · · · · · And the context here is that

20· ·anti-bullying got to where it is today because

21· ·of the focus on gay bullying and transgender

22· ·bullying.· It should have been there all the

23· ·time.

24· · · · · ·Q.· ·So your sentence here, the

25· ·sentiment is meant to say that bullying is an

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·1· ·important topic; is that correct?

·2· · · · · ·A.· ·Yes.

·3· · · · · ·Q.· ·Is there any problem with the

·4· ·anti-bullying campaigns that have focused on

·5· ·LGBTQ kids?

·6· · · · · ·A.· ·No.· None whatsoever.

·7· · · · · ·Q.· ·Okay.· Okay.· All right.· And then

·8· ·the last word is coddled as victims.· Can you

·9· ·just explain to me what the connotation of the

10· ·word coddled means here?

11· · · · · ·A.· ·It basically takes somebody who is

12· ·not a victim but is an emotionally troubled

13· ·person, and it basically says you're not

14· ·emotionally troubled.· You know, we have a

15· ·solution for you with affirmation that will

16· ·completely eliminate all your troubles.· And so

17· ·we're going to protect you from essentially

18· ·going and getting the cobwebs and the dark

19· ·places out of your life, and we're going to

20· ·just paint over those with a really shiny coat,

21· ·and I'm sure it's going to be fine some day. I

22· ·mean it's just going to be really fine.

23· · · · · · · · And what we know is that -- and we

24· ·talked about the people who've come back all

25· ·the way from 30 or 40 years living as trans

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·1· ·people, who come back from that and are now

·2· ·finally finding a voice as a group of

·3· ·individuals and saying, oh my God.· These are

·4· ·adults.· These are people who did things not

·5· ·because they were talked into it as a child.

·6· ·These are people who made the decision, who

·7· ·sought the treatment, who sought the medicine,

·8· ·who volunteered for the surgeries, and they are

·9· ·coming back now and saying, this is tragic.

10· ·This is never the answer.· It's really --

11· ·please, don't do this.· Please, don't do this.

12· ·Come talk to me.· I will tell you how I felt,

13· ·all the things that I went through that I can

14· ·teach you that I thought was a solution to the

15· ·problem, and I found out that it is not.· It

16· ·never was a solution, and what I really needed

17· ·to do was to find the therapy that I needed

18· ·right at the very beginning.

19· · · · · · · · And these people who are now

20· ·writing actually late in their life did that,

21· ·and they are crusaders standing up and saying,

22· ·please.· It's not that we're going to go and

23· ·sue the physicians that did this to us, because

24· ·we asked them to.· I mean, fully cognizantly

25· ·asked them to do this.· We chose this for

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·1· ·ourselves, but it's wrong for you, and I don't

·2· ·want you to go that direction.

·3· · · · · ·Q.· ·Are those like case study

·4· ·publications?

·5· · · · · ·A.· ·No.· These are actually people

·6· ·who -- I mean they're individuals who have been

·7· ·through that, who then come back and act as --

·8· ·then they're using the internet and blogging to

·9· ·say, hey, you know, you have a place to speak

10· ·here.· You don't have to hide.· These people

11· ·hid for the longest time out of shame.· I mean

12· ·their whole recommendation is that the majority

13· ·of transgender adults who are happy at their

14· ·point in life are going to be very strong at

15· ·promoting this as an answer, but the vast

16· ·majority that are unhappy have just been dead

17· ·quiet for fear that -- you know, they said, I'm

18· ·a fool.· I am the fool.· I'm going to stand up

19· ·in front of everybody and tell them that I'm a

20· ·fool.· You know, I'm just going to be quiet and

21· ·live my life.· I'm not going to answer surveys.

22· ·I'm not going to be a statistic.· I'm going to

23· ·disappear.· I probably am going to die early,

24· ·and so be it, and I'm a lonely, terrible

25· ·person.· And they have pulled these people out

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·1· ·of the woodwork to discuss things with them on

·2· ·blogs.

·3· · · · · · · · And so Walt Heyer is one of them,

·4· ·who has a blog, and I can't remember the name

·5· ·of his website, but I think the word is regret

·6· ·is in there.· But you can -- Heyer is his last

·7· ·name.· He's a beautiful human being who openly

·8· ·discussed all of the things he went through.

·9· ·Hasci Horvath, who's an epidemiologist at UC

10· ·San Francisco is another very articulate,

11· ·incredibly intelligent man, who knows.· He sort

12· ·of unraveled the myth of the suicide rates, and

13· ·he's written letters in blogs and published,

14· ·and that's another individual.· And they're

15· ·starting to support each other in network and

16· ·say, please, don't do this to yourself.

17· · · · · ·Q.· ·Okay.· Thank you.

18· · · · · ·A.· ·I'll spell that later.

19· · · · · ·Q.· ·Yeah.· I'm actually curious.· If

20· ·you don't mind spelling it now?

21· · · · · ·A.· ·Sure.· It's H-a-s-c-i

22· ·H-o-r-v-a-t-h or -- yeah.· Horvath, I think.

23· · · · · ·Q.· ·Thank you.

24· · · · · ·A.· ·Yeah.

25· · · · · ·Q.· ·Okay.· A few more exhibits here.

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·1· ·We can put this to the side.

·2· · · · · · · · (Thereupon, Plaintiffs' Exhibit

·3· ·19, Breitbart, Judge Finds Father Guilty of

·4· ·Family Violence For Not Using Transgender

·5· ·Teen's Preferred Pronouns, was marked for

·6· ·identification purposes.)

·7· ·BY MS. INGELHART:

·8· · · · · ·Q.· ·Do you recognize this exhibit

·9· ·that's been put before you?· It's Plaintiffs'

10· ·Exhibit 19.

11· · · · · ·A.· ·This one says, judge finds father

12· ·guilty of family violence for not -- yes.· Yes,

13· ·I am.· Yes.

14· · · · · ·Q.· ·Okay.· Thank you.

15· · · · · ·A.· ·This I believe is Vancouver case.

16· · · · · ·Q.· ·Okay.· Thank you for that.

17· · · · · ·A.· ·I only knew initials.· They never

18· ·gave us names.

19· · · · · ·Q.· ·Okay.· Yeah.· So this is

20· ·Plaintiffs' Exhibit No. 19.· It's a Breitbart

21· ·article.· 5.7 million in tax payer funds for --

22· ·oh.· Am I looking at the wrong one?

23· · · · · ·A.· ·It's the wrong one.

24· · · · · ·Q.· ·Okay.· We can look at that one.

25· ·Sorry.

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·1· · · · · ·A.· ·Okay.

·2· · · · · ·Q.· ·Okay.· My apologies.· They all

·3· ·look the same.· Okay.· So Plaintiffs' Exhibit

·4· ·No. 19.· We'll do that one.· Breitbart.· Judge

·5· ·finds a father guilty of family violence for

·6· ·not using transgender teen's preferred

·7· ·pronouns.· Can we turn to what will be Page 4

·8· ·of this printout?· Can you read into the record

·9· ·that quote from you on this page?

10· · · · · ·A.· ·There's nothing normal about the

11· ·environment where these children are brought

12· ·up.· There are emotional traumas left and

13· ·right.· It is so obvious that what we're doing

14· ·is painting over the trauma.

15· · · · · ·Q.· ·Okay.

16· · · · · ·A.· ·This is the recruitment of a cult.

17· ·It is so scary, and I am so overwhelmingly

18· ·worried about the welfare of this population of

19· ·people 30 years out.

20· · · · · ·Q.· ·Can you explain to me what you

21· ·mean by cult?

22· · · · · ·A.· ·It's a term that again is about

23· ·the recruitment online.· This is a -- it is

24· ·almost a religious faith, if you will, without

25· ·scientific basis.· It draws people in with a

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·1· ·promise of something that is not based on

·2· ·reality.· It separates kids from families.· So

·3· ·it's an indoctrination, if you will, and that's

·4· ·what I mean by cult.

·5· · · · · ·Q.· ·So you think the online presence

·6· ·or the transgender community is a cult?

·7· · · · · ·A.· ·It's an indoctrinating society.

·8· ·Cult.· Yeah.· That's what I mean.

·9· · · · · ·Q.· ·Thank you.· All right.· You can

10· ·put that aside.

11· · · · · · · · (Thereupon, Plaintiffs' Exhibit

12· ·20, Breitbart, $5.7 Million In TaxPayer Funds

13· ·For Study To Justify Sterilizing Children Who

14· ·Are Gender Confused, was marked for

15· ·identification purposes.)

16· ·BY MS. INGELHART:

17· · · · · ·Q.· ·We'll introduce Plaintiffs'

18· ·Exhibit 20.· Do you recognize this document?

19· · · · · ·A.· ·Yes.

20· · · · · ·Q.· ·Can you read the title and the

21· ·publication name?

22· · · · · ·A.· ·It's Breitbart, I assume News.

23· ·I'm not sure.· It just says Breitbart at the

24· ·top.· $5.7 Million in taxpayer funds for study

25· ·to justify sterilizing children who are gender

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·1· ·confused.

·2· · · · · ·Q.· ·Great.· Thank you.· On the what I

·3· ·think is the third page of your document

·4· ·there's a paragraph that starts with a

·5· ·quotation mark, since this has all started.· Do

·6· ·you see that?

·7· · · · · ·A.· ·Yes.

·8· · · · · ·Q.· ·Could you read that paragraph?

·9· · · · · ·A.· ·Since this has all started, every

10· ·single transgender patient who has come to me

11· ·has come from a totally dysfunctional family.

12· ·There's nothing normal about the environment

13· ·where these children are brought up.· There are

14· ·emotional traumas left and right.· It is

15· ·obvious that what we're doing is painting over

16· ·the trauma.

17· · · · · ·Q.· ·What do you mean, since this has

18· ·all started?· Could you explain?

19· · · · · ·A.· ·Since the movement of transgender,

20· ·the expansion of the number of patients and

21· ·their presenting of symptoms.

22· · · · · ·Q.· ·And is that related to the

23· ·transgender civil rights movement?

24· · · · · ·A.· ·It's just related to the advocacy

25· ·movement.· I don't look at it really as a civil

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·1· ·rights movement.

·2· · · · · ·Q.· ·Okay.· Okay.· And once again, all

·3· ·of these people come from dysfunctional

·4· ·families.· All of your 14 or 15 active patients

·5· ·now, each and every one comes from --

·6· · · · · ·A.· ·A dysfunctional family, yes.

·7· · · · · ·Q.· ·Okay.· Based on that criteria --

·8· · · · · ·A.· ·Yes.

·9· · · · · ·Q.· ·-- that we discussed before?

10· ·Okay.· We can put this aside.· Thank you.

11· · · · · · · · (Thereupon, Plaintiffs' Exhibit

12· ·21, Emergency Petition For Writ of Mandamus,

13· ·was marked for identification purposes.)

14· ·BY MS. INGELHART:

15· · · · · ·Q.· ·Okay.· One more exhibit.· What's

16· ·been presented before you is Plaintiffs'

17· ·Exhibit No. 21.· Do you recognize this

18· ·document?

19· · · · · ·A.· ·Let me go through it.

20· · · · · ·Q.· ·Sure.

21· · · · · ·A.· ·It's been a while.

22· · · · · ·Q.· ·Take your time.

23· · · · · ·A.· ·This is an Amicus brief.

24· · · · · ·Q.· ·In what matter?

25· · · · · ·A.· ·It related to Obergefell, I think.

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·1· ·The decision.· Let's see here.· Let me go

·2· ·through it.

·3· · · · · ·Q.· ·Sure.· Take your time.

·4· · · · · ·A.· ·This is about -- well, hang on.

·5· ·We've done a number of amicus briefs.· So this

·6· ·is in regard to same sex marriage.

·7· · · · · ·Q.· ·Okay.· Thank you.· Is this in the

·8· ·Supreme Court of the State of Alabama?

·9· · · · · ·A.· ·Yes, it is.

10· · · · · ·Q.· ·Okay.· And the date on this should

11· ·be pretty -- yeah.· It's in the top left corner

12· ·of the first page.· What's the date on this?

13· · · · · ·A.· ·11/06/2015 is what I've got.

14· · · · · ·Q.· ·Okay.· Do you recall what you were

15· ·asking the Alabama Supreme Court to do when you

16· ·signed onto this amicus effort?

17· · · · · · · · MR. BLAKE:· I'm just going to

18· ·object to this document and --

19· · · · · · · · THE WITNESS:· Okay.· (A) I did

20· ·not --

21· · · · · · · · MR. BLAKE:· Let me finish my

22· ·objection.

23· · · · · · · · THE WITNESS:· Okay.· Sorry.

24· ·Sorry.

25· · · · · · · · MR. BLAKE:· I'm just going to

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·1· ·object to this document and the line of

·2· ·questioning on the same grounds that I objected

·3· ·to the previous documents.

·4· · · · · · · · MS. INGELHART:· And we granted you

·5· ·the standing objection.· So we can just --

·6· · · · · · · · MR. BLAKE:· I didn't ask for a

·7· ·standing objection, but thank you.· On the same

·8· ·grounds as before, involving relevancy of

·9· ·questions and documents related to same sex

10· ·marriage in this case.

11· · · · · · · · Go ahead.· You can answer.

12· · · · · · · · THE WITNESS:· Okay.· So I did not

13· ·write this document, but it's a document where

14· ·the college chose to support the proven benefit

15· ·of a biological mother and father family to

16· ·raise a child.· And so to support that and to

17· ·say that disrupting that was not in the best

18· ·interest of children.

19· ·BY MS. INGELHART:

20· · · · · ·Q.· ·Okay.· Can you please turn to Page

21· ·37 of the actual brief.· The page numbering of

22· ·the brief changes many times.· I think you're

23· ·getting close to it, based on what I can see

24· ·across the table.· There's -- at the top of

25· ·Page 37 there's a sub heading that says, this

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·1· ·Court should consider, et cetera, et cetera.

·2· ·Do you see that?

·3· · · · · ·A.· ·Yes, I do.

·4· · · · · ·Q.· ·Okay.· Under that sub heading

·5· ·below that, foundations of American

·6· ·jurisprudence, can you read the first clause of

·7· ·the first sentence?

·8· · · · · ·A.· ·It is not beyond the scope of this

·9· ·Court to acknowledge the moral foundation of

10· ·God's law when considering the institution of

11· ·marriage:· But from the beginning of creation,

12· ·God made them male and female.· Therefore, a

13· ·man shall leave his father and mother and hold

14· ·fast to his wife, and the two shall become one

15· ·flesh.

16· · · · · ·Q.· ·Thank you.· Do you agree with

17· ·those statements?

18· · · · · · · · MR. BLAKE:· Objection.

19· · · · · · · · THE WITNESS:· As a person of

20· ·religious faith, it's part of my religious

21· ·beliefs.

22· ·BY MS. INGELHART:

23· · · · · ·Q.· ·Okay.· Do you have any religious

24· ·beliefs related to -- other religious beliefs

25· ·related to LGBT people?

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·1· · · · · ·A.· ·Yes.· Love thy neighbor as

·2· ·thyself.

·3· · · · · ·Q.· ·Okay.· Do you have any religious

·4· ·beliefs about people transitioning their

·5· ·gender?

·6· · · · · ·A.· ·Love thy neighbor, love thy child,

·7· ·show compassion.· It's the religious basis of

·8· ·what my faith tells me to do.

·9· · · · · ·Q.· ·Okay.· Have you been asked to

10· ·render an expert opinion regarding how the Ohio

11· ·Department of Health's position -- not to make

12· ·corrections or changes to the sex field on a

13· ·transgender person's Ohio birth certificate

14· ·affects transgender people?

15· · · · · ·A.· ·Render an opinion?· No, I have

16· ·not.

17· · · · · ·Q.· ·Okay.· Did you render another

18· ·opinion in this matter?

19· · · · · ·A.· ·That sex is biologic and gender is

20· ·a state of mind.

21· · · · · ·Q.· ·Okay.· Do you know what the

22· ·underlying dispute in this case is?

23· · · · · ·A.· ·That the plaintiffs are indicating

24· ·that their lives are affected adversely by

25· ·having a birth certificate which is not -- it

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·1· ·says that their sex is not identical to their

·2· ·gender.

·3· · · · · ·Q.· ·Okay.· Okay.· So that you were not

·4· ·asked to render an opinion about how the Ohio

·5· ·Department of Health's position, not to make

·6· ·those changes, could affect transgender people?

·7· ·That's not what you were asked to do?

·8· · · · · ·A.· ·I recall to say what is the

·9· ·difference between gender and sex and the basis

10· ·of those, and that's basically what I was

11· ·asked.

12· · · · · ·Q.· ·Okay.· And all of your expert

13· ·opinions are reflected in this report and this

14· ·rebuttal?

15· · · · · ·A.· ·Yes.· With the corrections of the

16· ·things that I misspoke.

17· · · · · ·Q.· ·Thank you.· Okay.

18· · · · · · · · MS. INGELHART:· Can we take a

19· ·quick break?· I have just one module left. I

20· ·just want to make sure I didn't miss anything

21· ·with my co-counsel.

22· · · · · · · · MR. BLAKE:· Sure.

23· · · · · · · · MS. INGELHART:· Can we go off the

24· ·record?

25· · · · · · · · THE COURT REPORTER:· Yes.

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·1· · · · · · · · (Thereupon, a break was taken.)

·2· ·BY MS. INGELHART:

·3· · · · · ·Q.· ·Okay.· Have you ever asked or

·4· ·applied to be a member of WPATH?

·5· · · · · ·A.· ·No, I have not.

·6· · · · · ·Q.· ·Can we look back at your CV in

·7· ·your report?· I just want to clarify my

·8· ·understanding of your presentations.

·9· · · · · ·A.· ·Okay.· Here's my report.

10· · · · · ·Q.· ·Sure.· Page 4 of your CV, when you

11· ·get to that, let me know.

12· · · · · ·A.· ·Mm-hmm.

13· · · · · ·Q.· ·Okay.· Under abstracts and

14· ·letters.· When we were researching these, some

15· ·of them had like locations and dates.· Are some

16· ·of these presentations?

17· · · · · ·A.· ·They were presentations.· Abstract

18· ·presentations.

19· · · · · ·Q.· ·Got it.

20· · · · · ·A.· ·Yeah.· So they were not then

21· ·included in a -- they were in a volume that was

22· ·germane to the meeting but not published.

23· · · · · ·Q.· ·I understand.· Is that the case

24· ·for all of them?

25· · · · · ·A.· ·No.

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·1· · · · · ·Q.· ·Okay.

·2· · · · · ·A.· ·Well, the third one was also a

·3· ·companion.· It was done as a presentation,

·4· ·which was not published.· The rest are Rogol

·5· ·and Kurt Midyett and George Bright.· Those were

·6· ·all part of presentations at meetings, and some

·7· ·of them were published.

·8· · · · · ·Q.· ·Okay.· Thank you.· And then on

·9· ·Page 5, the one that says Endocrine Society

10· ·meeting in Orlando, Florida, there's a number

11· ·of it looks like co-presenters with you on that

12· ·matter.

13· · · · · ·A.· ·Which?

14· · · · · ·Q.· ·It starts with Wayne V. Moore,

15· ·Patricia Y.

16· · · · · ·A.· ·Yes, yes, yes.

17· · · · · ·Q.· ·Okay.· It looks like there were a

18· ·number of co-presenters with you on that.

19· · · · · ·A.· ·Mm-hmm.

20· · · · · ·Q.· ·And the title of your presentation

21· ·was Safety and Efficacy of Somavariatan, et

22· ·cetera, et cetera.· I was able I think to find

23· ·a study by that title with a number of your

24· ·co-presenters as authors.· Did you present on

25· ·like a study of theirs with them?

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·1· · · · · ·A.· ·I did not present.· There were a

·2· ·number of papers that were from this group. I

·3· ·was part of a clinical study, and we had a

·4· ·large number of patients, and therefore I was

·5· ·asked to be -- it was a hierarchy of who gets

·6· ·to have their name on the paper, if they did a

·7· ·larger proportion of the work.· So the

·8· ·abstracts are written.· They are passed by us

·9· ·to review all the statistics.· Of course, we're

10· ·all part of that.· But I did not actually --

11· ·you know, I might have corrected a grammatical

12· ·error or something in there.· But they're asked

13· ·for us to review.

14· · · · · · · · And I'm a very poor editor.· So I

15· ·tended to say, as long as the facts looked

16· ·good, I'm not going to, you know, mess with it

17· ·anyway.· So...

18· · · · · ·Q.· ·Okay.· And now we are truly done

19· ·with exhibits.

20· · · · · ·A.· ·Okay.

21· · · · · ·Q.· ·Maybe not.· We are.· Okay.

22· · · · · · · · We talked earlier about a

23· ·conference I think you did in maybe Dallas or

24· ·Houston.· Houston.· Have you done other

25· ·conferences and presentations on transgender

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·1· ·related matters?

·2· · · · · ·A.· ·I have.

·3· · · · · ·Q.· ·How many-ish?

·4· · · · · ·A.· ·I was invited by the Australian

·5· ·Family Association last August to come and

·6· ·present essentially the same concept of a talk,

·7· ·historical background in comparisons of modes

·8· ·of therapy, and there was the same talk given

·9· ·in Sidney and Cabramurra and Melbourne and

10· ·Brisbane and Perth.

11· · · · · ·Q.· ·Okay.

12· · · · · ·A.· ·So that was last summer.· I gave a

13· ·presentation at the third meeting of the

14· ·International Federation of Therapeutic

15· ·Counseling Choice, in Budapest.

16· · · · · · · · I gave a talk in March at the

17· ·combined meeting that -- it was called the

18· ·Matthew Bulfin, B-u-l-f-i-n, Conference, and

19· ·that was held in -- oh, it's foggy, but it was

20· ·in March of this year, and I can tell you where

21· ·it was, but I've been traveling so much I

22· ·forget what city.· It was a combined conference

23· ·that we presented.

24· · · · · · · · And I presented at the Catholic

25· ·Medical and Dental Association in Ridgecrest,

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·1· ·North Carolina, in May.

·2· · · · · · · · And I presented at the Support 4

·3· ·Family Conference, in London, in June.

·4· · · · · ·Q.· ·Is that the extent of the

·5· ·conference presentations you've given on trans

·6· ·issues?

·7· · · · · ·A.· ·I don't want to misstate, but I

·8· ·think, yes, that's it.

·9· · · · · ·Q.· ·Okay.· Thank you.

10· · · · · ·A.· ·Oh.· Excuse me.· I also presented

11· ·a case report in the Southern Pediatric

12· ·Endocrine Society, in Orlando, in March.

13· · · · · ·Q.· ·Okay.· Great.· And just real quick

14· ·to clean up something from before.· The Dhejne

15· ·study in Sweden, just talking about the control

16· ·group versus not issue that I think we agreed

17· ·we understood each other on.· The study at no

18· ·point compares people who were affirmed through

19· ·social, medical and surgical treatment with

20· ·people who had gender dysphoria but were not

21· ·treated?

22· · · · · ·A.· ·That's correct.

23· · · · · ·Q.· ·Thank you.· During the course of

24· ·the deposition today, you frequently referred

25· ·to a number of publications and sources from

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·1· ·your personal like data bank.· To the extent

·2· ·that those aren't already included in your

·3· ·report, we'd like to request that you produce

·4· ·them, but we can do that after we kind of comb

·5· ·through the deposition.· Like you can take the

·6· ·time to see throughout the deposition, but we'd

·7· ·like to request those studies and reports that

·8· ·you developed your opinions upon.

·9· · · · · · · · MR. BLAKE:· If you'd like to put a

10· ·list together and send it to us, we'll look to

11· ·see which ones were relevant and which ones

12· ·weren't.

13· · · · · · · · MS. INGELHART:· I mean, if they

14· ·were brought up today.

15· · · · · · · · MR. BLAKE:· Obviously, if he

16· ·relied on it in forming his opinion.

17· · · · · · · · MS. INGELHART:· Okay.

18· · · · · · · · MR. BLAKE:· Just because it was

19· ·brought up today, we covered a lot of terrain

20· ·which I would say is not relevant to his

21· ·opinion.

22· · · · · · · · MS. INGELHART:· I see what you're

23· ·saying.

24· · · · · · · · MR. BLAKE:· But if it's relevant

25· ·to his opinion, we'll absolutely produce it.

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·1· ·Relevant or relied on to his opinion, we'll

·2· ·produce it.

·3· · · · · · · · MS. INGELHART:· Okay.

·4· ·BY MS. INGELHART:

·5· · · · · ·Q.· ·Speaking to that, are there any

·6· ·other bases or sources besides what we've

·7· ·discussed today that you're relying on to

·8· ·provide your testimony?

·9· · · · · ·A.· ·I guess just sort of personal

10· ·conversations with mentors and colleagues.

11· · · · · ·Q.· ·Okay.· But no primary or

12· ·documented sources?

13· · · · · ·A.· ·No.

14· · · · · · · · MS. INGELHART:· Thank you.· We

15· ·don't have any more questions at this time.

16· · · · · · · · MR. BLAKE:· I just have a couple

17· ·of quick questions.

18· · · · · · · · MS. INGELHART:· Okay.

19· · · · · · · · · · ·EXAMINATION

20· ·BY MR. BLAKE:

21· · · · · ·Q.· ·Dr. Van Meter, there was a lot of

22· ·conversation today about religious beliefs and

23· ·personal beliefs.· Do your religious or

24· ·personal beliefs prejudice you against

25· ·transgender people?

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·1· · · · · ·A.· ·No.· If anything, they increase my

·2· ·compassion for those patients.

·3· · · · · ·Q.· ·Do you harbor any animose or

·4· ·prejudice towards transgender people?

·5· · · · · ·A.· ·No.

·6· · · · · ·Q.· ·Do you believe that people who

·7· ·suffer from gender dysphoria deserve compassion

·8· ·and respect?

·9· · · · · ·A.· ·I certainly do.

10· · · · · ·Q.· ·Are any of your opinions in your

11· ·expert report or rebuttal report based on

12· ·agenda or political beliefs?

13· · · · · ·A.· ·No.

14· · · · · ·Q.· ·What are your opinions in your

15· ·report and rebuttal based on?

16· · · · · ·A.· ·Based on validated science, based

17· ·on the concept of being an advocate for

18· ·children.

19· · · · · ·Q.· ·And is it your opinion that many

20· ·of the opinions in Dr. Ettner's report are not

21· ·based on valid medical science?

22· · · · · ·A.· ·Yes.

23· · · · · ·Q.· ·And have you changed any of your

24· ·opinions based on any of the exhibits you've

25· ·seen or testimony you've given today?

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·1· · · · · ·A.· ·I did want to correct the one

·2· ·reference that I obviously misquoted, and

·3· ·that's the only thing I would change.

·4· · · · · ·Q.· ·And so all of your opinions remain

·5· ·the same?

·6· · · · · ·A.· ·Yes.

·7· · · · · · · · MR. BLAKE:· No further questions.

·8· · · · · · · · MS. INGELHART:· None from us

·9· ·either.

10· · · · · · · · (Thereupon, the deposition was

11· ·concluded at 3:37 p.m.)

12· · · · · · · · · · · *· ·*· ·*

13

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·1· ·STATE OF OHIO· · · · )

·2· ·COUNTY OF MONTGOMERY )· ·SS:· CERTIFICATE

·3

·4· · · · · · · · I, Donald Correll, a Notary Public

·5· ·within and for the State of Ohio, duly

·6· ·commissioned and qualified,

·7· · · · · · · · DO HEREBY CERTIFY that the

·8· ·above-named QUENTIN L. VAN METER, M.D., was by

·9· ·me first duly sworn to testify the truth, the

10· ·whole truth and nothing but the truth.

11· · · · · · · · Said testimony was reduced to

12· ·writing by me stenographically in the presence

13· ·of the witness and thereafter reduced to

14· ·typewriting.

15· · · · · · · · I FURTHER CERTIFY that I am not a

16· ·relative or Attorney of either party, in any

17· ·manner interested in the event of this action,

18· ·nor am I, or the court reporting firm with

19· ·which I am affiliated, under a contract as

20· ·defined in Civil Rule 28(D).

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·1· · · · · ·IN WITNESS WHEREOF, I have hereunto set

·2· ·my hand and seal of office at Dayton, Ohio, on

·3· ·this 11th day of October 2019.

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12· · · · · · · · · ·_______________________________

· · · · · · · · · · ·DONALD CORRELL

13· · · · · · · · · ·NOTARY PUBLIC, STATE OF OHIO

· · · · · · · · · · ·My commission expires 8-9-2022

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