08 July 2020

When is a "TERF" not a TERF?

In the responses to JK Rowling’s challenge to the more extremist (and vocal) factions of transgender activists, there has been much more name-calling than reasoning.  The most common such epithet has been to call her (or anyone else) a TERF, a “trans-exclusionary radical feminist.” 

Having been deeply involved in the science and clinical care of trans people for more than two decades, I have watched this particular term evolve and lose whatever meaning it originally had.  It used to refer to the most extreme of the other side:  There do indeed exist genuinely transphobic people who will refuse to recognize anyone’s transition under any circumstances and are accurately called TERF’s.  Now just a social media meme however, the term is bandied so broadly that it no longer carries any meaning at all.

I must first challenge the ironically binary premise that “exclusion” is all or none.  It’s only in the current climate of extremism that no moderate views get discussed.  Here is a range of some areas in which sex/gender require protection:

• Employment
• Housing
• Public accommodation…
• Locker rooms/showers, with nudity (sauna, hottub…)
• Locker rooms/washrooms, sex segregated
• Competitive sports teams, where physical size is an advantage

It would be perfectly accurate to call someone “trans exclusionary” for rejecting transpeople from all of these.  But that’s not meaningfully the same as (for example) a cis-woman who supports all civil rights, but feels uncomfortable naked in a locker room with a person whose every external feature is male (i.e., their female features are all internal).  I’m not saying I *agree* with this hypothetical cis-woman—I am pointing out the error of painting this entire range of opinions with a single dichotomous brush and dismissing them all as if they were all the most extreme imaginable.

Also on a spectrum is the point during transition at which one can/may/should be deemed which sex:

• Upon declaration
• Upon psych/medical exam/approval
• Upon declaration *despite* psych/medical exam results
• Upon part-time social living
• Upon full-time social living
• Upon hormone treatment
• Upon genital surgery
• Never

It’s easy to recognize “never” as genuinely transphobic/exclusionary.  But it is not meaningful to use the same term for everyone who breaks from the opposite extreme, based only on a recent (sometimes even curiously convenient) self-declaration.

Relatedly, there also exists debate over the age at which a youth should be permitted to begin to transition, socially and/or medically:

• Prepuberty (upon request/demand from child)
• Age 12 (mid-puberty, breaking point in outcomes research)
• Age 16 (usual age of consent for sex)
• Age 18 (legal age of adulthood)
• Age 25 (final brain maturation)
• Never

I support age 12, not for any ideological reason, but because that is what the (current) evidence supports:  The majority of prepubescent kids cease to feel trans during puberty, but the majority of kids who continue to feel trans after puberty rarely cease.  To someone who supports “upon demand,” however, everyone everywhere else on the spectrum is the same as the farthest opposite extreme.  It is not meaningful to claim that wait-until-12 is the same as never.

To repeat, I am not actually taking sides on any of these issues (except to indicate what is vs. not consistent with the science).  Rather, I am pointing out that “TERF” does not meaningfully convey anyone’s ideas about anything.  It is being used only as an epithet, to discredit rather than inform, holding even the slightest symbolic evidence of the smallest departure from one extreme as proof of membership of the other extreme....It is being used as an excuse not to engage with what the person is *actually* saying.

24 November 2019

The story of the Virtuous Pedophiles

The founders of the Virtuous Pedophiles movement, Nick and Ethan, recently wrote an excellent history of how the whole thing got started.  (You can also read my 2013 post about VirPed here.)  They first posted it to a listserv (Sexnet).  It's an important and interesting story, so I asked them if I could repost it here for others to have access too.

My admiration for what these people are doing in face of what they are dealt grows still.

People interested in supporting or receiving support from VirPed can contact the group at www.VirPed.org

 James Cantor


The beginnings of Virtuous Pedophiles are to be found in Nick's experiences on the Sexnet listserv and the b4uact pedophile peer support group.

In 2007, after coming to terms with his pedophilic interests, Nick reached out to a Northwestern University professor by the name of Mike Bailey who was an expert on scientific issues involving sexual matters. Nick had heard of Mike from one of Mike's former students, who had indicated that Mike was open-minded and had many beliefs that were outside the norm. Mike had never entertained the idea that there might be pedophiles who were committed to avoiding sexual contact with children and was intrigued. Sometime around 2009 or 2010, Mike invited Nick to join a listserv that he hosted which was known as Sexnet. The listserv was primarily for researchers on sexual matters, though some journalists were members as well. To Nick's surprise, the group was very welcoming, and he became friendly with several leading experts on pedophilia such as James Cantor, Ray Blanchard, David Prescott, Michael Seto, Robin Wilson and Paul Federoff.

Near the time that Nick joined, Richard Kramer, the head of an organization called b4uact, also joined Sexnet. B4uact was a group of pedophiles and professionals organized to improve access and quality of therapeutic care. They had a small support group which Nick joined.

Nick did not enjoy his time with b4uact. He thought they were unnecessarily antagonistic towards scientists who had befriended him. And, in fact, Richard Kramer alienated these scientists by aggressively criticizing them for supporting the view expressed in DSM that pedophilia was properly viewed as a disorder if it caused marked distress to an individual or lead to sexual abuse of children. Nick also believed that the societal hatred attached to pedophilia could be reduced if society could be made to understand the difference between pedophilia (sexual feelings towards children) and child sexual abuse (sexual acts with children). He felt that b4uact could make progress in this area, but only if it unequivocally stated that adults should not have sexual contact with children. B4uact refused to do this because it believed this would alienate pedophiles and also, Nick believed, because many of its leaders felt that adult-child sex should be legal. After trying to get b4uact to modify its views, Nick decided the differences were too great to be bridged, and in 2011 he resigned from the organization. He had the idea of creating a website that would express the reality that many pedophiles are dedicated to (and succeed at) avoiding sexual contact with children. 

Nick began work on a website for a new organization in 2012. At the same time, Ethan Edwards, who had heard of Sexnet through acquaintances, reached out to Mike. Mike knew of Nick's project, was impressed by Ethan, and put them in contact with one another. Nick sent Ethan an early version of the website and the collaboration began. Nick found Ethan's input sufficiently valuable that he invited him in as a co-founder.

One important precursor to Virtuous Pedophiles was a 2010 column by Dan Savage, featuring a letter from a pedophile who hadn't offended and was sure he would not. The column is titled Gold Star Pedophiles. That was the original working title for the group, but Ethan in particular thought it was demeaning, the relevant gold stars being shiny worthless paper things that adults bestowed on gullible children for work well done. Nick objected to Ethan's idea of "Celibate Pedophiles" because non-exclusive pedophiles are just child-celibate, not truly celibate. We chose "Virtuous Pedophiles". The name has generated considerable controversy but on the whole has served us well. 

Nick and Ethan put most of their effort into the website before it went live in June of 2012. We also put together a support group, without much initial thought. It was a google group, which still exists as an archive. Early members of the support group included a few from b4uact who shared our values, including Gary Gibson and Craig Dahlen.

The website received a considerable amount of positive press, including important support from James Cantor, and Nick and Ethan gave several anonymous interviews. Membership in the peer support group increased. One of the group's enthusiastic members was Sammy Jenkis, who had in the past run a phpbb support group, and he put together the basics of what we have today. It came up in September of 2013 and the Google group became an archive. Anyone who really likes VP owes Sammy a big debt for bringing that to fruition when he did. We could never have grown to the size we are if we were trying to do it in a Google group.

Sammy wasn't always consistently available to maintain things, which was a source of anxiety. "Urgeless" took over those responsibilities in the summer of 2018 (phew!) and in September of that year released a new, improved version of the phpbb board that included better support for mobile devices.

A couple of other events in our history really stand out. In August, 2014, Luke Malone wrote a wonderful article featuring one of our members, Adam. As a 16 year old, Adam had formed his own group for teenage pedophiles who were committed to not abusing children. At the end of 2014, This American Life hosted an episode featuring Luke, Adam and the noted scientist Elizabeth Letourneau, who has become a friend of our group.

In August, 2014, Todd Nickerson joined the group, and in September, 2015 he wrote a tremendous piece in Salon called I'm a Pedophile But Not a Monster, which received a tremendous amount of interest. Todd has become our most effective spokesperson.

No particular date, but over the years, Gary Gibson began attending ATSA meetings and assembled a list of friendly therapists. Gary regularly refers members to therapists and is also an effective public figure. Gary has long been one of our most valued members. Adam and our moderator Brett Matthews (known by the VP username "Daywalker") represented our group at the last ATSA meeting.

Prior to our formation, ATSA, a highly regarded organization specializing in the treatment of sex offenders, had on its website this quote: "Although virtually all pedophiles are child molesters, not all child molesters are pedophiles." After getting to know us, our allies in the scientific community challenged ATSA on this, and ATSA immediately removed the quote. One measure of what VP and similar organizations have accomplished since 2011 is that we don't think any serious scientist would write that any more or believe it. The thousands of us in this group make it pretty clear that "virtually all" is not the right descriptor for how many pedophiles molest children. It's only one small step, but a significant one.

Member Eddie Chambers was featured in two documentariesThe Pedophile Next Door (2014) and I, Pedophile (2016). Unfortunately, Eddie became disenchanted with the group and left, but his contributions while here were very important.

Last, but certainly not least, would be the era of Ender. He joined the group in 2014 and quickly became a moderator and then an administrator. It's easy to lose track of just how vital and central he was to this community when he was active. He is still #3 on the all-time list of posters. His interest then waned, and he started MAP Support Chat, with the controversial (wonderful but perhaps risky) policy of letting in people as young as 13 who thought they were pedophiles. He started a blog and was very active defending virtuous pedophiles on twitter. Unfortunately, he spent so much time on pedophile related matters, and spent so much energy engaging the haters, that he burned out and disappeared from the scene. We hope he is doing well. 

It's also worth a note that every non-pedophile we mentioned is identified by their true name. Almost all pedophiles in our support group are known only by pseudonyms, including the two of us founders. Notable exceptions are Gary Gibson, Todd Nickerson, and Eddie Chambers, who in fact have helped our cause enormously by showing their faces in public, often at considerable personal cost.

One unforeseen benefit of the peer support group has been as a vital source for scientific research on pedophilia. It is the first time that a substantial group of pedophiles has come together who have not offended and are not in favor of making adult-child sex legal and accepted. Scientists make posts inviting board members to participate in anonymous, online surveys. Several published papers have emerged and others are in progress. Also, novelists, playwrights, and film-makers often ask to join so they can portray pedophiles more accurately in their fictional work.

It has certainly been quite a ride. When we first started, we thought we would put up a website expressing our views and be done with it. Seven years later we have a support group that has been joined by about 4,500 people and has hosted about 200,000 posts. We feel that we've helped a lot of people come to terms with their pedophilia. We also think that we have helped to encourage some people to avoid sexual contact with children who otherwise might have behaved inappropriately with a child. We have strong relationships with leading organizations, such as ATSA, Dunkelfeld, Stop It Now, and Stop-So, and with leading therapists and sexologists. We feel that we've helped to change the narrative around pedophilia, and that the hatred is a bit less than it was before we came on the scene. Many favorable articles have been written about our organization and non-offending pedophiles; we are unaware of any having been written before. If there were any, there were certainly very few.

We recognize, however, that the road is long and hard. Hopefully the next seven years will see even more progress than the previous seven. 

Ethan and Nick

22 September 2019

It may sound PC, but van Anders et al. is a Trojan horse of language politics.

An essay about how to talk about trans issues at professional conferences has just been circulated by a group of five academics: Sari van Anders, M. Paz Galupo, Jay Irwin, Markie L. C. Twist, and Chelsea J. Reynolds.  (The essay is downloadable at Talking about Transgender Experiences, Identities, and Existences at Conferences.) In it, the authors "wanted to provide some guidelines for discussing studies with trans and transgender people, experiences, existences, backgrounds, and identities, and related aspects of gender diversity, at conferences for those individuals unaware or ignorant of current best practices or approaches".

Although I am strong advocate of consistency in language, just so we can all be sure when we are talking about the same/different things, I am frankly uncomfortable when someone—anyone—tells me what I may and may not say.  This document adds to the long and growing history of activists silencing scientists on this and other controversial issues.  Although I share 95% agreement with the document authors on many of these issues, I find it helpful to apply this bias-detector to myself: What if the same/equivalent thing came from a couple of people who I generally disagree with?  For example (I’m a devout atheist), what if a group of radically religious people posted how I, a scientist, may refer to god (or God) and whatever beliefs in my work and presentations?  

In that context, the power dynamics are more apparent, but the principle is the same.  We either apply it equally to people we agree or disagree with, or we are merely hypocrites doing unto others exactly the crimes that have been done unto us.

The language around trans issues is more than highly politicized.  This is true not only for the language recommendations in the document, but also in their absence.  For example, despite that every follow-up study of gender dysphoric kids showed that they will develop into cis-gendered gays/lesbians, the word “desistance” does not so much as appear in the document, even once.  The entire concept is disappeared.  

The document’s authors do not include clinicians:  The fields of expertise of the document’s authors are: neuroendocrinology, sociology, human development, communications, and experimental psychology.  None of them—not one—has borne the diagnostic/clinical responsibility of clients transitioning or de-transitioning or undergoing the process to decide.  Their experiences are their personal experiences (to the extent that some are openly trans): perfectly valid, but no more so than other peoples’, including the people they left out.  For example, the authors of the document include no desisters…again consistent with the complete disappearing of desistance in the document, despite that all the evidence indicates that the majority of children desist.

The message in leaving out desistance in conference language recommendations is, of course, that we may not talk about desistance at all.

Although the authors’ experiences are perfectly valid, this was not merely the sharing of language suggestions.  This was a declaration that “Because my path was the right path for me, my path is the right path for everyone” or “I didn’t desist, so there’s no such thing as desistance” or “The door to diverse experiences must be opened up enough for me, but no further.”  

We must not do unto others as was done unto us.

03 January 2019

Dear Dr. James: How can pedophiles find someone to talk about it with?

Dr. Cantor,

My name is Peter, I am 55 years old, and I am so very tired of being sexually attracted to teenage boys.  There, I said it.  I also want to say right up front that I am not a danger to myself or others.  I am not suicidal, and I am not an offender.

My entire life, I have been cursed by this attraction / orientation / compulsion / obsession / perversion.  Make no mistake, it is a curse, akin to vampirism or lycanthropy, and I want to help science solve it.  End it.  Learn to treat it.  Something along those lines.

I have friends, but no one really knows me, no one knows what I keep locked and chained in the basement of my mind.  I work, pay my bills, sometimes clean my house.  But I cannot wait until my workday is over, and I can race home, lock the door, and be safe.  I made up my mind to find someone to talk to about this, but there’s no safe way to do this, so I googled “therapy for pedophiles” and found your name and email address.

I really want to know the “why” behind my sexuality, and it is a terrible burden to realize that I most probably will never get this answer.  I feel like I live outside of normal human society.  I feel like an alien.

I would like to find someone in whom I could share my story, all of it, in the hopes that something could be learned about how this sickness takes hold.  And I’d like to donate my brain to science when I die, so that it can be researched and perhaps help in finding a key to the disease or (hoping against hope) a path towards some kind of effective treatment or cure for future people cursed with the same affliction.

I can’t talk with anyone in religion, because I refuse to believe in an invisible, imaginary, supernatural being who would ever create a life as painful and lonely as the one I have lived.  I cannot go to a local therapist because of mandatory reporting laws.  I cannot disclose this to a friend because, well, because I can’t afford to lose the few bits of human contact I have been able to nurture over the years.

I know it is folly to ask but can you help me?  Not treat me, or analyze me, or anything like that.  I know that there is no cure, only abstinence.  But help me tell my story, and maybe add a little information to the puzzle that is deviant sexuality.

At the very least, I’ve done what I promised myself I would do in 2019 – I’ve reached out.

Thank you for your time, and thank you in advance of any help you can provide.

Hello, Peter.  Congratulations on finally expressing it.  My own coming out (as gay) was hard enough, all I can do is imagine how much harder it is for you and others in your position.

The very best group I can send you to are the Virtuous Pedophiles at www.virped.org.  In case you have not already heard of them, they are other people who have come to appreciate that they are attracted to kids and support each other in remaining celibate (in some cases) or still maintaining a romantic relationship with another adult (in other cases).  You and they would all benefit from each others’ stories.  I am also posting it here (changing your identifying information) to help remind others in your position that none of you is alone.

Thank you very much for your generous (too small a word!) offer.  Unfortunately there does not yet exist a brain bank (or funding) for a project using actual brains.  I hope very much to be able to help establish such a thing.  It could be an amazing benefit to the generations that will follow you and me.  I certainly cannot not make any promises, but if I (or another scientist I find out about) ever does start such a thing, I will most certainly be doing everything I can to publicize it, including on my website, twitter account, and so on.  

I wish you the best of luck.

17 October 2018

American Academy of Pediatrics policy and trans- kids:

The American Academy of Pediatrics (AAP) recently published a policy statement entitled, Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents (Rafferty, 2018).  It was quite a remarkable document: Although almost all clinics and professional associations in the world use what’s called the watchful waiting approach to helping GD children, the AAP statement rejected that consensus, endorsing only gender affirmation.  With AAP taking such a dramatic departure from other professional associations, I was immediately curious about what evidence led them to that conclusion.  (Extraordinary claims require extraordinary evidence, and all that.)  As I read the works on which they based their policy however, I was pretty surprised…rather alarmed, actually:  These documents simply did not say what AAP claimed they did.  In fact, the references that AAP cited as the basis of their policy instead outright contradicted that policy, repeatedly endorsing watchful waiting. 

The AAP statement was also remarkable in what it left out—namely, the outcomes research on GD children.  There have been eleven follow-up studies of GD children, of which AAP cited one [Wallien & Cohen-Kettenis (2008)], doing so without actually mentioning the outcome data it contained.  The literature on outcomes was neither reviewed, summarized, nor subjected to meta-analysis to be considered in the aggregate—It was merely disappeared.  (I have presented the complete list of the outcome studies on this blog before; they appear again at the bottom of this page together with their results, for reference.)  As they make clear, every follow-up study of GD children, without exception, found the same thing: By puberty, the majority of GD children ceased to want to transition.  AAP is, of course, free to establish whatever policy it likes on whatever basis it likes.  But any assertion that their policy is based on evidence is demonstrably false, as detailed below. 

AAP divided clinical approaches into three types—conversion therapy, watchful waiting, and gender affirmation.  It rejected the first two and endorsed gender affirmation as the only acceptable alternative.  Most readers will likely be familiar already with attempts to use conversion therapy to change sexual orientation.  With regard to gender identity, AAP wrote:

“[C]onversion” or “reparative” treatment models are used to prevent children and adolescents from identifying as transgender or to dissuade them from exhibiting gender-diverse expressions….Reparative approaches have been proven to be not only unsuccessful38 but also deleterious and are considered outside the mainstream of traditional medical practice.29, 39–42

AAP’s citations are:
38.  Haldeman DC. The practice and ethics of sexual orientation conversion therapy. J Consult Clin Psychol. 1994;62(2):221–227
29.  Adelson SL; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2012;51(9):957–974
39.  Byne W. Regulations restrict practice of conversion therapy. LGBT Health. 2016;3(2):97–99
40.  Cohen-Kettenis PT, Delemarrevan de Waal HA, Gooren LJ. The treatment of adolescent transsexuals: changing insights. J Sex Med. 2008;5(8):1892–1897
41.  Bryant K. Making gender identity disorder of childhood: historical lessons for contemporary debates. Sex Res Soc Policy. 2006;3(3):23–39
42.  World Professional Association for Transgender Health. WPATH De-Psychopathologisation Statement. Minneapolis, MN: World Professional Association for Transgender Health; 2010. Available at: https://www.wpath.org/policies. Accessed April 16, 2017

AAP's claims struck me as odd because there are no studies of conversion therapy for gender identity.  Studies of conversion therapy have been limited to sexual orientation—specifically, the sexual orientation of adults—not to gender identity, and not of children in any case.  The article AAP cited to support their claim (reference number 38) is indeed a classic and well-known review, but it is a review of sexual orientation research only.  Neither gender identity, nor even children, received even a single mention in it.  Indeed, the narrower scope of that article should be clear to anyone reading even just its title: “The practice and ethics of sexual orientation conversion therapy” (Haldeman, 1994, p. 221, italics added).

AAP continued, saying that conversion approaches for GD children have already been rejected by medical consensus, citing five sources.  This claim struck me just as odd, however—I recalled associations banning conversion therapy for sexual orientation, but not for gender identity, exactly because there is no evidence for generalizing from adult sexual orientation to childhood gender identity.  So, I started checking AAP’s citations for that, and these sources too pertained only to sexual orientation, not gender identity (specifics below).  What AAP’s sources did repeatedly emphasize was that:

(1)   Sexual orientation of adults is unaffected by conversion therapy and any other [known] intervention;
(2)   Gender dysphoria in childhood before puberty desists in the majority of cases, becoming (cis-gendered) homosexuality in adulthood, again regardless of any [known] intervention; and
(3)   Gender dysphoria in childhood persisting after puberty tends to persist entirely. 

That is, in the context of GD children, it simply makes no sense to refer to externally induced “conversion”: The majority of children “convert” to cisgender or “desist” from transgender regardless of any attempt to change them.  “Conversion” only makes sense with regard to adult sexual orientation because (unlike childhood gender identity), adult homosexuality never or nearly never spontaneously changes to heterosexuality.  Although gender identity and sexual orientation may often be analogous and discussed together with regard to social or political values and to civil rights, they are nonetheless distinct—with distinct origins, needs, and responses to medical and mental health care choices.  Although AAP emphasized to the reader that “gender identity is not synonymous with ‘sexual orientation’” (Rafferty, 2018, p. 3), they went ahead to treat them as such nonetheless.

To return to checking AAP’s fidelity to its sources: Reference 29 was a practice guideline from the Committee on Quality Issues of the American Academy of Child and Adolescent Psychiatry (AACAP).  Despite AAP applying this source to gender identity, AACAP was quite unambiguous regarding their intent to speak to sexual orientation and only to sexual orientation: “Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and that attempts to do so may be harmful.  There is no established evidence that change in a predominant, enduring homosexual pattern of development is possible.  Although sexual fantasies can, to some degree, be suppressed or repressed by those who are ashamed of or in conflict about them, sexual desire is not a choice.  However, behavior, social role, and—to a degree—identity and self-acceptance are. Although operant conditioning modifies sexual fetishes, it does not alter homosexuality.  Psychiatric efforts to alter sexual orientation through ‘reparative therapy’ in adults have found little or no change in sexual orientation, while causing significant risk of harm to self-esteem” (AACAP, 2012, p. 967, italics added). 

Whereas AAP cites AACAP to support gender affirmation as the only alternative for treating GD children, AACAP’s actual view was decidedly neutral, noting the lack of evidence: “Given the lack of empirical evidence from randomized, controlled trials of the efficacy of treatment aimed at eliminating gender discordance, the potential risks of treatment, and longitudinal evidence that gender discordance persists in only a small minority of untreated cases arising in childhood, further research is needed on predictors of persistence and desistence of childhood gender discordance as well as the long-term risks and benefits of intervention before any treatment to eliminate gender discordance can be endorsed” (AACAP, 2012, p. 969).  Moreover, whereas AAP rejected watchful waiting, what AACAP recommended was: “In general, it is desirable to help adolescents who may be experiencing gender distress and dysphoria to defer sex reassignment until adulthood” (AACAP, 2012, p. 969).  So, not only did AAP attribute to AACAP something AACAP never said, but also AAP withheld from readers AACAP’s actual view.

Next, in reference 39, Byne (2016) also addressed only sexual orientation, doing so very clearly: “Reparative therapy is a subset of conversion therapies based on the premise that same-sex attraction are reparations for childhood trauma. Thus, practitioners of reparative therapy believe that exploring, isolating, and repairing these childhood emotional wounds will often result in reducing same-sex attractions” (Byne, 2016, p. 97).  Byne does not say this of gender identity, as the AAP statement misrepresents.

In AAP reference 40, Cohen-Kettenis et al. (2008) did finally pertain to gender identity; however, this article never mentions conversion therapy. (!)  Rather, in this study, the authors presented that clinic’s lowering of their minimum age for cross-sex hormone treatment from age 18 to 16, which they did on the basis of a series of studies showing the high rates of success with this age group.  Although it did strike me as odd that AAP picked as support against conversion therapy an article that did not mention conversion therapy, I could imagine AAP cited the article as an example of what the “mainstream of traditional medical practice” consists of (the logic being that conversion therapy falls outside what an ‘ideal’ clinic like this one provides).  However, what this clinic provides is the very watchful waiting approach that AAP rejected.  The approach espoused by Cohen-Kettenis (and the other clinics mentioned in the source—Gent, Boston, Oslo, and now formerly, Toronto) is to make puberty-halting interventions available at age 12 because: “[P]ubertal suppression may give adolescents, together with the attending health professional, more time to explore their gender identity, without the distress of the developing secondary sex characteristics. The precision of the diagnosis may thus be improved” (Cohen-Kettenis et al., 2008, p. 1894).

Reference 41 presented a very interesting history spanning the 1960s–1990s about how feminine boys and tomboyish girls came to be recognized as mostly pre-homosexual, and how that status came to be entered into the DSM at the same time as homosexuality was being removed from the DSM.  Conversion therapy is never mentioned.  Indeed, to the extent that Bryant mentions treatment at all, it is to say that treatment is entirely irrelevant to his analysis: “An important omission from the DSM is a discussion of the kinds of treatment that GIDC children should receive. (This omission is a general orientation of the DSM and not unique to GIDC)” (Bryant, 2006, p. 35).  How this article supports AAP’s claim is a mystery.  Moreover, how AAP could cite a 2006 history discussing events of the 1990s and earlier to support a claim about the current consensus in this quickly evolving discussion remains all the more unfathomable.

Cited last in this section was a one-paragraph press release from the World Professional Association for Transgender Health.  Written during the early stages of the American Psychiatric Association’s (APA’s) update of the DSM, the statement asserted simply that “The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide.”  Very reasonable debate can (and should) be had regarding whether gender dysphoria should be removed from the DSM as homosexuality was, and WPATH was well within its purview to assert that it should.  Now that the DSM revision process is years completed however, history has seen that APA ultimately retained the diagnostic categories, rejecting WPATH’s urging.  This makes AAP’s logic entirely backwards: That WPATH’s request to depathologize gender dysphoria was rejected suggests that it is WPATH’s viewand therefore, AAP policywhich falls “outside the mainstream of traditional medical practice.” (!)

AAP based this entire line of reasoning on their belief that conversion therapy is being used “to prevent children and adolescents from identifying as transgender” (Rafferty, 2018, p. 4).  That claim is left without citation or support.  In contrast, what is said by AAP’s sources is “delaying affirmation should not be construed as conversion therapy or an attempt to change gender identity” in the first place (Byne, 2016, p. 2).  Nonetheless, AAP seems to be doing exactly that: Simply relabeling non-gender affirmation models as conversion clinics.

Although AAP (and anyone else) may reject (what they label to be) conversion therapy purely on the basis of political or personal values, there is no evidence to back the AAP’s stated claim about the existing science on gender identity at all, never mind gender identity of children.

AAP also rejected the watchful waiting approach, repeatedly calling it “outdated.”  The criticisms AAP provided, however, again defied the existing evidence, with even its own sources repeatedly calling that model the current standard.  According to AAP:

[G]ender affirmation is in contrast to the outdated approach in which a child’s gender-diverse assertions are held as “possibly true” until an arbitrary age (often after pubertal onset) when they can be considered valid, an approach that authors of the literature have termed “watchful waiting.” This outdated approach does not serve the child because critical support is withheld. Watchful waiting is based on binary notions of gender in which gender diversity and fluidity is pathologized; in watchful waiting, it is also assumed that notions of gender identity become fixed at a certain age. The approach is also influenced by a group of early studies with validity concerns, methodologic flaws, and limited follow-up on children who identified as TGD and, by adolescence, did not seek further treatment (“desisters”).45,47

The citations from AAP’s reference list are:
45.  Ehrensaft D, Giammattei SV, Storck K, Tishelman AC, Keo-Meier C. Prepubertal social gender transitions: what we know; what we can learn—a view from a gender affirmative lens. Int J Transgend. 2018;19(2):251–268
47.  Olson KR. Prepubescent transgender children: what we do and do not know. J Am Acad Child Adolesc Psychiatry. 2016;55(3):155–156.e3

I was surprised first by the AAP’s claim that pubertal onset was somehow “arbitrary.”  The literature, including AAP’s sources, repeatedly indicated the pivotal importance of puberty, noting that outcomes strongly diverge at puberty.  According to AAP reference 29, in “prepubertal boys with gender discordance—including many without any mental health treatment—the cross gender wishes usually fade over time and do not persist into adulthood, with only 2.2% to 11.9%  continuing to experience gender discordance” (Adelson & AACAP, 2012, p. 963, italics added), whereas “when gender variance with the desire to be the other sex is present in adolescence, this desire usually does persist through adulthood” (Adelson & AACAP, 2012, p. 964, italics added).  Similarly, according to AAP reference 40, “Symptoms of GID at prepubertal ages decrease or even disappear in a considerable percentage of children (estimates range from 80–95%).  Therefore, any intervention in childhood would seem premature and inappropriate. However, GID persisting into early puberty appears to be highly persistent” (Cohen-Kettenis et al., 2008, p. 1895, italics added).  That follow-up studies of prepubertal transition differ from postpubertal transition is the very meaning of non-arbitrary.  AAP gave readers exactly the reverse of what was contained in its own sources.  If AAP were correct in saying that puberty is an arbitrarily selected age, then AAP will be able to offer another point with as much empirical backing as puberty has.

Next, it was not clear on what basis AAP could say that watchful waiting withholds support—AAP cited no support for its claim.  The people in such programs often receive substantial support during this period.  Also unclear is on what basis AAP could already know exactly which treatments are “critical” and which are not—Answering that question is the very purpose of this entire endeavor.  Indeed, the logic of AAP’s claim appears entirely circular:  If one were pre-convinced that the gender affirmation is the only acceptable alternative, then watchful waiting withholds critical support only in the sense that it delays gender affirmation, the method one has already decided to be critical.

Although AAP’s next claim did not have a citation appearing at the end of its sentence, binary notions of gender was mentioned both in references 45 and 47.  Specifically, both pointed out that existing outcome studies have been about people transitioning from one sex to the other, rather than from one sex to an in-between status or a combination of masculine/feminine features.  Neither reference presented this as a reason to reject the results from the existing studies of complete transition however (which is how AAP cast it).  Although it is indeed true that the outcome data have been about complete transition, some future study showing that partial transition shows a different outcome would not invalidate what is known about complete transition.  Indeed, data showing that partial transition gives better outcomes than complete transition would, once again, support the watchful waiting approach which AAP rejected.

Next was a vague reference alleging concerns and criticisms about early studies.  Had AAP indicated what those alleged concerns and flaws were (or which studies they were), then it would be possible to evaluate or address them.  Nonetheless, the argument is a red herring: Because all of the later studies showed the same result as did the early studies, any such allegation is necessarily moot.

Reference 47 was a one-and-a-half page commentary which off-handedly mentions criticisms previously made of three of the eleven outcome studies of GD children, but does not provide any analysis or discussion (Olsen, 2016).  The only specific claim was that studies (whether early or late) had limited follow-up periods—the logic being that had outcome researchers lengthened the follow-up period, then people who seemed to have desisted might have returned to the clinic as cases of “persistence-after-interruption.”  Although one could debate the merits of that prediction, AAP (and Olson) instead simply withheld from the reader the result from testing that prediction directly:  Steensma and Cohen-Kettenis (2015) conducted another analysis of their cohort, by then ages 19–28 (mean age 25.9 years), and found that 3.3% (5 people of the sample of 150) later returned.  That is, the childhood sample showing 70.0% desistence instead showed 66.7% desistance in long-term follow-up.  It is up to the reader to decide whether that difference challenges the aforementioned conclusion that that majority of GD children cease to want to transition by puberty or represents a grasping at straws.

Steensma, T. D., & Cohen-Kettenis, P. T. (2015). More than two developmental pathways in children with gender dysphoria?  Journal of the American Academy of Child & Adolescent Psychiatry, 52, 147–148.

Reference 45 did not support the claim that watchful-waiting is “outdated.”  Indeed, that source said the very opposite, referring to watchful waiting as the current approach:  “Put another way, if clinicians are straying from SOC 7 guidelines for social transitions, not abiding by the watchful waiting model favored by the standards, we will have adolescents who have been consistently living in their affirmed gender since age 3, 4, or 5” (Ehrensaft et al., 2018, p. 255).  Moreover, Ehrensaft et al. said there are cases in which they too would still use watchful waiting: “When a child’s gender identity is unclear, the watchful waiting approach can give the child and their family time to develop a clearer understanding and is not necessarily in contrast to the needs of the child” (p. 259).  Ehrensaft et al. are indeed critical of the watchful waiting model (which they feel is applied too conservatively), but they do not come close to the position the AAP policy espouses.  Where Ehrensaft summarizes the potential benefits and potential risks both to transitioning and not transitioning, the AAP presents an ironically binary narrative.

In its policy statement, AAP told neither the truth nor the whole truth, committing sins both of commission and of omission, asserting claims easily falsified by anyone caring to do any fact-checking at all.  AAP claimed, “This policy statement is focused specifically on children and youth that identify as TGD rather than the larger LGBTQ population” (p. 1); however, much of that evidence was about sexual orientation, not gender identity.  AAP claimed, “Current available research and expert opinion from clinical and research leaders…will serve as the basis for recommendations” (p. 1-2); however, they provided recommendations entirely unsupported and even in direct opposition to that research and opinion.

AAP is advocating for something far in excess of mainstream practice and medical consensus.  In the presence of compelling evidence, that would be exactly called for.  The problems in Rafferty (2018), however, do not constitute merely a misquote, a misinterpretation of an ambiguous statement, or a missing reference or two.  Rather, AAP’s statement is a systematic exclusion and misrepresentation of entire literatures.  Not only did AAP fail to provide extraordinary evidence, it failed to provide the evidence at all.  Indeed, AAP’s recommendations are despite the existing evidence. 


Outcome Studies of GD Children and Their Results

Lebovitz, P. S. (1972). Feminine behavior in boys: Aspects of its outcome. American Journal of Psychiatry, 128, 1283–1289.
Zuger, B. (1978). Effeminate behavior present in boys from childhood: Ten additional years of follow-up. Comprehensive Psychiatry, 19, 363–369.
Money, J., & Russo, A. J. (1979). Homosexual outcome of discordant gender identity/role: Longitudinal follow-up. Journal of Pediatric Psychology, 4, 29–41.
Zuger, B. (1984). Early effeminate behavior in boys: Outcome and significance for homosexuality. Journal of Nervous and Mental Disease, 172, 90–97.
Davenport, C. W. (1986). A follow-up study of 10 feminine boys.  Archives of Sexual Behavior, 15, 511–517.
Green, R. (1987). The "sissy boy syndrome" and the development of homosexuality. New Haven, CT: Yale University Press.
Kosky, R. J. (1987). Gender-disordered children: Does inpatient treatment help? Medical Journal of Australia, 146, 565–569.


Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423.

Drummond, K. D., Bradley, S. J., Badali-Peterson, M., & Zucker, K. J. (2008). A follow-up study of girls with gender identity disorder. Developmental   Psychology, 44, 34–45.
Singh, D. (2012). A follow-up study of boys with gender identity disorder. Unpublished doctoral dissertation, University of Toronto.
Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582–590.

*For brevity, the list uses “gay” for “gay and cis-”, “straight” for “straight and cis-”, etc.