17 October 2018

American Academy of Pediatrics policy and trans- kids:
Fact-checking


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

These 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 gender identity, and not 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 fall “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 appear 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 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 model is the only acceptable one, 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 or 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 for them 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.

Reference
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.”  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 missing a 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.


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Outcome Studies of GD Children and Their Results

Count
 Group
Study
2/16
4/16
10/16
gay
trans-/crossdress
straight/uncertain
Lebovitz, P. S. (1972). Feminine behavior in boys: Aspects of its outcome. American Journal of Psychiatry, 128, 1283–1289.
2/16
2/16
12/16
trans-
uncertain
gay
Zuger, B. (1978). Effeminate behavior present in boys from childhood: Ten additional years of follow-up. Comprehensive Psychiatry, 19, 363–369.
0/9
9/9
trans-
gay
Money, J., & Russo, A. J. (1979). Homosexual outcome of discordant gender identity/role: Longitudinal follow-up. Journal of Pediatric Psychology, 4, 29–41.
2/45
10/45
33/45
trans-/crossdress
uncertain
gay
Zuger, B. (1984). Early effeminate behavior in boys: Outcome and significance for homosexuality. Journal of Nervous and Mental Disease, 172, 90–97.
1/10
2/10
3/10
4/10
trans-
gay
uncertain
straight
Davenport, C. W. (1986). A follow-up study of 10 feminine boys.  Archives of Sexual Behavior, 15, 511–517.
1/44
43/44
trans-
cis-
Green, R. (1987). The "sissy boy syndrome" and the development of homosexuality. New Haven, CT: Yale University Press.
0/8
8/8
trans-
cis-
Kosky, R. J. (1987). Gender-disordered children: Does inpatient treatment help? Medical Journal of Australia, 146, 565–569.
21/54
33/54

trans-
cis-

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.

3/25
6/25
16/25
trans-
lesbian/bi-
straight
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.
17/139
122/139
trans-
cis-
Singh, D. (2012). A follow-up study of boys with gender identity disorder. Unpublished doctoral dissertation, University of Toronto.
47/127
80/127
trans-
cis-
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.

11 comments:

  1. I am not a psychologist but as an academic citing sources that don't support what is being claimed should be reason for the retraction of a paper. I agree with what AAP is trying to do but this is not how to go about it. Academic integrity has to mean something. Could they be trying to reduce harm to those who DO turn out to be transgender as teens and adults, and their parents? In my humble opinion, "affirm" and give hormones probably isn't right either.

    Hear me out.

    Think of how the average, at least a little transphobic, parent is likely to implement "watchful waiting". Consider as an example the movie "Ma Vie En Rose". It could be said what they were doing in the beginning of the movie was a watchful waiting approach. "It's normal until about age 7," and all that. They were fine with Ludo dressing like a girl and having dolls and all of that until then.

    The parents were told that if they watchfully waited the kid would likely "normally" stop. What happens when the kid does not stop? They loose it. They try to force them to stop being different. In real life that is often how trans gender youths end up as wards of the state. Part of watchful waiting has probably been a hope that the kid would not be trans in the end.

    A month ago a well known transgender model posted a video about a frank discussion with her mother. When she had surgery her mother felt like her son "went on vacation then never came back". Her mother mourned. She still hoped somehow it wouldn't go that far.

    That is the danger of watchful waiting for those who DO turn out to be transgender IF the people around them agreed in the hope they would desist.

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    1. And...what about the harm of parents going 'whole-hog' affirming the gender whims of a toddler? I had a 3 year old daughter who was sure she would grow up to be Barney. Suppose I had 'affirmed' that. Every day, for years. How f'd up would my daughter (now a happy, well-adjusted 26 yr old woman) have potentially become? Would she have struggled to conform to my expectations that she grow to become someone she could never be?

      Putting a young child on puberty blockers (off-label use and with known negative physical effects) then on cross-sex hormones (also off label and with known adverse health ramifications) is conversion therapy on steroids. NOT allowing young people to mature into gay men and lesbian women but encouraging, even harassing them, into transitioning then abandoning them to suffer the consequences, alone.

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  2. @Hontas This is a mental health issue. Any medical interventions to treat mental health issues have huge risks, known and unknown, and are not "cures" for gender dysphoria. Medical action should never be positioned as the ultimate "end game" strategy for those who suffer--but that's not what you find in social media today, especially for children. If medical action is, after careful consideration, taken, some see a great reduction in their gender dsyphoria, some gain relief for a while before it returns in waves leading to more medical interventions b/c the last one was "not enough", and some get worse, some much worse. It depends. The motivations for the behavior are as varied as there are people, and the problem is that the AAP's take on "affirmation only" assumes only one action is correct. It's like saying all depressed people are depressed for the same reason and this is the one way to treat it. Basically, the AAP are guilty of being Distinction Deniers, and fail to see the harm they are exposing to others. How?

    Well, for instance, the problem for us parents with teens with rapid onset gender dysphoria (ROGD) is that this is a social contagion highly influenced by social media. Teens and young adults have relatively easy--meaning no mental or medical health analysis required--access to cross sex hormones. Some can get them by mail. Some Planned Parenthoods have started giving out hormones with informed consent forms.

    I'm sure there are some parents who are transphobic, but I'm more than sure that many parents do not want their child to take drastic medical interventions for something of dubious benefit when they want to give their child the gift of time to work things through and treat any underlying comorbid conditions.

    Ironically, if your arguing that what AAP is doing is protecting that small number of children who will not desist after puberty (childhood GD is different from ROGD), you must also recognize that this will result in many false positives which encompasses ROGD teens and young adults. As the greatest predictor of persistence in an identity is social transition and that is fully endorsed in the affirmation model--and leads many of the afflicted to go on and seek medical "cures." Regrets will be many. These drugs are off-label use and do harm, visable and invisable. These kids are the experiment.

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  3. As a pediatrician gender affirmation makes more sense and is more child/patient centered vs the outdated view of watchful waiting (which is really parental centric hopeful thinking that their child we end up "normal"). your review and view is failing to see the "big picture."

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    1. Do you have any support for those claims beyond, "Because I said so?"

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    2. To "Anonymous" Did you even read the article?

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    3. I think the pediatrician is missing the big picture.

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    4. I think the whole transgender thing is a social fad that will die off within a few years. In the meantime, this fad is leaving a lot of victims. The young people who take hormones seem very unhappy, and it looks like many of them commit suicide. I haven't seen studies on this, but I have heard of so many of them killing themselves. The hormones basically create an untenable situation for the person -- they might have the secondary sex characteristics of the opposite sex, but they do not have the sex organs or the bodily or emotional functions. There is also a lot of murder of men who appear to be women - so-called transgender women. Is this any surprise? They trick men into wanting to have sex with them, and then the men find out they are with a man. That naturally leads to a negative and often violent reaction. This should surprise no one, but people keep acting as if this is unexpected. AS a woman, a real woman, I find it highly offensive that men think they can dress like a woman and that makes them a woman. It does not. Most of us women do not want our bathrooms and locker rooms invaded by men pretending to be women. We do not want men pretending to be women to take spots on our sports teams, to take up scholarships or jobs meant for actual women. Worst of all, we do not want men pretending to be women to show up at meetings of women telling us whatt "we" want or need. My gender and sexuality are not your costume. You men can take as many hormones as you want and you will never have periods, you will never get pregnant, you will never be able to nurse a baby. You are men. You might end out men with weird diseases caused by taking hormones and you might even end out mutilated men caused by surgeries. But you will not ever be women. You will harm the actual women who are unfortunate enough to have you in their bathrooms and locker rooms, in their social groups and running around pretending to be them. You can toss out the word "transphobic" at people, but "phobia" means "fear," and no one fears you-- we think you are selfish, idiotic assholes. You are looking for a body modification that you think is more extreme and more cutting edge than tattoos or piercings. You are idiots, especially when you write things such as, "Trans women are real women." No, they are not. Don't you dare tell us real women that you are women -- you with your penises taped up in your pants and your fake boobs that will never feed a baby and never get breast cancer. Transgenderism is a stupid, dangerous fad. In a few years, when you decide you are done with the fad -- will your penis work? Probably not, and definitely not if you had it lopped off. You're being sold a box of bricks by doctors and therapists with an agenda. Does it ever occur to any of you to question who is pushing this agenda? Could it be pharmaceutical companies who want to sell you expensive hormones, the long term effects of which are unknown? Dress however you want, act as fluffy as you want, but don't say you are a woman if you are not, because it is a deep insult to all of us who actually are women. And for god's sake, do not show up at a meeting of women, pretending to be a woman, and tell us what "we" need or want -- ths is the ultimate oppression of women conducted by men. You tell women they are not allowed to argue against your idiotic insulting presumptions, because to do so would be "transphobic." So-called trans women are the most oppressive members of the male sex. They not only want to control and oppress real women, they have the audacity to think they are us.

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  4. I think he/she is not even a pediatrician. Happens more than we think.

    Good solid work Dr. Cantor. You are helping to save lives and families. Indeed it affects our entire society. Harming children is as evil as it gets.

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  5. Where are you communicating this, aside from this site? It's important that it it communicated more broadly, and for the AAP to respond.

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  6. Thank you for this, Dr. Cantor! I am going to print it out to bring with me to my daughter's next appointment. I am very frightened as to what our doctor might say to her if she announces she is a boy trapped in a girl's body. Please continue to be the voice of reason. We cannot thank you enough.

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