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
view—and therefore, AAP
policy—which 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.
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” (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
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.
|
0/5
5/5
|
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.
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