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American Academy of Pediatrics
From the American Academy of PediatricsPolicy Statement

Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents

Jason Rafferty, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE and SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS
Pediatrics October 2018, 142 (4) e20182162; DOI: https://doi.org/10.1542/peds.2018-2162
Jason Rafferty
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  • RE: Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
    Paul Johnson
    Published on: 10 November 2018
  • RE: Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
    Leonard Sax
    Published on: 23 October 2018
  • Published on: (10 November 2018)
    RE: Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
    • Paul Johnson, Developmental and Behavioral Pediatrician, Private Practice

    Thank you for the opportunity to submit a comment on the article mentioned above. Upon reading what I submitted initially, I realize that one salient point was not included in my comments. I would like to submit my comments in their entirety as below:

    The excellent points made by Dr. Sax (see comment from 23 Oct 2018 below) encompass many of my concerns about this AAP statement. His clear writing and references clearly call for amendments to this policy statement. Two other important considerations regarding this policy statement are as follows:
    1) This AAP statement clearly mischaracterizes watchful waiting as unsupportive and a way of pathologizing. This could not be further from the truth. A watchful waiting approach acknowledges that changes happen as the brain develops and humbly realizes that the ultimate outcome is unknown at an early age. It allows the child self-expression without strict adherence to a label that may not fit in the future. Watchful waiting is both compassionate and flexible; there is no reason to demonize this legitimate clinical approach. Please revise the statement to provide a more accurate description of watchful waiting.
    2) The 4th bullet of gender-affirming care states "if a mental health issue exists, it most often stems from stigma and negative experiences rather than being intrinsic to the child". However, the policy statement reports that 20% of matched controls have experienced suicidality and 11% have a...

    Show More

    Thank you for the opportunity to submit a comment on the article mentioned above. Upon reading what I submitted initially, I realize that one salient point was not included in my comments. I would like to submit my comments in their entirety as below:

    The excellent points made by Dr. Sax (see comment from 23 Oct 2018 below) encompass many of my concerns about this AAP statement. His clear writing and references clearly call for amendments to this policy statement. Two other important considerations regarding this policy statement are as follows:
    1) This AAP statement clearly mischaracterizes watchful waiting as unsupportive and a way of pathologizing. This could not be further from the truth. A watchful waiting approach acknowledges that changes happen as the brain develops and humbly realizes that the ultimate outcome is unknown at an early age. It allows the child self-expression without strict adherence to a label that may not fit in the future. Watchful waiting is both compassionate and flexible; there is no reason to demonize this legitimate clinical approach. Please revise the statement to provide a more accurate description of watchful waiting.
    2) The 4th bullet of gender-affirming care states "if a mental health issue exists, it most often stems from stigma and negative experiences rather than being intrinsic to the child". However, the policy statement reports that 20% of matched controls have experienced suicidality and 11% have attempted suicide which is not due to gender-related issues. We have no reason to believe that TGD children would be immune from non gender-related mental health conditions that are often intrinsic to other children and adults. This statement makes this dangerous and often repeated assertion that causes some of the mental health needs of TGD children to be overlooked and under treated. Please revise this bullet.

    Sincerely, Paul Johnson MD

    Show Less
    Competing Interests: None declared.
  • Published on: (23 October 2018)
    RE: Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
    • Leonard Sax, Family Physician, Montgomery Center for Research in Child & Adolescent Development

    What is best practice, when a 7-year-old boy announces that he is really a girl? We do have longitudinal cohort studies which provide useful evidence. Wallien and Cohen-Kettenis (2008) reported on 45 boys and 14 girls who presented with gender dysphoria with a mean age of 8.4 years. Ten years later, 28 of those boys, and 5 of the girls, were no longer gender dysphoric. In other words, of 45 boys followed over ten years, 28 boys, or 62%, did not persist in gender dysphoria. In another study (Singh 2012), 139 boys with gender dysphoria were enrolled at an average age of 7.5 years; at follow-up, averaging 13 years later, only 17 boys out of 139 (12.7%) were still gender-dysphoric. These studies, and others like them (see Zucker 2008 for review), suggest that the majority of boys who identify as gender-dysphoric prior to the onset of puberty will not persist in gender dysphoria after the onset of puberty.

    Suppose parents consult a physician regarding their 7-year-old son who has said that he is really a girl. Suppose the physician, mindful of Wallien & Cohen-Kettenis (2008), Singh (2012), and Zucker et al. (2012), advises a cautious wait-and-see approach. The 7-year-old wants to study ballet? Excellent. But he will study ballet as a boy, not a girl, at least for the next year.

    Rafferty & Committee (2018) savagely denounce such an approach as “outdated.” Even worse: that physician is trying “to prevent children and adolescents from identifying as transg...

    Show More

    What is best practice, when a 7-year-old boy announces that he is really a girl? We do have longitudinal cohort studies which provide useful evidence. Wallien and Cohen-Kettenis (2008) reported on 45 boys and 14 girls who presented with gender dysphoria with a mean age of 8.4 years. Ten years later, 28 of those boys, and 5 of the girls, were no longer gender dysphoric. In other words, of 45 boys followed over ten years, 28 boys, or 62%, did not persist in gender dysphoria. In another study (Singh 2012), 139 boys with gender dysphoria were enrolled at an average age of 7.5 years; at follow-up, averaging 13 years later, only 17 boys out of 139 (12.7%) were still gender-dysphoric. These studies, and others like them (see Zucker 2008 for review), suggest that the majority of boys who identify as gender-dysphoric prior to the onset of puberty will not persist in gender dysphoria after the onset of puberty.

    Suppose parents consult a physician regarding their 7-year-old son who has said that he is really a girl. Suppose the physician, mindful of Wallien & Cohen-Kettenis (2008), Singh (2012), and Zucker et al. (2012), advises a cautious wait-and-see approach. The 7-year-old wants to study ballet? Excellent. But he will study ballet as a boy, not a girl, at least for the next year.

    Rafferty & Committee (2018) savagely denounce such an approach as “outdated.” Even worse: that physician is trying “to prevent children and adolescents from identifying as transgender”. Such an approach they label “reparative therapy.” They then assert that reparative therapies have been shown to be unsuccessful. In support of that assertion they provide one citation, citation #38, a 1994 report of the lack of success of strategies intended to change the sexual orientation of homosexual men and women. Outdated, indeed. A report documenting the failure of efforts to change the sexual orientation of adults is of doubtful relevance to the question of whether a 5-year-old boy who says that he is a girl should be encouraged to transition.

    Rafferty & Committee assert that “more robust and current research” has proven that the old strategy of “watchful waiting” is harmful, and that gender-affirmative strategies should be deployed in prepubertal children. They set no lower age limit for the age at which a child can decide that the child should be reassigned to a different gender. They provide no longitudinal cohort study documenting any outcomes significantly different from those cited above. However, if a clinician were to conclude from studies such as Wallien & Cohen-Kettenis (2008) that watchful waiting is a reasonable approach, Rafferty & Committee harshly reject such an approach, without providing any more recent longitudinal cohort study documenting different outcomes.

    Common sense suggests that a 3-year-old boy who says that he is a girl should be subject to some degree of watchful waiting before the boy is put in a dress and has his name legally changed. But such common sense is notably lacking from Rafferty & Committee.

    Leonard Sax MD PhD

    References:

    Singh D. A follow-up study of boys with gender identity disorder. Ph.D. Dissertation, University of Toronto, 2012. Online at http://images.nymag.com/images/2/daily/2016/01/SINGH-DISSERTATION.pdf.
    Wallien MS, & Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1413–1423

    Zucker KJ. On the ‘natural history’ of gender identity disorder in children. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1361-1363.

    Zucker KJ. A developmental, biopsychosocial model for the treatment of children with gender identity disorder. J Homosexuality 2012:59(3):369-397.

    Show Less
    Competing Interests: None declared.
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Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
Jason Rafferty, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE, SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS
Pediatrics Oct 2018, 142 (4) e20182162; DOI: 10.1542/peds.2018-2162

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Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
Jason Rafferty, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE, SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS
Pediatrics Oct 2018, 142 (4) e20182162; DOI: 10.1542/peds.2018-2162
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