The ACP's Latest Transphobic Screed

Well ... I will give the American College of Pediatricians  a little bit of credit.  Their previous position paper on transgender children was astonishingly vacant of references to literature.  They've posted a new one, which actually has some references in it.  However, as one might expect, it's an exercise in mental gymnastics to go through it, because they haven't used the literature properly. 

Reasoning Issues

"Recruiting Through Social Media"

There are a number of problems in this essay, and the start of them is in how they draw their conclusions.  Consider the following:

Anecdotally, there is also an increasing trend among adolescents to self-diagnose as transgender after binges on social media sites such as Tumblr, Reddit, and YouTube. This suggests that social contagion may be at play. In many schools and communities, there are entire peer groups “coming out” as trans at the same time.6 Finally, strong consideration should be given to investigating a causal association between adverse childhood events, including sexual abuse, and transgenderism. The overlap between childhood gender discordance and an adult homosexual orientation has long been acknowledged.24 There is also a large body of literature documenting a significantly greater prevalence of childhood adverse events and sexual abuse among homosexual adults as compared to heterosexual adults. Andrea Roberts and colleagues’ published a study in 2013 that found “half to all of the elevated risk of childhood abuse among persons with same-sex sexuality compared to heterosexuals was due to the effects of abuse on sexuality.”25 It is therefore possible that some individuals develop GD and later claim a transgender identity as a result of childhood maltreatment and/or sexual abuse. This is an area in need of research.

6. Youth Trans Critical Professionals. Professionals Thinking Critically about the Youth Transgender Narrative. Available at: https://youthtranscriticalprofessionals.org/about/. Accessed June 15, 2016.
24. Zucker KJ, Spitzer RL. Was the Gender Identity Disorder of Childhood Diagnosis Introduced into DSM-III as a Backdoor Maneurver to Replace Homosexuality? Journal of Sex and Marital Therapy. 2005;31:31-42.
25. Roberts A. Considering alternative explanations for the associations among childhood adversity, childhood abuse, and adult sexual orientation: reply to Bailey and Bailey (2013) and Rind (2013). Arch Sexual Behav 2014;43:191-196.

I have 3 problems with this single paragraph.

1. First, it hinges on the writings on a blog, not a peer reviewed journal article to raise a bogeyman spectre of children and youth "choosing to identify as transgender" after exposure to social media.  Frankly, this appears little different to me than the utter nonsense we were exposed to in the 1980s, when some parents decided that Road Runner cartoons were "too violent".  For a position statement from a supposedly professional body, relying on assertions in a blog seems at best sloppy, at worst a bad case of "flailing about until you find something that agrees with your suppositions. 
2. The second point I want to raise is that the Zucker and Spitzer (2005) paper they reference is a retrospective article on another subject.  To say that it demonstrates a long standing body of literature supports an association between transgender identity in youth and the development of homosexual identity later in life conveniently ignores the last 20 years of additional research into transgender youth since the emergence of puberty suppression treatments.  
3. They use the Roberts (2014) paper to leap to the possibility that transgender identity might be associated with childhood abuse patterns.  In doing so, they conveniently ignore the fact that gender identity is distinct from sexual identity.  Further, they provide absolutely nothing to substantiate even a possible correlation (must less causal relationship) between abuse and gender identity.  

Inference is a valid instrument in scientific inquiry, however in this case the inferences made appear to be overly convenient for the authors' preconceived biases.  Further, they appear to have ignored more recent research on transgender youth, as well as failed entirely to demonstrate that a causal connection exists where they claim it does is deeply troubling when considering the validity of this document.

Treatment Using Puberty Suppressing Drugs

Moving along, the writers argue against GnRHa medication to suppress puberty as follows:

In a follow-up study of their first 70 pre-pubertal candidates to receive puberty suppression, de Vries and colleagues documented that all subjects eventually embraced a transgender identity and requested cross-sex hormones.46 This is cause for concern. Normally, 80 percent to 95 percent of pre-pubertal youth with GD do not persist in their GD. To have 100 percent of pre-pubertal children choose cross-sex hormones suggests that the protocol itself inevitably leads the individual to identify as transgender.

46. De Vries ALC, Steensma TD, Doreleijers TAH, Cohen-Kettenis, PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 2011;8:2276-2283.

Actually it does not make any such implication at all.  Consider the following from the De Vries study abstract:

Of the first 70 eligible candidates who received puberty suppression between 2000 and 2008, psychological functioning and gender dysphoria were assessed twice: at T0, when attending the gender identity clinic, before the start of GnRHa; and at T1, shortly before the start of cross-sex hormone treatment. Behavioral and emotional problems (Child Behavior Checklist and the Youth-Self Report), depressive symptoms (Beck Depression Inventory), anxiety and anger (the Spielberger Trait Anxiety and Anger Scales), general functioning (the clinician's rated Children's Global Assessment Scale), gender dysphoria (the Utrecht Gender Dysphoria Scale), and body satisfaction (the Body Image Scale) were assessed. Behavioral and emotional problems and depressive symptoms decreased, while general functioning improved significantly during puberty suppression. Feelings of anxiety and anger did not change between T0 and T1. While changes over time were equal for both sexes, compared with natal males, natal females were older when they started puberty suppression and showed more problem behavior at both T0 and T1. Gender dysphoria and body satisfaction did not change between T0 and T1.

The study authors clearly point out that gender dysphoria symptoms did not change between T0 and T1, but general functioning did improve.  Further, if they had read more carefully, they would have noted the phrase "eligible".  In other words, patients who met the criteria for Gender Identity Disorder (as it would have been labelled in the DSM IV at the time), and were generally seen to be consistent and persistent.

While the De Vries study certainly raises a number of questions that deserve to be studied in more depth, we should be cognizant of the fact that the sample itself was specifically selected for appropriateness. To claim that persistence might have been a consequence of the protocol itself seems to be something of a leap from a carefully curated (and small) sample.

Also, the inference is really little more than fearmongering on the part of the authors.  It plays to the "recruitment" narrative, and nothing could be further from the reality.

Using Questionable Sources

Over the past two decades, Hayes, Inc. has grown to become an internationally recognized research and consulting firm that evaluates a wide range of medical technologies to determine the impact on patient safety, health outcomes, and resource utilization. This corporation conducted a comprehensive review and evaluation of the scientific literature regarding the treatment of GD in adults and children in 2014. It concluded that although “evidence suggests positive benefits” to the practice of using sex reassignment surgery in gender dysphoric adults, “serious limitations [inherent to the research] permit only weak conclusions.”39 Similarly, Hayes, Inc. found the practice of using cross-sex hormones for gender dysphoric adults to be based on “very low” quality of evidence:
Statistically significant improvements have not been consistently demonstrated by multiple studies for most outcomes. Evidence regarding quality of life and function in male-to-female (MtF) adults was very sparse. Evidence for less comprehensive measures of well-being in adult recipients of cross-sex hormone therapy was directly applicable to GD patients but was sparse and/or conflicting. The study designs do not permit conclusions of causality and studies generally had weaknesses associated with study execution as well. There are potentially long-term safety risks associated with hormone therapy but none have been proven or conclusively ruled out.40
Regarding treatment of children with GD using gonadotropin releasing hormone (GnRH) agonists and cross-sex hormones, Hayes, Inc. awarded its lowest rating indicating that the literature is “too sparse and the studies [that exist are] too limited to suggest conclusions.”40

39. Hayes, Inc. Sex reassignment surgery for the treatment of gender dysphoria. Hayes Medical Technology Directory. Lansdale, Pa.: Winifred Hayes; May 15, 2014.
40. Hayes, Inc. Hormone therapy for the treatment of gender dysphoria. Hayes Medical Technology Directory. Lansdale, Pa: Winifred Hayes; May 19, 2014.

Besides the earlier section which cites a blog as its primary source, we find the authors relying on publications by Hayes, Inc. for summative evaluation of the effectiveness of treatment protocols.  The issue here is that the Hayes publications are not peer review publications, instead they represent a summary opinion of the author(s) of whatever literature they have happened to review on the subject. The resulting publications are used by the insurance industry to decide whether they will fund particular treatments.  We should recognize that these do not represent an expert opinion on all subjects, rather they are an "industry opinion".

The Swedish Study

For example, a 2001 study of 392 male-to-female and 123 female-to-male transgender persons found that 62 percent of the male-to-female (MtF) and 55 percent of the female-to-male (FtM) transgender persons were depressed. Nearly one third (32 percent) of each population had attempted suicide.51 Similarly, in 2009, Kuhn and colleagues found considerably lower general health and general life satisfaction among 52 MtF and 3 FtM transsexuals fifteen years after SRS when compared with controls.52 Finally, a thirty-year follow-up study of post-operative transgender patients from Sweden found that the rate of suicide among post-operative transgender adults was nearly twenty times greater than that of the general population. To be clear, this does not prove that sex reassignment causes an increased risk of suicide or other psychological morbidities. Rather, it indicates that sex reassignment alone does not provide the individual with a level of mental health on par with the general population.

Pretty much every time you see this study trotted out, it's a deliberate attempt to suggest that gender reassignment surgery (GRS) is ineffective.  GRS is intended to address one issue, and one issue alone - gender dysphoria.  It has nothing to do with any other aspect of the person's functioning or issues.  A patient who is depressed before GRS, will likely be depressed afterwards; a person with financial problems (and associated stress and anxiety) before surgery will still be facing those issues afterwards.

The ACP seems to think that GRS magically fixes problems other than what it is intended to.  That is holding it to an unreasonable standard.  By far the most significant issue that transgender people face is discrimination and hostility.  These forces are part of everyday life, even for those who are reasonably passable.  Under and un-employment are rampant among the transgender population as a result, and the ACP thinks that one aspect of treatment is supposed to "fix it all"? Seriously?

Conclusions and Analysis

The college writes:

As stated earlier, the College is also concerned about an increasing trend among adolescents to self-diagnose as transgender after binges on social media sites. While many of these adolescents will seek out a therapist after self-identifying, many states have been forced by non-scientific political pressure to ban so-called “conversion therapy.” These bans prevent therapists from exploring not only a young person’s sexual attractions and identity, but also his or her gender identity.

As previously noted, the "social media effect" is at best anecdotal, assertions drawn from another blog, making this a very suspect claim to begin with.  The claim that banning conversion therapy prevents therapists from exploring a young person's sexual and gender identities is simply nonsense.  Conversion therapies are naturally coercive, and as such are inherently unethical.  Psychotherapy is inherently open to exploring all aspects of a person's inner landscape.  This conclusion is nothing more than a political ploy that they hope can be used to influence legislators.

The ACP also criticizes the fact that there are no predictive tests for whether a given child will be persistent in their cross-gender identification after puberty.  This is a silly complaint in many respects.  The fact is that persistence of any condition is difficult to predict, and no psychological test is in fact predictive.  They can tell you about the person in the moment, and assuming they are moderately stable, in the not so distant future.  As for how they will be even the following week, that is another matter entirely.

Perhaps the most damning omission in the ACP's analysis is the fact that not once do they even so much as reference the WPATH Standards of Care document.  Given that most of the professionals who work with transgender people follow this document pretty carefully, I think that they would find most of their objections are addressed in there, or in the associated literature.