Catholic Medical Quarterly

The Journal of the Catholic Medical Association (UK)

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Catholic Medical Quarterly Volume 67(3) August 2017

The American College of Pediatricians Statement on “Gender Ideology”:
A Note of Caution

David Albert Jones

“Paediatricians back Pope Francis”[1]

In March 2016, the American College of Pediatricians released a position statement entitled “Gender Ideology Harms Children”.[2] This statement seemed to echo concerns that had been raised by Pope Francis, among others, about “an ideology of gender that denies the difference and reciprocity in nature of a man and a woman and... leads to educational programmes and legislative enactments that promote a personal identity and emotional intimacy radically separated from the biological difference between male and female.”[3]

The position statement received widespread media coverage and was reproduced in a number of Catholic publications and websites,[4] not least the Catholic Medical Quarterly in August 2016. There it was introduced by a short paragraph urging that the statement was “very important and therefore we recommend that it be read”.[2] The statement has even been cited by a number of bishops, including the bishop of Illinois, in the United States,[5] the bishop of Calgary, in Canada.[6]

The long shadow of “conversion therapy”

If one knew nothing about the American College of Pediatricians except for the name then one would imagine it was a national professional body representing a significant proportion, if not all, paediatricians practicing in the United States. In fact, the main professional organisation, with a membership of over 60,000 is the American Academy of Paediatrics (AAP). In contrast the American College of Paediatrics has less than 600 members, not all of whom are paediatricians. It was founded in 2002 by a small group of paediatricians who opposed the AAP policy on adoption by gay couples. Clearly, as the membership includes less than 1% of paediatricians in the United States, this body does not represent the profession as a whole nor most practicing Catholics in the profession.

In the Frequently Asked Questions section of the College website, the view that “non-heterosexual attractions are inborn or innate”[7] is contested.  Instead it is argued that scientific evidence supports the contrary position that “these attractions develop from the interaction of a multitude of influences in an individual’s life”.[7] On this basis, the College expresses overt support for “therapy for children and adolescents with unwanted non-heterosexual attractions... [as there is] evidence that change toward heterosexual attraction is possible for some people”.([7] emphasis in original)

The practice of reparative, conversion, or reorientation therapy for “unwanted non-heterosexual attractions” is highly controversial, to say the least. In 2009, a task force of the American Psychological Association conducted a systematic review of the peer-reviewed journal literature on sexual orientation change efforts (SOCE) and concluded that “efforts to change sexual orientation are unlikely to be successful and involve some risk of harm”.[8] Subsequently several States in the United States,[9] and one country in Europe (Malta), have placed legal restrictions on these therapies, especially for use with minors.

A recent article in the Linacre Quarterly, has argued, quite reasonably, that all mental health interventions carry some risk of harm and that there is no good scientific evidence as to whether “the degree of risk for harm from professional care for unwanted [same sex attraction] is greater, the same as, or less than the risk of other psychotherapy”.[10] Be that as it may, neither is there good scientific evidence that conversion therapies are effective in changing sexual orientation. In general, the risks of therapy are accepted because of the reasonable prospect of benefit. However, while people do change in relation to the pattern of their sexual desires, there is little evidence that, for most people, therapy can facilitate “change toward heterosexual attraction”. The weakness of evidence of effectiveness is a reason for caution in accepting the risks of such interventions, especially for use in minors.

Catholic teaching on conversion therapies

Catholic teaching is that homosexual intercourse is contrary to the virtue of chastity. However, the Catholic Church has never endorsed the use of therapy for unwanted same-sex attraction. When the Governor Cuomo of New York proposed an order banning private and public health insurers from covering conversion therapy for minors, a spokesperson for the New York State Catholic Conference, stated that,

“In the past, bills have been introduced in the state legislature that would have banned insurance coverage for these therapies for minors. The Catholic Conference has not taken a position on these bills, and we do not foresee taking a position on the Governor’s executive action in this regard either.”[11]

Similarly, while the Maltese bishops’ conference approved a position paper by an expert panel that opposed the banning of such therapies, Archbishop Scicluna later expressed regret that this document was not contextualised by a more pastoral statement from the bishops themselves. He also emphasized that the bishops did not endorse conversion therapy but were opposed to it.

“I want to reassure [the gay community] that we are dead set against conversion therapy because we believe, as they do, as government does, that it goes against human dignity.”[12]

No doubt there are Catholic clinicians in good faith who have seen potential benefits in reparative methods for unwanted same-sexual attraction and who at the same time have sought, in their practice, to minimise the risks of harm. However, Church authorities should be very wary of encouraging therapy that certainly involves some risk and does not seem to offer a realistic prospect of benefit. As one commenter puts it, “By promoting celibacy, we are simply promoting what the sexual ethics of the churches demands. But by promoting orientation change, we are promoting a shift far deeper, far more rooted in someone’s particular personhood... If it succeeds, well and good. But if it does not, great damage can be done, and we can end up implicated.”[13]

Therapies that attempt sexual orientation change remain deeply controversial and, hitherto, Catholic authorities and institutions have been wary of endorsing them, especially for use in minors. It is important to give due consideration to the overt support by the American College of Pediatricians for such therapies in minors before endorsing this organisation as a guide to the clinical care of children expressing or experiencing gender dysphoria.

An elusive golden mean

The position statement of the College includes a reference to a paper from 2005 by Zucker and Bradley.[14] Kenneth Zucker is a highly-respected clinician, the author of dozens of peer reviewed journal articles on gender dysphoria. He was also a member of the working party that developed The World Professional Association for Transgender Health Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People.[15]

Regrettably and most unfairly, Zucker has become something of a hate-figure for many in the transgender movement because he does not subscribe to the view that self-reporting of gender identity in children should always be taken on face value. He argues that gender confusion in childhood can often be a symptom of other psycholog­ical problems and may resolve when these problems are addressed. Nevertheless, in clear distinction from the American College of Pediatricans, Zucker has always been opposed to conversion therapy for same-sex attraction and he does not consider his approach as in any way analogous to reparative approaches. Thus, according to Jesse Singal,

“Zucker did believe that in some cases transition was the best bet, and according to my reporting his clinic never tried to “switch back” a child who had already transitioned (none of the in-depth reporting that has been done on his clinic has found any evidence that he has, despite the frequency of allegations to the contrary). He seems to view transition clinically — as a treatment, in a sense, that offers better outcomes for intensely and persistently dysphoric people than anything else we have.”[16]

Zucker represents the elusive and perhaps shrinking middle ground between different versions of “one size fits all”.[17] On the one hand, reparative approaches and heavy-handed legal interventions can assume that all gender dysphoric children will eventually come to accept their biological sex, despite evidence that in a significant minority of cases gender dysphoria in childhood will persist into adulthood. In those who do persist, evidence also suggests that the distress can often be ameliorated, at least in the medium term, if the adolescent transitions to live in the opposite gender role.[18] On the other hand, gender-affirming   therapeutic approaches and heavy-handed legal interventions in the opposite direction can sometimes require that self-reported gender identity in childhood be taken as something fixed and stable. Such requirements fly in the face of evidence that, with time and support, most children with dysphoria will resolve their incongruence by accepting their biological sex. The unfair dismissal of Zucker, and closure of his clinic,[19] show how difficult it is to treat each child as an individual and to pursue evidence based medicine in this area. It also seems clear that the efforts of groups such as the American College of Pediatricians to associate themselves with Zucker are both misleading and are harmful to those, such as Zucker, who seek some responsible middle way.

Inaccuracies, exaggerations of oversimplifications

The position statement of the College contains numerous oversimplifications and inaccuracies. For example, while the statement correctly observes that “no one is born with an awareness of themselves as male or female”,[2] this is misleadingly simplified to “no one is born with a gender”[2]. Gender is a sociological as well as a psychological concept and the child possesses a social identity from birth, if not before. This social aspect of gender identity is evident, for example, in the naming of the child. An adequate account of gender dysphoria requires careful delineation of the relationship between biological sex, social gender role and psychological gender identity. The position statement seeks to short-circuit this analysis by dismissing the very significance of “gender”.

The authors of the statement assert that Gender dysphoria (GD) “is a recognized mental disorder”,[2] listed in the Diagnostic Manual of the American Psychiatric Association (DSM-V), and assert that it was “formerly listed as Gender Identity Disorder (GID)”.[2] This latter assertion is inaccurate in that the scope of the two diagnoses is different. The category of GID implied that gender incongruence, the mismatch between a person’s biological sex and his or her gender identity, was itself a mental illness or a disorder. In the new classification of GD, gender incongruence is not itself a disorder but is accepted as a form of human diversity. It is only the distress (the “dysphoria”) associated with gender incongruence that constitutes a mental health problem. The College’s identification of GD with GID is inaccurate and misleading.[1]

The position statement also draws attention to research from Sweden that shows very high rates of suicide in adults who have transitioned, having undergone gender reassignment surgery and hormone treatment.[20] The authors then pose the rhetorical question, “What compassionate and reasonable person would condemn young children to this fate”?[2] However, this rhetorical move involves a fallacy. It implies that individuals with gender dysphoria are at higher risk of suicide if they transition and undergo surgery than if they do not. This is not demonstrated by the research from Sweden. Had they not transitioned they might have had an even higher risk of suicide. The research says nothing about this one way or the other. Most significantly, the rhetorical question ignores the possibility that seeking to prevent expressions of gender incongruity might in some cases add to some­one’s distress, at least temporarily, and might thereby increase the risk of suicide. The high-profile suicide of a transgender teenager in Ohio drew attention to this danger.[21] This is an area in which it is important to proceed with caution and where there is a great need for better quality evidence for the benefits and risks of different interventions. The task of developing such an evidence base is not helped by misuse of research by organisations such as the American College of Pediatricians to support conclusions not implied by the data.

The language of abuse and the abuse of language

In addition to the inaccuracies and non sequiturs it contains, the position statement of the American College of Pediatricians is also deeply problematic for its tone and its language.

Divergences of sexual development (DSDs) are described as “deviations from the sexual binary norm”, and “disorders of human design”. The gender incongruence of “an otherwise healthy biological boy [who] believes he is a girl”, is described as a “mental disorder”. Transitioning to a gender role that does not correspond to one’s biological sex is described as “impersonation”. Hormone therapy is described as “toxic”. Gender reassignment surgery is described as “unnecessary surgical mutilation”. Approaches that seek to affirm a child’s gender identity are described as “conditioning children”. Finally, in a phrase which seems calculated to attract media attention, such gender-affirming approaches are described as “child abuse”.

A harsh word stirs up anger (Proverbs 15.1) and the use of this deliberately provocative terminology serves to increase antagonism in relation to an area that is already difficult. In particular, the word “disorder”, used thirteen times in the document, echoes, perhaps consciously, the language of the Congregation for the Doctrine of the Faith that not only the acts, but also, “the particular inclination of the homosexual person... must be seen as an objective disorder”.[22] While the statement of the CDF was intended to bring clarity, the phrase became itself the focus of controversy and perhaps generated as much confusion as it dispelled. Nevertheless, at least the CDF were concerned with an inclination to actions which were clearly contrary to a Catholic understanding of chastity. Hence the language of “disorder” was at least anchored overtly in a moral context.

In contrast, the statement of the American College of Pediatricians moves uneasily between the use of the term “disorder” in relation to the physical variations of sexual development (“disorder of human design”), the psychological variations of gender incongruence (“mental disorder”) and, implicitly, the moral disorder of “non-heterosexual attractions”. The “deviations from the sexual binary norm” in the physical and psychological order suggest a parallel deviancy in the moral order but this moral judgment remains implicit and unacknowledged. The language thus carries the connotation of moral condemnation without clarifying precisely which acts are morally impermissible or why. This is not helpful.

It should be noticed that the language of “disorder” is now regarded as problematic in relation to DSDs and this has led many to reject the term “Disorders of Sexual Development” in favour of “Divergences of Sexual Development”,[23] or to retrieve the language of 'intersex'. Similarly, the word “disorder” is problematic in a mental health context and is no longer part of the terminology of gender dysphoria. The repeated use of the term “disorder” demonstrates the great distance between the College’s position statement and contemporary understanding of clinical best practice.

The language of “impersonation”, used four times in the document, is also heavily loaded and misleading. It implies wilful deception, the deliberately false presentation of a persona which one knows to belong to another and not to oneself. This does not seem accurately to represent the psychology of someone who experiences gender incongruence. It is rather that for such persons, their sense of gender identity, the persona with which they identify, is not reflected in their physiology nor the in the gender role in which they were brought up. Transitioning to a new gender role certainly raises ethical concerns, not only in relation to the surgery that it might involve but also in relation to marriage and sexual ethics.[24] Nevertheless, it is misleading to characterise transition as involving the intention to “impersonate” the sex of another. It aims, rather, to express what the person takes to be his or her own persona. Furthermore, like the term “disorder”, the term “impersonation” carries with it the connotation of moral failure, of dissimilation or bad faith.

The word “toxic”, which is used in the statement in relation to the physical side-effects of hormones, also has negative psychological and moral connotations. Actions can be morally toxic. Furthermore, all medical treatments have side effects but one would not usually refer to medicine per se as “toxic”. The question is whether there are sufficient benefits that offset these risks for a particular patient. There are good reasons to challenge the prevalent approach of prescribing hormone blockers to children with suspected gender dysphoria, as there are good reasons to challenge the over-prescription of medicines to children more generally. However, to use of the word “toxic”, simply on the basis that the intervention carries the risk of sideeffects, is to beg the question.

The word “mutilation” is used only once, but it has prominence because it is the very last sentence of the document. In contemporary culture the most immediate association of the word is with female genital mutilation, an outrage perpetrated primarily on children. In a Catholic context (and the statement shows some signs of having been written with a Catholic audience in mind) the term evokes the teaching of Pope Pius XI[25] and of Pope Pius XII.[26] It is a moot point whether all gender reassignment surgery is “mutilation” in this technical moral theological sense. If the surgery destroys sexual or reproductive function then it would fall within the traditional condemnation. However, the term “gender reassignment surgery” covers many procedures some of which are cosmetic in focus and do not destroy function (think, for example, of breast augmentation in the context of male-to female reassignment). Such cosmetic procedures may or may not be justified but they are not “mutilation” in the sense given to the term by traditional moral theology.

The last and most problematically loaded term used in the document is “child abuse”. As already indicated, there are good reasons to be concerned about the imposition of puberty blockers on gender dysphoric children. There are also reasons to be concerned about the potential risks of psychotherapy (whether “gender-affirming” or “reparative” or of some other form), for such interventions have the potential to do harm as well as good. However, it is not helpful to describe these potential harms as “child abuse”. The term “child abuse” is rightly reserved, at least in the first instance, for sexual abuse or serious physical violence against children. There is a growing understanding that public authorities (including church organisations, but also the police, the judiciary, social services, and public broad­casters) have failed to identify and prevent such abuse in the past, and even now have not fully acknowledged the extent of the problem. To invoke the language of “child abuse” for other harms to children is not only sensationalist. It also adds insult to injury for those who have been the victims of sexual abuse or physical violence during childhood.

There are ideologies of gender, erroneous philosophies of sex and gender that Pope Francis has rightly criticised. There are also clinical approaches to gender dysphoria that seem to be driven more by political considerations than by scientific evidence. Assessing the evidence is made more difficult by the emergence of a political transgender movement that seeks control over social space in a way that can undermine the possibility of open and critical public discussion. Finally, and of the greatest importance, in the midsts of this political clash of ideologies, there remains the challenge of providing sensitive and appropriate pastoral care to children and adults with gender dysphoria.

The statement of the College includes neither the philosophical sophistication nor the clinical evidence needed to meet this challenge. It also lacks the pastoral sensitivity to communicate to people with gender dysphoria “the depth of God’s love for them and their intrinsic worth and beauty”.[27] There is an urgent need for the Church to develop the theological resources, in dialogue with clinicians and with people experiencing gender incongruence and those close to them, to help address the pastoral needs of children and adults with gender dysphoria. However, the position statement produced by the American College of Pediatricians is not the place to start.

 

David Albert Jones is Director of the Anscombe Bioethics Centre, Oxford, Research Fellow at Blackfriars Hall, Oxford and Research Fellow at St Mary’s University, Twickenham