Catholic Medical Quarterly

The Journal of the Catholic Medical Association (UK)

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Correspondence

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

Adrian Treloar

Dear Sir,

I am worried about Professor Jones’ assessment of the American College of Pediatricians statement [1] for a number of reasons.

The background of the American College of Pediatricians

It is good see that Professor Jones affirms the Catholic Medical Quarterly’s view that the statement was significant. The widespread coverage he describes appears to further support that view. The benefit of reproducing it in the CMQ was, perhaps, to enable a debate upon such an important issue.

Professor Jones is keen to point out, the American College of Pediatricians is, in effect, a minority view which is not endorsed by the larger professional paediatric organisa­tions in America. While it is legitimate to point that out, the reality should be that in debating the issue at hand, that is not the central issue. The question is whether or not the views expressed are valid. There have been many times throughout history when minorities have expressed an unpopular view and been disregarded and dismissed as a result. In the end, those minority views have often prevailed. But he should not use the “minority views” argument to dismiss those views or attempt in any way to side-line them as they may be a minority view.

I also worry that in his critique he uses many value laden adjectives and descriptors in doing so. The issue at debate here should be the robustness of the data and should not rely upon such value terms. The use of terms such as (for example) “Regrettable and most unfair treatment” and “adds insult to injury” are among many value laden comments which do not, I think, easily facilitate an exploration of the facts.

Concerns around conversion therapy are not of primary relevance to the issue of transition in childhood.
While his long and detailed discussion of conversion therapy is interesting and worthy of its own paper, it does not really (as far as I can see) contribute to the issue of the College’s position statement. Perhaps, in a nutshell, conversion therapy is indeed dismissed by many and seen as nothing but a bad thing. And yet, there are at least some who state that it has helped them and been an effective remedy to their serious difficulties. Some of those testimonials are to be found on the American College of Pediatricians website, but there are more elsewhere. Perhaps in the context of that tension and debate, a world which values diversity should be pleased to see and hear views that differ from the mainstream. All of which perhaps means that the controversy over conversion therapy is not of key relevance to the College of Pediatricians position statement on transgender issues in childhood.

The relevance of gender fluidity

Professor Jones discusses the work of Zucker and the quoting of his papers. It is surely reasonable to quote published works and it is hard to see how the “Regrettable and most unfair treatment” of him by the transgender movement really could justify a decision not to quote his work which sets out the evidence for gender fluidity during childhood and adolescence. And again, while what is said is of interest, it is really not germane to the discussion of this position statement. The simple point made in the position statement is that gender fluidity is a real issue. It therefore follows that if gender fluidity is an issue, then “transition” clearly risks creating something im­mutable (transition) in a person whose identity is fluid. It is perhaps a little more alarming when it becomes clear the children as young as 12 are treated with puberty blockers in the UK [2]. As mentioned earlier, symptoms of GID at pre-pubertal ages decrease or even disappear in a considerable percentage of children (estimates range from 80–95%)[3]. Therefore, any intervention in childhood would seem premature and inappropriate. However, in the Amsterdam gender identity clinic for adolescents, none of the patients who were diagnosed with a GID and considered eligible for SR [sex reassignment] dropped out of the diagnostic or treatment procedures or regretted SR[3]. That must raise concern that puberty blockers may solidify a fluid gender dysphoria and lead onto an irreversible progress towards transition. It is pleasing to see that Professor Jones emphasises the reality of that fluidity. One cannot then easily ignore the risks of immutable transition alongside that fluidity.

The gender identity as disorder or dysphoria

The International Classification on diseases (ICD-10) states that mental "Disorder" is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here."(WHO, 1992 [4] ).
Professor Jones rightly notes that classificatory systems which attempt to define gender identity are, to a degree, in a process of change and development. Within ICD gender identity was previously clearly stated to be a disorder, but has been increasingly seen as a clinically identifiable condition which is associated with distress and dysphoria but not, in fact, a disorder. ICD has thus moved from describing Gender Identity Disorder towards calling it Gender Identity Dysphoria. But as the American College of Pediatricians rightly point out a brief drill down underneath the meaning of the term dysphoria does mean that the definition of a disorder as involving “distress and with interference with personal functions" soon draws the diagnostician towards seeing Gender Indentity Dysphoria as a disorder. Which appears to be what the American College of Pediatricians have done.

There is a philosophical and ideological conflict within this. ICD defines a disorder as a clinically identifiable set of signs and or symptoms which are recognisable and associated with that clinically identifiable sign and symptom set. If we accept the ICD definition then it is easy to argue that, with high rates of depression, substance misuse, self-harm, suicide, relationship breakup and relationship fluidity GID is indeed a disorder. Indeed the same set of negative outcomes are significant issues among homosexual people. Fergusson [5] (for example) found that elevated rates of reported suicide attempts in youth who identified as Lesbian, Gay and Bisexual, were associated with significantly higher rates of depression, generalized anxiety disorder and conduct disorder than were observed among heterosexual youth. HIV and other sexually transmitted diseases retain their very high prevalence among homosexual communities. Since the 1980s, men who have sex with men have remained the group most at risk of HIV in the UK. In 2014, the most recent data available, there were 103,700 people with HIV in the UK. Of those an estimated 45,000 were men who have sex with men [6]. This means roughly 1 in 20 men who have sex with men aged 15 to 44 are living with the virus. The prevalence rate is 4.9% nationally among this group, rising to 9% in London. [3]

Authorities on both sides of the debate agree that there is severe suffering associated with GID and transsexualism. High suicide rates are just one part of that problem. Conversely, if disorders are socially and politically defined, it is clear that, in the current Western socio-political environment, neither homosexuality nor GID are seen as disorders. That is in contrast to the view of the Church which, while making a clear distinction between homo­sexual inclination and homosexual activity, does describe homosexuality as a disorder [7].

The point here is that the identifiable and clearly negative clinical symptoms and outcomes associated with being GID are well known and of huge concern. That in turn means that the ICD definition of a disorder could easily be used to support a conclusion that these are disorders. However, in moving away from seeing gender identity as a dysphoria rather than a disorder ICD has clearly migrated towards that Western socio-political view. It is I think, therefore, a little risky to try to apply science to what is in fact a definition which is modified and led by the prevailing societal view. In stating that “The College’s identification of GD with GID is inaccurate and misleading” Professor Jones is, I think, at risk of applying a socio-political conclusion to clear scientific evidence that transsexualism is accompanied by some very severe and distressing challenges. The suffering of transsexual people is very great and must be an urgent cause for concern. t is not clear that all of those challenges are solely the result of stigma, prejudice and discrimination.

Recognising harm associated with transition.

In that context, Professor Jones further complains that it is not reasonable to be concerned about the high suicide rate associated with transition because, he states, “had they not transitioned they might have had an even higher risk of suicide”. Clearly the evidence to test that hypothesis is not there and Professor Jones quotes a moving story of an Ohio boy who killed himself [8]. But that tragic story does not remove the reality that (from the scientific data available) that a sex change clearly does not remove the risk of suicide. A Swedish study found an adjusted hazard ratio of 19.1 for suicide (95% CI 5.8–62.9) [9]. In a Danish study of 104 people, somatic morbidity increased after transition and premature mortality was high (9.6% of the sample died at an average age of 55y between 1978 and 2010. [10]. Any other medical procedure with such a high excess mortality should be, and would be questioned. Any medical device that led to such a high death rate would be withdrawn, regardless of whether or not there were hoped for benefits. It is just not safe enough to hypothesise that a very high post­surgical suicide rate is justified by an (undemonstrated) even higher suicide rate if surgery does not happen. Rather perhaps, we should be willing to question whether or not surgical transition is not an adequate response to the distresses and challenges that accompany people with GID. Professor Jones is, I think, unreasonable to criticise the American College of Pediatricians for pointing out such a high post transition suicide rate. As an outcome measure that is surely, in itself, evidence that transition has limited benefits which require exploration and good understanding. The US National Transgender Discrimination Survey (NTDS), conducted by the National Gay and Lesbian Task Force and National Center for Transgender Equality, found that 41 percent of people who identify as transgender have attempted suicide. That “vastly exceeds the 4.6 percent of the overall U.S. population who report a lifetime suicide attempt, and is also higher than the 10-20 percent of lesbian, gay and bisexual adults who report ever attempting suicide”[11] . Perhaps if transition does not solve the suicide problem, and there are excess rates of depression and early mortality, that is a clue that transition does not solve at least some of the major challenges which people with GID face.

Toxicity, toxicology and mutilation

Professor Jones is concerned that the use of the word “toxic” to describe the side effects of oestrogen and progesterone is inappropriate. Medicine understands well the issues of toxicology and there is no doubt that the hormones used in transition do indeed produce significant side effects and challenges. Similarly, mutilation is an accurate description of the removal or adaptation of a body part, especially if a healthy organ is to be removed or permanently scarred. Professor Jones is simply wrong to state that “one would not usually refer to medicine per se as “toxic””. And his complaint that such words should not be used because they have “negative psychological and moral connotations” is therefore unreasonable. We should not desist from using words which we would use in other contexts, or disguise realities simply because we are anxious about acknowledging the side effects of treatments for transition. To do so would be dishonest.

Abuse

Professor Jones similarly objects to the use of the word abuse. Happily society is clear that sexual abuse is unacceptable and gravely wrong. The International response to Female Genital Mutilation is testament to that and to be greatly welcomed therefore [11]. Abuse is abuse and is unacceptable.

As described above, young children are being given puberty blockers in America and Britain. Up to 100% of them go onto transition. And yet, if it is true that gender identification is fluid, and if transition is given to young people, then it must at least be possible for some young people to undergo transition when their gender identity will revert to their biological state if nothing is done. If early intervention means that young people end up transitioning when they otherwise would not then that is reasonably called abuse. In my view therefore, to state that the use of the word “abuse” by the American College of Pediatricians is inappropriate has to be based upon a view that “gender-affirming approaches” are universally good and harm free. If in fact “gender-affirmation” does lead to inappropriate care, inappropriate use of hormones, inappropriate surgery and high rates of mental disorder, distress and suicide then the use of the word “abuse” seems less unreasonable.

Conclusion

Professor Jones states that “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. “

While disagreeing with some of Prof Jones’ arguments, I absolutely agree with this view. The need is very urgent. It appears to be the view of the College of Paediatricians that silence on this matter risks neglecting the welfare of both children and adults. Surgical transition and artificially delayed puberty remains at best deeply problematic and at worst harmful especially if it is performed on young people who are still maturing and whose sexuality remains (according to published data) liable to fluidity. For my part, I am bold enough to suggest a few key points that might inform that dialogue.

1. We must show great care, compassion, and understanding of the difficulties and challenges faced by people who have GID and same sex attraction.
2. We attest the humanity, dignity and worth of each and every person
3. We must seek to protect people from harm, and especially protect the young from harm.
4. To do this we must
   1. Be willing to think about, discuss and embrace the difficulties faced by people with GID
   2. Be willing therefore to understand the high rates of
      1. Gender fluidity, relationship instability and relationship breakdown
      2. Depression
      3. Self harm
      4. Suicide
      5. Substance misuse
      6. Sexually transmitted diseases including HIV
5. To be willing to explore to what extent those difficulties are the result of prejudice, stigma and discrimination and as well as to what extent they may be outcomes of GID and same sex attraction themselves.
6. And we must be willing to view actions which are abusive as abuse even when they occur in the context of GID