American Academy of Pediatrics pulls back on “affirmative care” while a Seattle hospital pushes it, offering surgery and puberty blockers to adolescents

August 23, 2022 • 11:45 am

Enlightened medical opinion seems to be coming around to the view that for adolescents who want to change gender, i.e. become transsexual, the use of puberty blockers is not necessarily a good way to go. The blockers, which are supposed to stop puberty in its tracks (in a completely reversible way) are given to allow young people a pause to ponder their options. But they are increasingly seen as untested and possibly unsafe. European countries like Sweden, France, and Finland have either limited the use of puberty blockers to “exceptional cases” or clinical trials, or have prohibited their use entirely.

This is all part of a pushback against “affirmative care”: the idea that if a child decides they want to become transsexual, they must be completely supported, with psychotherapy not examining their decision or encouraging throughtful assessment, with parents urged to accept their child’s wishes, and with the medical establishment dispensing whatever hormone therapy or surgery the child wishes.

The problem with this is not that support shouldn’t be given. It’s that children or teenagers who are too young are being pushed by doctors, parents, and peers to make decisions about issues that may involve irreversible medical interventions. European countries vary in the age at which sex reassignment surgery is legal, usually ranging from 15 to 18. For transgender hormone therapy, ages in Europe range from a minimum of 14 up to 18, with most countries having minimums of 16 to 18.

That kind of therapy causes irreversible changes in the body, while genital surgery renders one sterile and often incapable of orgasm. I have no strong views on age limits except that they should be after puberty and not lower than 16. Your mileage may vary.

And I’ve just discovered, through an article in the City Journal, that the American Academy of Pediatrics, which used to be all for “affirmative care”, seems to have suddenly started reevaluating its position. The article notes this:

Moira Szilagyi, president of the AAP, has written that “gender-affirming care . . . doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.”

This is a welcome development, and marks a reversal of the AAP’s previous policy. That policy was announced in a 2018 Pediatrics article, whose lead author was Jason Rafferty; it argued that “watchful waiting” is akin to “conversion therapy” and should be avoided. “Watchful waiting” refers to an approach that emphasizes psychotherapy as a measure of first (and hopefully last) resort to help minors in distress feel comfortable in their bodies. Its premise, confirmed by 11 studies, is that the vast majority of children with gender dysphoria will desist by adolescence and feel comfortable enough in their bodies not to require medical transition. The Dutch researchers who developed pediatric transition explicitly warned against early transition. Yet transgender activists in the United States have criticized this model, insisting that because transgender identity (i.e., body rejection) is a normal and healthy aspect of human existence, mental health professionals should never steer patients toward a “cisgender” outcome.

If Szilagyi believes that medicalization is the wrong way to go “for the vast majority of children” with gender dysphoria, then this constitutes a de-facto repudiation of the Rafferty statement and the AAP’s previous policy.

Here’s an extract from AAP President Szilagyi’s piece, an an op-ed in the Wall Street Journal called “Academy of Pediatrics Responds on Trans Treatment for Kids: To ‘affirm’ a child or teen means destigmatizing gender variance and promoting the child’s self-worth.”

Regarding Julia Mason and Leor Sapir’s op-ed “The American Academy of Pediatrics’ Dubious Transgender Science” (Aug. 18): In its recommendations for caring for transgender and gender-diverse young people, the AAP advises pediatricians to offer developmentally appropriate care that is oriented toward understanding and appreciating the youth’s gender experience. This care is nonjudgmental, includes families and allows questions and concerns to be raised in a supportive environment. This is what it means to “affirm” a child or teen; it means destigmatizing gender variance and promoting a child’s self-worth. Gender-affirming care can be lifesaving. It doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.

This isn’t the story that is being told by anti-transgender activists. No European country has categorically banned gender-affirming care when medically appropriate. Contrary to what Dr. Mason and Mr. Sapir claim, the U.K. isn’t moving away from gender-affirming care. It is moving toward a more regional, multidisciplinary approach, similar to what is practiced in the U.S.

This does seem to be a change of policy. “Affirmation” no longer means “go full steam ahead for the gender change” but, properly, to “promote a child’s self-worth.” Further, affirmative care no longer means “pushing medical treatments or surgery; for the vast majority of children it recommends the opposite.”

I’d say that this is a move towards enlightenment, even if it was promoted by what European countries are doing. It’s not clear, though, that this will become the AAP’s official policy.

Nevertheless, some places, like Seattle Children’s Hospital, continue to offer surgery, puberty blockers, and hormones to children as young as nine. Granted, you need parental permission for this treatment, and you can’t get bottom surgery until you’re over 18, but dispensing blockers, drugs, and cutting off the breasts of females younger than 16 is not something I’m a fan of.

This story comes from KOMO news in Seattle, a station and website affiliated with ABC, and you can check its assertions by going to the Seattle Children’s Hospital website on gender care (link below). Click to read:

This is from KOMO:

The gender clinic at Seattle Children’s Hospital (SCH) provides children as young as 9 years old with “gender-affirming medical care,” like puberty blockers, and children in their “mid-teens” with non-genital transition procedures known as “top” surgeries.

We accept new patients ages 9 to 16,” the SCH gender clinic website states. “Patients ages 17 and older and patients who have not yet started puberty will be directed to community resources.”

The website notes that the clinic “primarily provides gender-affirming medical care (such as puberty blockers  and gender-affirming hormones)” to patients. Children must receive parental consent for any “gender-affirming” treatment.

“Brief mental health support” is also available, according to the site, but the clinic suggests that “if you are looking for gender-affirming mental health services only, or for ongoing mental health support,” there are better resources that focus solely on that.

Patients must be 18 years or older to receive gender transition surgeries involving genitals, such as vaginoplasties and phalloplasties, according to another page on SCH’s gender clinic website.

Sure enough, the website link given above says this:

We accept new patients ages 9 to 16. Patients ages 17 and older and patients who have not yet started puberty will be directed to community resources. Our clinic primarily provides gender-affirming medical care (such as puberty blockers and gender-affirming hormones). Brief mental health support focused on family decision making and mental health documentation prior to initiating gender-affirming care is also available. If you are looking for gender-affirming mental health services only, or for ongoing mental health support, here are some community resources.

Puberty blockers, with their attendant medical unknowns, are offered to children who have started puberty but haven’t completed it, and those in their “mid-teens” can get surgeries like double mastectomies, breast augmentation, thyroid cartilage surgery, and “facial gender-affirming surgery.” I can’t find the age at which hormone therapy is given, but I presume it’s either after puberty has begun or in one’s mid-teens.

But there are some claims that seem dubious, like these given at the Hosptial’s pdf on puberty blockers:

No, puberty blockers are not permanent. If you decide to stop puberty blockers without starting cross sex hormones, your body will start going through the puberty of your sex at birth. You can stop the puberty blockers at any time, but we will work with you on how to do that.

We can safely and legally recommend puberty blockers for you based on our medical experience and judgement and your specific health needs. The Endocrine Society and the World Professional Association for Transgender Health support puberty blockers. The Food and Drug Administration (FDA) approves puberty blockers for children who start puberty at a very young age, but has not approved puberty blockers for transgender children.

But at the same place they say this:

The long-term safety of puberty-blocking medicines is not completely understood. There may be long-term risks that we do not know about yet.

Indeed, this is in line with Britain’s new NHS guidelines to not give hormonal treatment, including puberty blockers, to adolescents under 16. Further, Sweden’s Karolinska institute says this:

  • In light of the above, and based on the precautionary principle, which should always be applied, it is hereby decided that hormonal treatments (i.e., puberty blocking and cross-sex hormones, see above) will not be initiated in gender dysphoric patients under the age of 16.
  • For patients between ages 16 and 18, it is hereby decided that treatment may only occur within the clinical trial settings approved by the EPM (Ethical Review Agency/Swedish Institutional Review Board). The patient must receive comprehensive information about potential risks of the treatment, and a careful assessment of the patient’s maturity level must be conducted to determine if the patient is capable of taking an informed stance on, and consenting to, the treatment.

The U.S. is often touted as having the world’s best medical care. But when it distorts the dangers of hormonal treatment, or rushes children and adolescents onto an escalator towards transsexuality without proper therapy and information, it’s a travesty.

h/t: Williams

15 thoughts on “American Academy of Pediatrics pulls back on “affirmative care” while a Seattle hospital pushes it, offering surgery and puberty blockers to adolescents

  1. Below are updated (February 2022) guidelines from the Swedish National Board of Health (not a right wing group!):

    – From strong use of hormones to use only in exceptional cases
    – ASD (autism spectrum disorder) relevance to treatment
    – Marked change in demographics (young girls) is not understood
    – Move towards psychological care as first line of treatment
    – Treatments to be based on distress and not self identification
    – More good stuff at the link

    The question that pops to mind is why was not this the always the default position, and how did advocacy sink the science?

  2. Don’t modify the individual’s body to externally represent the changeable internal perception of self’s sex until adulthood.

    Society exerts pressure on individuals to select and display male vs female characteristics by dress and choice of activities societally deemed male or female. None of this is genetic. Unless the individual wants to procreate, he/she can be/do whatever is internally determined.

    This is not new or unique. Native American cultures for centuries have encompassed (or not) the individual’s need for sexual and gender self-expression. Read about the “berdache” or “two spirit”.

  3. I have heard interviews that specifically state that puberty blockers are not totally reversible, even though advocates will say that they are. What I have not heard or read whether the reversibility/non-reversibility is dependent, as one would expect, on length and dosage.

    I don’t have links at the moment to substantiate the above. What have others heard and do you have links to that information?

    1. The problem with puberty blockers is that once prescribed they almost inevitably (98% IIRC) lead to the use of cross-sex hormones, the effects of which most certainly aren’t reversible.

      By contrast, many cases of childhood gender dysphoria resolve themselves without medication or surgery after puberty provided that it is allowed to happen.

      I think the stats are in Helen Joyce’s excellent book Trans: When Ideology meets Reality – I’ll try to find the page numbers ASAP.

  4. Additional comment: One of the critical factors involved is that, to my knowledge, there is now way to differentiate between children who will be trans, on the one hand,
    and sissy boys and tomboy girls, who grow up to be gays and lesbians and grow out of their gender dysphoria. Most putative gay organizations are now in fact trans rights organizations.

    BTW, a short and very interesting thread from Jesse Singal:

  5. Let’s hope the tide is turning. Seattle Children’s seems to have not yet gotten the memo. It’s a big and prominent hospital here in the Seattle area. If it moves it’s policy in the right direction—which I hope it will—it will have a strong impact here.

    1. That’s a good article (and a good cartoon) and, of course, I’m afraid to share it publicly 🙁

  6. The ultimate in conversion therapy is to take a generation of kids who will likely grow up to be happy and gay, and mutilate them surgically and hormonally so that they won’t be gay, they’ll be straight but with bodies made by Frankenstein. One day we may look back on unthinking affirmation and youthful transition as the holocaust in which a generation of gays were wiped out.

    1. I fear that you are correct – and all at the behest of organisations claiming to represent LGB youth. You couldn’t make it up.

  7. I do not quite understand the alarm over puberty blockers, since my understanding is that they have proven very safe for a group of children about whom there is no controversy whatsoever—children with precocious puberty. Puberty blockers have been used for decades in such cases, so I’m puzzled by the claims that they are untested.

    I became familiar with the use of blockers in precocious puberty from one of my daughter’s best friends growing up. This girl had an extreme case—she began entering puberty when she had only just turned 2 years old (when her mother was horrified to discover a pubic hair when she was changing her baby’s diaper!).

    The child was then put on puberty blockers for the next ten years or so until she was at the right age and height to experience normal puberty, at which point the meds were withdrawn. Her development was totally normal from that point onward and she is now a healthy and fertile 30 year old.

    My intention is certainly not to defend pushing puberty blockers in any case a child momentarily questions their gender. But I do wonder if the real reason to object to the use of puberty blockers is less because they are harmful to health than because the prescribers are being disingenuous about their intentions when they prescribe them. That is, while they claim that they only want to DELAY puberty in order to give the child more time to mentally mature so that they can make a truly informed decision about whether or not to transition, the fact is that, in practice, blockers are being used as the first stage in transitioning—i.e., in order to prevent children diagnosed* as transgender from developing the secondary sex characteristics of their natal sex before they are legally old enough to be prescribed hormones and have surgery.

    * If the ideologues insist on characterizing sex as something that is arbitrarily ‘assigned’ to children by physicians at birth, rather than being something objectively real, we ought to similarly insist on characterizing transgender identity as something that is arbitrarily ‘diagnosed’ by self-anointed experts in transgender clinics, rather than being something objectively real. (I’m not entirely serious, of course. The truth is that I’m 100% convinced that gender dysphoria is, in many cases, every bit as real and immutable as biological sex and that hormones and surgery may often be the only intervention that could possibly alleviate the misery in such cases. But since transgenderism is hugely over-diagnosed, the diagnoses often tell you far more about the diagnostician than the patient.)

  8. The concern with puberty blockers given when puberty is expected to occur is that we don’t know that delaying the timing of puberty doesn’t mess up the synchronization of a number of things that happen in adolescence. (If “we” do, the enthusiasts aren’t shouting the reassuring results from the rooftops. Rather they resist publicizing the disquieting news, see below.) The obvious sexual signs of puberty are accompanied by bone growth to adult height, achievement of adult bone density, and maturation of the brain. In most children given puberty blockers, irreversible treatment with opposite-sex hormones begins a couple of years later — because that’s what the clinics push — without any chance for normal puberty to resume. If puberty blockers are stopped, we don’t know if all these processes will catch up, or how long it will take, or if some processes have missed the boat. Do the growth plates obligingly stay open to allow resumption of the growth spurt at 15, when most girls have long since stopped growing and mineralizing? Does calcium flood into the bones to make them strong?

    A girl accumulates all the calcium-based mineral she will ever have in her skeleton by age 13. Her long-bone growth plates fuse soon after as she reaches her adult height. From then on, even with the estrogen of normal adult life, it’s downhill for her bones, retarded chiefly by weight-bearing exercise and, later in life, by lucratively expensive drugs. Older women are more afraid of falling and breaking something than they are about anything else except a stroke. A Colle’s fracture is significantly albeit temporarily disabling. A hip fracture is fatal about a third of the time and many others will never walk again even with surgery.

    The onus is on practitioners to prove that drugs given to 10-year-old girls for cosmetic and psychological reasons will not increase their risk of osteoporotic fractures 50 years on, or sooner.

    Another post from the source cited by JezGrove at #3 looks at data from the Tavistock Clinic.

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