The American College of Pediatricians (ACPeds) is a national organization of pediatricians and other healthcare professionals dedicated to the health and well-being of children. Formed in 2002, the College is committed to fulfilling its mission by producing sound policy, based upon the best available research, to assist parents and to influence society in the endeavor of childrearing.
The College currently has members in 47 states, and several countries outside of the US. The College is a not-for-profit corporation organized for scientific and educational purposes, exempt from taxation under Section 501(c)(3) of the U.S. Internal Revenue Code.
Dr. Michelle Cretella, MD, FCP, is the Executive Director of ACPeds and a pediatrician with experience in behavioral health. She has been a researcher, writer, spokesperson and board member of the ACPeds for 13 years. She also serves on the Advisory Board of the Alliance for Therapeutic Choice and Scientific Integrity. She is regularly consulted by media outlets and others to share her scientific opposition to transgenderism. Dr. Cretella received her medical degree in 1994 from the University of Connecticut School of Medicine. She completed her internship and residency in pediatrics in 1997 at the Connecticut Children’s Medical Center. She completed a fellowship in College Health through the University of Virginia in 1999.
Dr. Quentin Van Meter, MD, FCP, is the president of ACPeds and an actively practicing pediatric endocrinologist. He is a highly sought after expert in pediatric gender dysphoria. His endocrine fellowship training at Johns Hopkins occurred during the tenure of Professor John Money when transgender issues were in their infancy. As a practicing pediatrician, mental health issues have been a large part of his practice experience and the specialty of pediatric endocrinology is innately tied to emotional health. He is consulted worldwide for his expert opinion on the subject of gender incongruence and the management thereof. He is on the clinical faculty of Emory University School of Medicine and Morehouse College of Medicine.
Dr. Avak Albert Howsepian MD, PhD, is a consultant to the ACPeds. He is Staff Psychiatrist and Director of Electroconvulsive Therapy at the Veterans Administration Central California Health Care Center in Fresno, Clinical Professor of Psychiatry in the University of California, San Francisco – Fresno Medical Education Program (UCSF-FMEP), and Instructor in the Department of Counseling Education and Rehabilitation at California State University, Fresno and in the Department of Philosophy at Fresno Pacific University. He teaches courses in Psychopharmacology, Psychiatry and Religion, Psychiatric Ethics, Sexual Dysfunction, Paraphilias and Perversions, Electroconvulsive Therapy, Forensic Psychiatry, and Philosophy of Mind. He also has a private practice, ‘Comprehensive Psychiatry Consultation Services.’ Dr. Howsepian has approximately 50 publications in Psychiatry, Neurology, and Philosophy journals. His Ph.D. is in Philosophy from the University of Notre Dame.
Dr. Cretella, Dr. Van Meter, (‘ACPeds’, when answering together) and Dr. Howsepian (AP) kindly engaged with Savvy Street’s Chief Editor, Vinay Kolhatkar (VK) in a wide-ranging discussion about the politicization of medicine.
VK: “In 1917, the APA [American Psychiatric Association] recognized 59 psychiatric disorders. When DSM-I was published in 1952 it had 128. By 1987 there were 253. DSM-IV has 347.”
If your disorder is in the DSM, it’s easier to get your health insurer to pay for treatment; you may even qualify for public funds. That helps parents, patients, and even psychiatrists and psychologists. Is that why the DSM grew at such a phenomenal rate (with potential adverse consequences being overmedicated children)?
AH: I have no evidence to suggest that the DSM system of nosology grew at a phenomenal rate as a function of the stated economic considerations, but there is good reason to believe that the reason that ‘Gender Dysphoria’ (GD) can be found in the DSM-5 is because public funding and insurance payment for the ‘treatment’ of persons with GD (where ‘treatment’ in the current psychiatric milieu involves affirming one’s patient’s ‘gender identity’ and, if requested, assisting in one’s patient’s stated degree of transitioning in the direction of his or her desired sex) requires, at least for the time being, of its being a codable DSM diagnosis.
VK: Re Gender Identity Disorder, DSM-5 did not take psychiatrists out of the equation, but allowed other interventionists (endocrinologists, surgeons) to move into treatment.
“Gender identity disorder. Individuals who believe their biological gender doesn’t match their gender identification will no longer be labeled with a disorder. Instead, if they seek psychiatric treatment, they can be labeled with ‘gender dysphoria.’”
Was the workgroup that “settled on a formal diagnosis – potentially qualifying a patient for insurance-paid treatment if they want it – but with a less pejorative name than ‘disorder,’” under pressure from political groups?
The ICD-11 has moved ‘Gender Incongruence’ out of the ‘Mental Disorders’ section into the ‘Sexual Health Conditions’ section.
AH: If not ‘groups’, certain persons on the APA subcommittee dealing with gender issues were under pressure. It is relevant to note that the ICD-11 (the 11th Revision of the International Classification of Diseases) has moved ‘Gender Incongruence’ out of the ‘Mental Disorders’ section into the ‘Sexual Health Conditions’ section. The DSM architects appear clearly to favor heading in this direction, but decided, for the time being, to retain a diagnostic category called ‘Gender Dysphoria’ — which is nowhere in the DSM-5 referred to as a ‘disorder’ — for economic and other public policy reasons.
VK: In your opinion, what gives rise to gender-identity disorder? How would you treat it?
ACPeds: This is not a matter of opinion. Identical twin studies demonstrate that non-shared post-natal events (environmental factors) predominate in the development and persistence of gender dysphoria.
Studies suggest that social reinforcement, parental psychopathology, family dynamics, abuse, and social contagion facilitated by mainstream and social media, all contribute to the development and/or persistence of GD in some vulnerable children.
Studies suggest that social reinforcement, parental psychopathology, family dynamics, abuse, and social contagion facilitated by mainstream and social media, all contribute to the development and/or persistence of GD in some vulnerable children. There may be other as yet unrecognized contributing factors as well.
There is no single family dynamic, social situation, adverse event, or combination thereof that has been found to destine any child to develop GD. This fact, together with twin studies, suggests that there are many paths that may lead to GD in certain vulnerable children.
Most parents of children with GD recall their initial reactions to their child’s cross-sex dressing and other cross-sex behaviors to have been tolerance and/or encouragement. This suggests that acceptance and reinforcement leads to persistence. Sometimes parental psychopathology is at the root of the social reinforcement. For example, among mothers of boys with GD, a small subgroup of mothers who had desired daughters experienced what has been termed “pathologic gender mourning.” Within this subgroup the mother’s desire for a daughter was acted out by the mother actively cross-dressing her son as a girl. These mothers typically suffered from severe depression that was relieved when their sons dressed and acted in a feminine manner.
A large body of clinical literature documents that fathers of feminine boys report spending less time with their sons between the ages of two and five as compared with fathers of typical boys. This is consistent with data that shows feminine boys feel closer to their mothers than to their fathers. In his clinical studies of boys with GD, Stoller observed that most had an overly close relationship with their mother and a distant, peripheral relationship with their father. He postulated that GD in boys was a “developmental arrest … in which an excessively close and gratifying mother-infant symbiosis, undisturbed by father’s presence, prevents a boy from adequately separating himself from his mother’s female body and feminine behavior.”
It has also been found that among children with GD, the rate of maternal psychopathology, particularly depression and bipolar disorder is “high by any standard.” Additionally, a majority of the fathers of GD boys are easily threatened, exhibit difficulty with affect regulation, and possess an inner sense of inadequacy. These fathers typically deal with their conflicts by overwork or otherwise distance themselves from their families. Most often, the parents fail to support one another, and have difficulty resolving marital conflicts. This produces an intensified air of conflict and hostility. In this situation, the boy becomes increasingly unsure about his own self-value because of the mother’s withdrawal or anger and the father’s failure to intercede. The boy’s anxiety and insecurity intensify, as does his anger, which may all result in his inability to identify with his biological sex.
Systematic studies regarding girls with GD and the parent-child relationship have not been conducted. However, clinical observations suggest that the relationship between mother and daughter is most often distant and marked by conflict, which may lead the daughter to dis-identify from the mother. In other cases, masculinity is praised while femininity is devalued by the parents. Furthermore, there have been cases in which girls are afraid of their fathers who may exhibit volatile anger up to and including abuse toward the mother. A girl may perceive being female as unsafe, and psychologically defend against this by feeling that she is really a boy; subconsciously believing that if she were a boy she would be safe from and loved by her father.
There is also evidence that psychopathology and/or developmental diversity may precipitate GD in adolescents, particularly among young women. Recent research has documented increasing numbers of adolescents who present to adolescent gender identity clinics and request sex reassignment (SR). Kaltiala-Heino and colleagues sought to describe the adolescent applicants for legal and medical sex reassignment during the first two years of an adolescent gender identity clinic in Finland, in terms of sociodemographic, psychiatric, and gender-identity related factors and adolescent development. They conducted a structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013. They found that the number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding the onset of GD was common. Many youth were on the autism spectrum. These findings do not fit the commonly accepted image of a gender dysphoric child. The researchers conclude that treatment guidelines need to consider GD in minors in the context of severe psychopathology and developmental difficulties.
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.
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. 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. 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.” 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 further research.
VK: Do surgery and hormonal treatment have the ability to completely alter biologically-determined gender? Are medical professionals violating their Hippocratic Oath?
ACPeds: No amount of drugs or surgery can change sex. Sex is determined by DNA at fertilization. Sex declares itself in utero and is recognized prenatally via ultrasound and at birth.
No amount of drugs or surgery can change sex. Sex is determined by DNA at fertilization.
When physicians and others promote the lie that people may be trapped in the wrong body, prescribe puberty blockers and cross-sex hormones (which often sterilize children), and surgically maim and amputate healthy body parts, they violate the medical ethics principle of “first do no harm”. [Technically, “first do no harm” is not part of the Oath of Hippocrates, but is as ancient a medical principle].
VK: Are the equality-of-results (not opportunity) postmodernists responsible for trying to diminish intrinsic gender differences? Is the move to transgender surgery a politically-motivated ploy?
ACPeds: As physicians, all we can say is that those pushing gender ideology and transgenderism are not motivated by science, biological reality or what is best for children.
VK: To what extent are masculinity and femininity learned behaviors?
ACPeds: There is not an exact answer to this question. Masculinity and femininity are both biologically influenced and culturally influenced. There are some very important genetic sex differences between men and women that affect every organ system of the body — including the brain — that do not and cannot change. The social and psychological differences between men and women, are certainly influenced by these biological differences, but also to some degree, by environmental factors.
Gender identity, however, is the result of a cognitive developmental process. An awareness of oneself as male or female is learned over time; it is not determined at fertilization or birth. By age 3 most children can correctly self-identify as the proper sex; at age 5 most understand that boys grow into men, and girls grow into women, but it is not until age 7 that most children understand that changing one’s outward appearance does not change one’s sex. In other words, gender identity develops over time and its normal development can be derailed, especially when authority figures promote the lie that some kids may be trapped in the wrong body.
VK: Should there a lesser hurdle for women to qualify for combat roles in the armed forces (social engineering) or the same hurdle for everybody (equal opportunity)?
ACPeds: This is not an appropriate question for the ACPeds or AH to answer.
VK: What sort of hate mail and calls are you receiving?
ACPeds: We receive a significant amount of positive feedback and appreciation from professionals and laypersons across the political spectrum both by phone and email almost daily. We also receive numerous requests from parents who are desperate to avoid having their child placed on the toxic sex change pathway.
Hate toward the ACPeds is expressed in occasional puerile phone calls, emails and in online forums and videos. They consist of ad hominem attacks and the misrepresentation of science. The now discredited Southern Poverty Law Center has us on its hate list which we consider a badge of honor.
VK: Turning now to matters outside of sexual mores and sexuality, was Viktor Frankl right—Is an intensely-purposeful life an excellent, if not the best antidote to clinical depression in children (and adults)? If no, what is?
Living an intensely purposeful life is both therapeutic and prophylactic with respect to a wide variety of emotional disorders.
AH: Unfortunately, the healing dimensions of meaning and purpose have been frequently neglected or minimized — including in research context — or restricted to discourse involving ‘existential psychiatry’, much to the detriment of our profession. There is no question, however, that what scant research there is on this topic combined with clinical and general life experience demonstrates time and time again that living an intensely purposeful life is both therapeutic and prophylactic with respect to a wide variety of emotional disorders.
VK: What can we do to stop politicization of medicine?
ACP: One step would be to ensure a diversity of worldviews among research investigators and among the leadership of medical guilds like the AMA, APA, and AAP. It is necessary to have bipartisan teams when confronting areas of medicine that intersect with morally contentious social issues. Worldview diversity will decrease the risk of groupthink in the development of hypotheses, experimental methodology, interpretation of study results and the development of policy. Medicine must once again respect the First Amendment. Science depends upon freedom of thought; the freedom to pose and test hypotheses without fear of retribution should the hypotheses and/or results be considered politically incorrect.
VK: Thank you for you time, Dr. Cretella, Dr. Van Meter, and Dr. Howsepian. We wish you the very best and hope you succeed in all your endeavors.