Parents petition American Academy of Pediatrics in response to policy statement on trans-identified youth

The letter from the parents’ Gender Critical forum (discussed and reproduced below) is also an online petition. To tell the American Academy of Pediatrics that kids deserve more careful assessment and cautious treatment than the affirmation approach recommended by the AAP, you can sign the petition here.

A group of parents from the 1000+-member Gender Critical Support forum ( launched a communications campaign this week in response to the recent policy statement about medical treatment for trans-identified children issued by the American Academy of Pediatricians (AAP). Members of the Gender Critical parents’ forum assert that affirmation therapy is a potentially harmful approach, and detail their perspective in the letter they are sending to the AAP Executive Committee, Board Members, Ethics Committee, and to doctors who will speak at the organization’s annual conference in Florida, November 2-6, 2018.

In an email, representatives of the Gender Critical parent forum told 4thWaveNow:

We parents know first-hand the results of the affirmation approach because many of our teens have been subject to it. Many of our children were offered prescriptions after one or two doctor visits, or they were given a referral to a gender clinic to consult about transition after no attempt was made to explore other reasons for the sudden transgender claim.

In many areas of the United States, it’s no longer considered a matter of commonsense to question a sudden announcement of being “born in the wrong body” in adolescence (with no previous signs), especially when preceded by or concurrent with anxiety, depression, autism, and/or questioning of sexual orientation. This affirm-only approach is outside the mainstream of international practice. We’ve outlined five problems with the fundamentals of the AAP’s policy statement in our letter to them.

The letter from the parents’ Gender Critical forum is also an online petition, reproduced in its entirety below. To tell the AAP that kids deserve more careful assessment and cautious treatment than the affirmation approach recommended by the AAP, you can sign the petition here.

4thWaveNow responded briefly to the AAP policy statement in this earlier post. Readers may also be interested in a critique of the AAP’s policy statement written by James Cantor, PhD., available at this link.

Dear American Academy of Pediatrics (AAP):

We need you and our children need you. There is a great and growing disservice that needs your attention, scientific curiosity, critical thinking, clinical experience, and compassion.

We have serious concerns about the AAP’s Policy Statement “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents” (Rafferty et al., 2018). While we believe that AAP’s intention behind this position statement is to protect the health of today’s gender-diverse youth (children through young adults), we are deeply concerned that the clinicians using affirmation therapy are inadvertently inflicting physical and psychological harm.

We are members of a rapidly growing online community of over 1,100 parents of transgender-identifying youth who need your help. We have no unifying political affiliation. We empathize with mature transgender-identifying people who deserve respect. We need to stop the harm to our children.

It is our concern that the AAP’s Policy Statement will continue, and possibly worsen, the harm brought to many children by the recent radical changes to treatment guidelines for transgender-identifying youth. Over the past decade, there has been an exponential rise of predominantly adolescent girls who are suddenly declaring themselves trans after the onset of puberty and who have no previous history of gender dysphoria (GD). Historically, GD showed at a much earlier age and has been exceedingly more common in boys. A recent groundbreaking study of an emergent late-onset, predominantly female trans-identifying patient population, finds significant parallels with the phenomenon of eating disorders, and includes social contagion as a key factor (Littman, 2018). The drastic increase in trans-identification and the switch to the predominant adolescent girl patient has prompted the United Kingdom (UK) Government to launch an investigation over concern that the 4400% increase in the last decade could be due to a social phenomenon (Rayner, 2018).

There is great harm being done to girls and some boys by medicalizing their gender non-conforming (GNC) behavior based on gender stereotypes, homosexuality, and/or underlying mental health issues that have led to trans-identification. The medicalization with gonadotropin releasing hormone (GnRH) agonists is highly experimental and comes with serious long-term consequences for bone health, potentially for neurological health, and as sterilizes the child when followed by cross-sex hormones. The harms of sex-aligned hormones (e.g., testosterone given to natal males) are well-known, include significant cardiovascular disease, and are increasingly exposed in lawsuits for non-transgender adults. Astonishingly, cross-sex hormones are given to the opposite sex in trans-identifying adolescents who are expected to be treated for their full lives and have permanent effects. The harms of surgeries are self-evident and irreversible, which is problematic for youth who change their minds.

The justification for non-FDA–approved medicines and surgeries is that the youth will commit suicide if these drastic measures aren’t taken (although this is not acknowledged in the AAP’s statement). There is no clinical data that supports that medical transition prevents suicide. Contrarily, long-term studies (>10 years) demonstrate increases in suicide rate, psychiatric hospitalization, and lower quality of life after sex reassignment surgery in adults (Dhejne et al., 2011; Simonsen et al., 2016; Kuhn et al., 2009).

Most transgender youth in the US who were reported in the news as having completed suicide were affirmed by social transition; thus, disproving that affirmation prevents suicide completion. The Williams Institute California GNC study reported that the percentage of teens identifying as either highly GNC or as androgynous has increased to nearly 30% and that neither group statistically differ from non-GNC teens in rates of lifetime suicide thoughts and attempts (Wilson, 2017). Furthermore, the risk of suicide in transgender-identifying youth is comparable or even less than that of youth who are non-heterosexual but who are not trans (CDC 2018, page 24, col 2, para 5), who have eating disorders (Smith, 2018), or who are referred to youth mental health services in the UK (GIDS, 2018) and yet, the “transition or die” mantra pervades as if transition is the only option.

We ask that you (1) consider our knowledge-based concerns presented as a scientific rebuttal to five main points made in the AAP position statement, (2) query AAP and other pediatricians anonymously to understand broader views, (3) conduct a more inclusive scientific debate with GD experts critical of affirmation therapy (e.g., and (4) retract the AAP statement pending your inquiry. Please consider this letter a call to lead the way in exploring alternative non-invasive, non-harmful treatments. Your AAP oversight over the smaller subcommittee of “trans experts” is urgently needed.


Rafferty et al. state “transgender identities and diverse gender expressions do not constitute a mental disorder.” (p 4) and “Some youth who identify as TGD also experience gender dysphoria, …” (p 3)

If transgender-identification is not a mental disorder, what is it? Is it a medical condition? If so, how is it diagnosed? How can the TGD “condition” be both a mental health disorder for “some youth” and not for others but both are treated the same way?

These questions are never answered directly by Rafferty et al. or other “trans experts,” as well as the American Psychological Association (APA) and the World Professional Association for Transgender Health (WPATH) because the answer is simply that the youth just needs to proclaim that they are transgender – it is purely self-diagnosed.

If “being transgender or gender diverse” isn’t a mental disorder or a medical condition, why are youth treated with the life-altering, non-FDA-approved drugs (experimental GnRH agonists are used for years and hormone therapies are used for a lifetime) and irreversible, serial cosmetic surgeries in an attempt to achieve a scientifically impossible goal?

We have experienced doctors giving prescriptions without adequate mental health consideration and after only 1-2 visits.

Summary: Diagnosis is the youth’s self-diagnosis. The life-altering medical treatments offered do not match the diagnostic process or the clinical evaluation standards of medicinal or surgical safety and efficacy.


Rafferty et al. acknowledge that trans-identifying youth have “high rates of depression, anxiety, eating disorders, self-harm, and suicide” (p 3) and that “If a mental health issue exists, it most often stems from stigma and negative experiences rather than being intrinsic to the child” (p 4)

The view that trans-IDing youth have mental health problems because of their incongruity with their natal sex is a widespread assumption among “trans experts.” Another valid hypothesis is that mental health issues cause the person to trans-identify. Normal adolescent challenges coupled with the recent unfortunate declines in adolescent mental health (e.g., increases in anxiety, depression, self-harm, and suicide), the social media and iPhone explosion (Twenge et al., 2017), and the plethora of platforms targeting youth with transgender promotion are a recipe for adolescent trans-identification.

The role that mental health plays in a sudden proclamation of transgender status is discussed in a peer-reviewed scientific study that only begins to investigate the social influences on trans-identifying youth and reveals the emergence of rapidnset gender dysphoria (ROGD; Littman, 2018).

Physicians, GD experts and clinicians have been critical of the rush to affirm an adolescent’s trans-identification, especially where no history of GD exists. Some of these professionals are part of the Pediatric and Adolescent Gender Dysphoria Working Group (, but many, including several AAP pediatricians are not voicing their concern in public for fear of career reprisal (Kearns, 2018).

Trans-identification offers a way out of the misery of poor mental health, misogyny, loneliness, and hatred of oneself. It offers a completely new identity (i.e., it’s identity suicide with the advantage of being reborn). Trans-identification provides body alteration, commands authority figures to alter their language and behavior, comes with a fight for social justice, and provides a sense of belonging. Can you see this ultimate recipe for disaster? We see it playing out in our homes every day and it is torture that this is therapist- and pediatrician-sanctioned and encouraged.

Summary: We have experienced that providers (pediatricians, psychologists, etc.) do not explore, or only superficially inquire about, on-going or historical mental health, trauma experiences, or any potential causes of trans-identification before affirming the child’s self-diagnosis and proceeding with medical treatment, which is consistent with Dr. Littman’s study. We have also experienced that our children are using transgender-identification as a maladaptive coping mechanism as discussed in Dr. Littmans’s study. This idea is also supported in the context of anorexia nervosa and demonstrates similar adolescent clinical presentation profiles and social contagion aspects with the modern additional factor of pervasive social media exposure to transgender promotion.


Rafferty et al. state “…children who are prepubertal and assert an identity of TGD know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender…” (p 4)

Eleven scientific studies indicate that transgender-identification is transient in most youth as demonstrated by desistance from transition and/or ceasing trans-identification after puberty (Cantor 2017). The dismissal of all 11 of these studies by Rafferty et al. is not scientifically validated by two citations consisting of opinion statements written by pro-affirmation extremists (Ehrensaft, 2018; Olson, 2016) who decide to throw out all the data that was astonishingly reproducible. All 11 studies demonstrate 60-90% of prepubertal children desist and further detailed scientific discussion has refuted criticisms of this unanimity of research findings (Zucker, 2018). In fact, two of the three references cited by Rafferty et al. that are used erroneously to cite support for affirmation therapy (see below under “the problem of not applying clinical science”), state that fewer than 20% of children persist in their transgender identity following puberty. In addition to the clinical data, desistance and detransition occur regularly as evidenced by verified published anecdotal accounts in several publications, all in 2018 alone (Anderson, 2018; Brunskell-Evans, 2018; Hope, 2018; Singal, 2018; Sullivan, 2018).

Several GC forum members are parents of desisters. Some of our children recognize that their trans-identification was part of a maladaptive coping mechanism. One girl desister says she was “ridiculously shy and incredibly awkward” and states that “I became depressed and I hated myself. I hated everything about me: my body, the way my voice sounded, my awkward personality, my face. Everything. I began questioning why I felt so awkward in my body and why I hated myself. I started questioning my gender. Not before long, I was 100% sure that I was actually a boy.” Many of our children have comorbid mental health issues and many watched some of the top 100 YouTube transgender celebrity vloggers in admiration just prior to their trans-identification.

Our families have experienced tremendous and unnecessary suffering brought on by irresponsible transgender promotion and iatrogenic therapy and there are thousands more who are trans-identifying for the same wrong reasons and yet they are 100% convinced of their self-diagnosis as well as their therapists, teachers, doctors, and some parents who accept their self-diagnosis as recommended by APA, WPATH, and now, AAP.

Summary: Desistance is the most common outcome among children. Persistence of the exponentially increased population of predominantly natal female, late-onset GD adolescents (including those newly identified as having ROGD) has not been studied. Today, youth are affirmed and either receive treatment or wait until they can get treatment, thus ensuring that they will be more likely to persist. Mistaken medical affirmation leading to detransition occurs regularly.


Rafferty et al. state “gender identity evolves as an interplay of biology, development, socialization, and culture…” (p 4)

Three of these factors in determining if a youth will trans-identify can be summarized as the effect of the environment on the youth’s cognitive processes during development. This is exactly as we have experienced; these social factors are the dominant factors, and not biology. Evidence for social contagion is emerging in the literature (Littman, 2018) and is consistent with our experiences. By immersing themselves in trendy transgender-indoctrinating videos recommended when they open YouTube or when their friend groups decide they are transgender together in clusters, they become myopically fixated on transition.

When the natural developmental pubertal processes are artificially ceased by treatment with GnRH agonists, this negates the adolescent’s natural ability to desist from gender confusion. The majority of gender dysphoric youth desist after puberty, thus, stopping these profoundly important integrated developmental processes of neurochemistry and physiology can prolong persistence of GD. This is demonstrated by gender clinics admission that approximately 100% of children on GnRH agonists continue onto cross-sex hormones (Olson, 2018). It is also demonstrated in a study conducted at the Gender Identity Development Service (GIDS) where “persistence was strongly correlated with the commencement of physical interventions such as the hypothalamic blocker (t=.395, p=.007) and no patient within the sample desisted after having started on the hypothalamic blocker. [In contrast,] 90.3% of young people who did not commence the blocker desisted. For the children who commenced the blocker, feeling happier and more confident with their gender identity was a dominant theme that emerged during the semi-structured interviews at 6 months. However, the quantitative outcomes for these children at 1 years’ time suggest that they also continue to report an increase in internalising problems and body dissatisfaction, especially natal girls. [emphasis added]” as presented at a WPATH symposium (Carmichael, 2016).

As for the biological underpinnings of transgenderism, we know that it is not purely genetic as demonstrated by only 28% concordance in monozygotic twins and we know little else. Neuroimaging studies provide no unifying observations. The few MRI studies that show a minor difference in neuroanatomical substructures, gray matter volume, or cortical thickness are overtly flawed by the use of subjects who have been living daily life as a transgender individual (years of neuroplasticity at play), many have been using cross-sex hormones resulting in a myriad of neuroendocrine and potential neuroplastic changes, and most egregiously, cannot possibly rule out the probability that these small differences are due to personality differences such as the tendency to engage in behavior that is stereotypically associated with the opposite sex (gender non-conforming [GNC]) or such as homosexuality.

Most kids who desist grow up to be gay (Wallien et al., 2008). Are we converting “gays” to “straights”? Perhaps extremes on both sides of the political spectrum have motivations to accept or even encourage their child to trans-identify. Far-right parents may be embarrassed by GNC behavior and homosexuality and far-left parents may be eager to embrace the latest civil rights movement.

We are accepting of our kids’ GNC behavior and/or homosexuality. We don’t accept that their bodies are wrong and need to match gender stereotypes or become heterosexual.

Summary: There are several factors and individual trajectories leading a youth to trans-identify with the most dominant factors being environmental. The “trans experts” have ignored all environmental factors, attempted to over-emphasize any biological components, failed to tease-apart GNC behaviors or homosexuality from any minor biological basis of transgender identification, and focused solely on the false position that the youth is infallible in their self-diagnosis despite conclusive clinical evidence that children diagnose themselves incorrectly 60-90% of the time.


Rafferty et al. states “There is a limited but growing body of evidence that suggests that using an integrated affirmative model results in young people having fewer mental health concerns whether they ultimately identify as transgender.” (p 4)

Two of the three references provided to support this statement contain no data and do not reference clinical data supporting this claim (Edwards-Leeper, 2012; Menvielle, 2012). One reference is a parent survey with inclusion criteria of parents who were seeking affirmation therapy and therefore biased in their ratings of affirmation therapy (Hill et al., 2010). Numerous other flaws include that some surveys were completed at baseline before affirmative care was administered and that the sample was unrepresentative of the study populations used for comparison in terms of social class and an unusually high adoption rate (52%). All these flaws and more have been eloquently discussed in Singh et al., 2011.

Rafferty et al.’s “growing body of evidence” turns out to be an erroneous, unsupported claim. The use of citations to support affirmation therapy were fact-checked by Clinical Psychologist James Cantor (Cantor, 2018). His critical commentary reveals how the citations actually demonstrate that the most common outcome of GD is desistance, the watchful waiting approach (not affirmation) is the approach recommended by most experts and institutions, and the citations used to claim that therapists opposed to affirmation therapy are engaged in conversion therapy have nothing to do with GD because they are studies on homosexuality (not GD). There are no comparative clinical studies between (1) affirmation therapy, which includes consideration or engagement in affirmative pharmaceutical therapies and serial cosmetic surgeries and (2) other non-affirmation therapies that exclude medicalization (but it can be reserved it as a last resort for the distant future).

This grave scientific error is repeated in the on-going National Institute of Health (NIH) study where there is no comparative or control group and only affirmation therapy is tested in clinic-registered youth (Olson, 2015). An example of an appropriate comparative therapy group would include one that was holistically treated for underlying mental health issues, engaged in regular physical activity that is enjoyable to the youth, assisted with building strong social connections, and supported by loving families who do not affirm that the youth is in the wrong body and instead only ask the youth to be open to all the possible reasons why they feel that way. “Watchful waiting” approach could be enhanced by exploring and resolving the youth’s underlying mental health issues and improving psychosocial skills, mind-body connection (i.e., engaging in physical activity), and family dynamics.

There is no mention of evaluating efficacy of affirmation therapy by Rafferty et al. Even the cited scientific publications do not evaluate efficacy of affirmative medical treatments and only offer speculation. Where is the data? Data need to show unequivocally that youth will benefit over the course of their lives from the experimental therapies.

The serious safety risks of GnRH agonists and cross-sex hormones (used alone or in combination) include cardiovascular events (venous thromboembolic disease, myocardial infarction and death), bone growth inhibition, psychological (e.g., aggression), sterilization, sexual dysfunction and potential neurological risks; all of which are scarcely mentioned in the position statement. No studies exist on the effects of these pharmaceuticals on children treated over five years and cross-sex hormones are intended for lifelong use. Long-term (>10 years) studies have demonstrated that medical transition leads to worsening of mental health and worsening of physical outcomes (Dhejne et al., 2011; Simonsen et al., 2016; Kuhn et al., 2009).

Herein lies another error in the ongoing NIH study (Olson, 2015) in that outcomes for efficacy and safety need to span past 10 years to justify the lifelong intention to medicate these youth; however, the study duration is only listed for 5 years. The idea of a honeymoon period post transition followed by a period of a return to worse mental health is supported by experienced psychiatrist, Dr. Roberto D’Angelo, who works with teen and adult trans-identifying people and their families. He has seen “that difficulties can resurface many years later and often these are the original difficulties that the person hoped transitioning would address”( In contrast, Dr. Johanna Olson, one of the NIH authors, belittles the tragedy of regret by saying, “And here’s the other thing about chest surgery: If you want breasts at a later point in your life, you can go and get them” (Robbins, J, 2018).

We have used several supportive but non-affirming strategies and some of us have seen our children desist. Many of the strategies we’ve tried are reflected in the caring guidance offered by two clinical professionals, Lisa Marchiano and Sasha Ayad, who consider the full context of the youth’s experience, history, and parental input (Marchiano, 2017; Toward a more nuanced exploration, 2018).

Summary: With no clinical data and a flawed ongoing NIH study, how can the medical transition of youth who would normally desist be justified? Modern non-affirming strategies need to be evaluated.


After you consider our concerns and engage in critical evaluation, can you stand by this position statement? How about other AAP pediatricians (those outside the committee who authored this statement) – do they stand by it? We request that you investigate their attitudes and observations by surveying them – anonymously so they aren’t targeted for non-compliance with the forces of transactivism. We request that you stand by the AAP’s commitment to be “Dedicated to the health of all children” and retract this position statement while you conduct an inquiry.

If you have any doubt as to why we are anonymous, you need to look no further than Rafferty et al.’s recommendation to consider legal “support” in cases where parents do not comply with subjecting their children to experimental therapies (p 8).

Similarly, pediatricians and therapists remain silent or anonymous after witnessing the slander of those using non-affirmation approaches as demonstrated by world-renowned GD expert, Dr. Kenneth Zucker (Singal, 2016), and his long-awaited vindication (CAMH, 2018; The Canadian Press, 2018).

Please read our enclosed GC forum letter (also available at with our four proposals and more support for our position (including further discussion on transgender suicide) with many more references that couldn’t be included here.

Copies of this letter and the enclosed have been sent to the media.

We sincerely thank you for your consideration,

Parents of trans-identifying youth

REFERENCES (note: all links were accessed October 2018)

CAMH Apology. (n.d.). Retrieved from

Cantor, J (2017) How many transgender kids grow up to stay trans? PsyPost

Cantor, J (2018) American Academy of Pediatrics policy and trans- kids:Fact-checking. (n.d.). Retrieved from

Carmichael, P et al. (2016) Gender Dysphoria in Younger Children: Support and Care in an Evolving Context (n.d.). WPATH Symposium. Retrieved from

Center for Disease Control (CDC) (2018) MMWR Surveill Summ 2018;67(No. 8) Retrieved from

Dhejne, C. et al. (2011) Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one, 6(2), e16885.

Edwards-Leeper, L & Spack N (2012) Psychological Evaluation and Medical Treatment of Transgender Youth in an Interdisciplinary “Gender Management Service” (GeMS) in a Major Pediatric Center, Journal of Homosexuality, 59:3, 321-336.

Ehrensaft, D et al. (2018) Prepubertal social gender transitions: What we know; what we can learn—A view from a gender affirmative lens. International Journal of Transgenderism, 1-18.

Gender Identity Service (GIDS) (2018) Our response in full to the ITV series Butterfly Retrieved from

Hill, D et al. (2010) An affirmative intervention for families with gender variant children: Parental ratings of child mental health and gender. Journal of sex & marital therapy36(1), 6-23.

Hope, L (2018) Is changing gender the new anorexia? We investigate if transgenderism has become a coping mechanism for teens. The Sun. Retrieved from

Kearns, M (2018) Don’t Let Transgender Activists Politicize Child Health Care. National Review. Retrieved from

Kuhn, A et al. (2009) Quality of life 15 years after sex reassignment surgery for transsexualism. Fertil Steril. 92:1685–9.

Littman, L (2018) Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PloS one 13(8): e0202330.

Marchiano, L (2017) Guidance for Parents of Teens with Rapid Onset Gender Dysphoria. Retrieved from

Menvielle, E (2012) A comprehensive program for children with gender variant behaviors and gender identity disorders. Journal of Homosexuality59(3), 357-368.

Olson, J et al. (2015) The Impact of Early Medical Treatment in Transgender Youth. Retrieved from Accessed October 2018.

Olson, J (2017) Deciding when to treat a youth for gender re-assignment.

Olson, K (2016) Prepubescent transgender children: What we do and do not know. Journal of the American Academy of Child & Adolescent Psychiatry55(3), 155-156.

Rafferty, J & Committee on psychosocial aspects of child and family health (2018) Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics, e20182162.

Rayner, G (2018) Minister orders inquiry into 4,000 per cent rise in children wanting to change sex. Retrieved from

Robbins, J (2018) U.S. Doctors Are Performing Mastectomies On Healthy 13-Year-Old Girls. Retrieved from

Singal, J (2016) How the Fight Over Transgender Kids Got a Leading Sex Researcher Fired. New York Magazine.

Singh, D et al. (2011) Commentary on “An Affirmative Intervention for Families with Gender Variant Children: Parental Ratings of Child Mental Health and Gender” by Hill, Menvielle, Sica, and Johnson (2010). Journal of Sex & Marital Therapy,37(2), 151-157. doi:10.1080/0092623x.2011.547362

Simonsen, R et al. (2016) Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality. Nordic journal of psychiatry, 70(4), 241-247.

Smith, A et al. (2018) Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research. Current opinion in psychology22, 63-67.

The Canadian Press (2018) CAMH reaches settlement with former head of gender identity clinic. CBC News Retrieved from

Toward a more nuanced exploration: An interview with Sasha Ayad. (2018) Retrieved from

Twenge, J (2017) Are Smartphones Ruining a Generation? The Atlantic

Wallien, M. & Cohen-Kettenis, P (2008) Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child & Adolescent Psychiatry47(12), 1413-1423.

Wilson, B et al. (2017) Characteristics and Mental Health of Gender Nonconforming Adolescents in California: Findings from the 2015–2016 California Health Interview Survey. The Williams Institute and UCLA Health Center for Health Policy Research

Zucker, K (2018) The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender non-conforming children” by Temple Newhook et al. (2018), International Journal of Transgenderism, 19:2, 231-245.

AAP petition

Attempted suicide by American LGBT adolescents

by Michael Biggs

Michael Biggs is Associate Professor of Sociology at the University of Oxford and Fellow of St Cross College. He researches social movements and collective protest.

Pediatrics just published an article showing that trans-identified children are substantially more likely to report attempted suicide than the general adolescent population. When the results are examined closely, however, we find that the risk extends to kids who identify as lesbian, gay, or bisexual. Emphasis on the exceptional fragility of trans adolescents overlooks the importance of sexual orientation. Indeed, my analysis suggests that gender-nonconforming girls are the most vulnerable, whether they consider themselves to be transgender, bisexual, or lesbian.

Previous evidence on suicide attempts among trans-identified youth has been methodologically flawed, even ignoring the most egregious examples. First, surveys have recruited respondents haphazardly—rather than sampling from a population. Second, respondents have not been asked for their sex, but only for their gender identity. In the United Kingdom, Stonewall’s School Report was marred on both counts.

Toomey, Syvertsen, and Shramko (2018)’s article in Pediatrics provides the first rigorous study of self-reported suicide attempts. They use data on 121,000 adolescents aged from 11 to 19, who were surveyed at schools across the United States. The findings, as reported by LGBTQ magazine The Advocate, are dramatic:


Bear in mind that asking respondents whether they have ever attempted suicide will elicit an overestimate of the actual rate; we know from other studies that more probing questions are needed to distinguish genuine attempts to end life. Therefore we should interpret ‘attempted suicide’ broadly, to include all self-harming behaviors, including those not intended to result in death.

When the original article is examined closely, the results are more complicated than the headline suggests. The authors statistically analyze all the risk factors for attempted suicide, including sex and gender identity, sexual orientation, age, race, and parental education. Surprisingly, perhaps, the biggest single risk factor is actually sexual orientation.

The authors are publishing a companion article on sexual orientation. Until that becomes available, it is possible to estimate (from their Table 2) how the risk of attempted suicide varied according to different combinations of gender identity and sexual orientation—after adjusting for other characteristics like age and race.

The calculation is straightforward for heterosexual, lesbian, gay, and bisexual teens who were not trans-identified. (For simplicity the intermediate categories of ‘mostly heterosexual’ and ‘mostly lesbian or gay’ are omitted.) For each transgender category, I calculate the risk averaged across the observed distribution (from Table 1) of sexual orientations within the category. A caveat is that the these estimates have considerable margin of error because they derive from small numbers: 202 identified as male-to-female, 175 as female-to-male, and 344 as not exclusively male or female (‘nonbinary’ for short). A further 1,052 adolescents were not sure of their gender.


The graph above shows the estimated odds of a student reporting attempted suicide, compared to heterosexual boys. As the Advocate emphasized, teens who identified as female-to-male transgender had the highest risk of attempted suicide; the odds were four times higher than for heterosexual boys. What went unnoticed is that the risk was just as high for bisexual girls.

The next highest rates (triple the odds compared to heterosexual boys) were for bisexual boys, lesbian girls and for kids who identified as nonbinary. The latter’s sex was not recorded, but the majority are likely to be female; other survey evidence suggests that two-thirds of trans-identified adolescents are female (Eisenberg et al. 2017).

The next highest rates (roughly double the odds for heterosexual boys) were for gay boys, for male-to-female transgender kids, and for kids who were unsure of their gender identity (whose sex was not recorded). Finally, heterosexual girls had a significantly higher risk than heterosexual boys.

Stephanie Davies-Arai and Nic Williams’ critique of Stonewall’s School Report suggested that “[t]he ‘transgender’ category may just serve to cover up the scale of suicide attempts and self-harm rates of girls and young women.” Their conjecture is vindicated by this survey evidence from the United States. Over two thirds of the girls who identified as boys were sexually attracted to females (inferred from the proportion calling themselves heterosexual or bisexual), and so arguably are most similar to lesbian and bisexual girls. In sum, then, gender-nonconforming females were the group most likely to report attempted suicide, regardless of whether they identified as male or nonbinary—or as bisexual or lesbian.

James Cantor shreds American Academy of Peds gender-affirmative policy statement

Anyone who is paying attention knows the US holds the dubious distinction of being the world’s incubator for the “gender affirmative” approach. This treatment pathway–increasingly, the only pathway available in the United States–frequently consists of:

  • full social transition for children, starting as young as toddlerhood;
  • cross-sex hormones and even “top” and “bottom” surgeries for young teens, some of whom showed no childhood gender discomfort and only announced a trans identity in adolescence; and
  • affirmation of a child’s trans identity at any age, regardless of other possible causative/related factors (such as autism, social contagion, or same-sex attraction). Some of the more fervent US clinicians eschew careful psychological assessment before they prescribe full social and/or medical transition, asserting that such thorough evaluation is unnecessarily onerous or “triggering” to the young patient.

The American Academy of Pediatrics recently released a policy statement  which essentially rubber-stamps the affirmative approach. (While the Academy itself has tens of thousands of members, a recent article pointed out that the policy document was the work of a very small, activist-inspired subgroup). The AAP document creates the impression that affirmative treatment is a matter of settled clinical consensus.

Nothing could be further from the truth.

The AAP policy has a number of glaring flaws. To take just one example, it omits a significant body of research evidence that is inconvenient to the AAP’s affirmation-only doctrine. Worse: the research the AAP document does cite ironically substantiates the very “watchful waiting” approach dismissed by the AAP. The truth is, this more cautious approach is the most commonly used and evidence-based treatment for childhood gender dysphoria recognized by clinicians around the world.

There’s a lot more to pick apart in the AAP’s policy statement, and James Cantor, PhD., a Toronto-based sexologist, researcher, and clinical psychologist, did just that today. His long (but worth it) fact-checking article is required reading for anyone interested in the topic of pediatric transition.

Please read and share Dr. Cantor’s piece widely. You can read the whole thing here.

Cantor sex today lead aap

There’s a sudden surge of trans students coming out at my college … and I’m scared to talk about it

by Emily Williams

Emily is a 20-year old college junior at a selective liberal arts university in the US. She is using a pseudonym for obvious reasons. All respectful commenters welcome, as always, but if you’re also a college/university student, we’d especially like to hear from you.

I have always been empathetic and sensitive to suffering. From a young age, I remember worrying about families who lost their health insurance, the exploitation of women, and the huge discrepancies of wealth in the world. So when I first heard stories about transgender teens, I was very troubled.

emily college silencedI got my Instagram account when I started high school six years ago. That’s when I started learning about the transgender community. I stumbled across their images without even trying. Most were young, 14 or 15, and laid a tragic narrative of being sickeningly confined to breasts and intolerant parents. Many of these internet strangers used the Instagram platform to connect with other trans youth, share their progress and unhealthy coping mechanisms, and discuss their comorbid mental health issues, such as anxiety, depression, and the fallout from sexual abuse. I did not interact with their posts, but read them out of curiosity and an attempt to understand.

That same year, I met my first real-life transgender person — the first of many. When I started high school, she went by her given name, Ingrid. She had buzzed hair, long winged eyeliner, combat boots, and lots of mini skirts. Clearly aiming to be different and cool. She was a senior, and spent most of her time painting in the art studio. Her look did not change throughout the year, but her name and pronouns did — at some point I began to hear people referring to someone named Diego. Before Diego/Ingrid graduated, s/he gave a presentation on “the transgender experience,” at which s/he defined what it feels like to have gender dysphoria, cited the suicide rate of trans people, and, most memorably, taught us trans etiquette: how to refer to trans people, use pronouns, and to never assume another person’s gender.

Throughout the rest of high school I came across this phenomenon several more times. Many more people I knew by association came out as trans. I heard more and more about trans people in the media (including celebrities like Laverne Cox and Caitlin Jenner), and began to hear LGBT or LGBTQ thrown around a bit more in a political context. I remained empathetic towards those who came out as trans, and tried to remember the politically correct language as best I could, often at the cost of what I had learned to be grammatically correct in my AP English Language class. While I still did not really understand how being or feeling transgender could work, I did not hear anyone else questioning it and felt I could not without offending or being insensitive.

emily college pullquote
But I was not ready for the culture shock of university, a small, selective liberal arts college. On the first day of orientation after moving into my new dorm, we had a floor meeting in which we introduced ourselves by name, location, fun fact, and preferred pronouns. “Remember, you cannot assume ANYONE’S gender identity!”  I felt silly having to tell a room of 40+ people that I prefer she/her pronouns, yet many people, at least five or six, who looked obviously male or female announced that they preferred the opposite pronouns. No one flinched or stuttered or acted like this activity was superfluous–though one international student asked me later, privately, why we had to do that. One person even announced that “some days” she would prefer to be called she, but other days would be going by he. Everyone nodded along, as if, of course, this makes sense.

By one month into my freshman year, the number of trans people I knew personally or by association was growing steadily. The school is small enough that even if you don’t know someone by name, you’ve probably seen them around. There were many boys wearing eyeliner but those were boys. There were girls wearing eyeliner that were also boys. Boys with small beards that were actually girls. And everything in between. One of my roommates started dating a “cis-passing” trans boy. Someone I met at the beginning of the year whose name was Tim would now like me to relearn that name as Rebecca. Someone else who started school with hair to her waist cut it all off and became Andrew. If you can’t determine gender by someone’s appearance, why have gender at all? Why not just call each other by our biology, whether we are happy with it or not, if only for consistency and clarity’s sake? I was trying to be empathetic but it was not easy, and confusing at best. No one said anything skeptical, and neither did I.

Two months into my freshman year, the signs on the bathrooms in an academic building were changed. Rather than being marked for men/women, both bathrooms were now “multi-stall.” The only indication that one was for men was the small print “with urinals,” vs “without urinals.” …

emily college pullquote 2It seemed that most of the students who were suddenly transitioning were biological females who were smart but socially awkward. They revealed their identities as trans men, usually through a haircut and new wardrobe, followed by a Facebook post alerting associates to a name and pronoun change. They would soon take to social media, student forums, and classroom discussions to rant about “cis privilege,” how oppressed they are because they get stared at by strangers, how they want to assault people who misgender them, and how in love with their “queer” identities they are.

A few weeks ago, a research paper was published suggesting that the recent increase in transgender identification among young people is the result of social contagion. This seems obvious to me. Yet officials at Brown University censored this paper. I shouldn’t be surprised. This is a topic that we can’t discuss on my college campus, either.

There is no doubt in my mind that there is a social contagion among college students. At my school, it is trendy to be transgender, and to people who feel like they don’t fit in, particularly with other people of their biological sex, choosing to transition to the opposite sex, and become a member of the opposite sex, may certainly seem like a more viable option than continuing to feel rejected while trying to fit in. But a lot of this culture surrounding trans teens and college students is aggressively narcissistic and cutesy — selfies captioned “i love being nonbinary,” “you’re gay no matter who you date,” and “baby’s first binder!” At best these random, new identities are invented to fit an aesthetic. At worst they are aggressively anti “straight white men,” apparently the worst species on earth and the ones responsible for all hardship, as they threaten professors and other students who dare to hint at an observation that doesn’t sound affirmative of transgender identities.

urinal dressWithin the past year, my second year at this college, I have had girlfriends who had to share a room with a biological male who decided, within the year, to change his name to Valerie. My two friends felt bad for Val, who was clearly socially awkward, had very low self confidence, and was always asking for their approval, (“do you think I look pretty?”). When they said yes of course, to validate Val, Val would reply with “I don’t think so.”

The odd part is that when we apply for housing we are able to select sex segregated or non-gender-based housing. If you select sex segregated as a female, you are paired with females, but if you select non-gender-based housing, you are paired with other people who selected non-gender-based housing, regardless of gender. These two girl friends of mine signed up for sex segregated housing, expecting to be roommates with only other females. Val signed up for non-gendered housing, yet it seems they did not have anyone to pair Val with, and thus decided it would be better to pair a biological male with two girls than two boys.

This is concerning for me, as a feminist. There is a reason why sex-segregated housing exists, and it is not for sexist reasons. Many, even most, women and college-aged girls are not comfortable sharing a room with a man they have never met. While sexual assault can happen in a number of circumstances, forcing women to room with men seems an easy way to increase the possibility. It has been important, historically, that women have spaces that are not open to men, for their own safety.

college piece flagSimilarly, this past year, on the “trans day of visibility,” all of the bathroom signs throughout school were replaced with paper signs that made all of the bathrooms gender neutral. This was done by the campus LGBT club, in order to make straight people get “what it feels like to decide which bathroom to use as a trans person.” I doubt this was accurate though, because I was still caught trying to decide which bathroom would not have men in it. I opted for the bathroom I remembered had been the women’s room, as did most women. One of my directionally challenged girl friends forgot which one it was and picked the men’s. She was immediately embarrassed and confused and went to hunt for the single stall a couple floors up. If our bathrooms were more European-style bathrooms, with floor to ceiling private doors, I would probably mind very little. However, these are cheap stalls that come up to your knees, and in the men’s room of course the urinals are open to all to see. One girl shared with me that she walked into the “women’s” gender neutral bathroom to find one of our younger male professors. She was overwhelmed and went to a different bathroom. She admitted to feeling bad, as she gets the point of gender neutral bathrooms and believes that trans people should be able to use any bathroom, but she just couldn’t bring herself to pee in front of our professor. Understandably.

What has been even more upsetting is to see is how quickly these new identities are accompanied by medical changes. I know several young women who were able to easily access testosterone soon after deciding they were trans. I know four who have had mastectomies. One is currently raising funds for her breast removal as part of  a GoFundMe campaign.

While I have tried my best, and initially succeeded, in believing the narratives of the transgender experience, it struck me at college that this phenomenon is so widespread, so political, and so trendy, that I am now completely dubious. I am not allowed to speak honestly and openly on this subject without being defamed as a conservative, a transphobe, intolerant, and anti-feminist. As someone who is not trans, I am not allowed to think or talk about trans issues unless I am agreeing with a trans person. Because I can’t know what it’s like to feel born in the wrong body.

At the present time, I now know about 30 trans people personally, and another 20 by name. Given that I attend such a small school, this is a very high percentage. Even the RA of my freshman year floor, who introduced herself two years ago with she/her pronouns, now goes by he/him and identifies as a boy.

This issue became personal when my childhood friend announced she is transgender, We played with Barbies and dressed as Disney princesses when we were young. We talked about our crushes on boys, and experimented with makeup and fashion when we were teens. I can’t believe that she really thinks she is a man. She plans to medically transition. I am scared for her.  But I am afraid to say anything.

I find it biologically and statistically improbable that all of these people, born at around the same time, were actually “born in the wrong body.” I find it strange that they think they need hormones and surgery that will sterilize them permanently. What seems obvious to me is that they are uncomfortable with their bodies, suffer from other issues like anxiety and depression,  and see the attention and attractiveness of transition as a way out.

What I don’t understand is why all of my friends act like this is normal. Am I really the only one who has concerns? Or is everyone as scared as I am to say something?