Former Dean of Harvard Medical School Criticizes Brown University’s Actions Regarding Gender Dysphoria Study

At Quillette, former Dean of Harvard’s Medical School Jeffrey Flier provides a scathing review of Brown University’s lack of support for Assistant Professor Lisa Littman and her study of rapid onset gender dysphoria (see my summary of this issue). Setting the stage for his review, Flier makes it clear that this issue is relevant to academic freedom for all:

This week’s controversy surrounding an academic paper on gender dysphoria published by Brown University assistant professor Lisa Littman—brought on by the post-publication questioning of Dr Littman’s scholarship by both the journal that published it, PLOS One, and Brown’s own School of Public Health—raises serious concerns about the ability of all academics to conduct research on controversial topics.

Flier spends the bulk of his article taking apart Brown University’s rationale for removing their press release about Littman’s PLOS One paper.  He then concludes with this stinging call for a defense of academic freedom:

At a time such as this, when a university’s academic mandate is under threat from diverse ideological actors, there is simply no substitute for a strong leader who supports academic freedom and discourse. The dean’s letter raises serious questions about whether the dean of Brown’s School of Public Health is willing to be such a leader.

For centuries, universities struggled to protect the ability of their faculties to conduct research seen as offensive—whether by the church, the state, or other powerful influences. Their success in this regard represents one of the great intellectual triumphs of modern times, one that sits at the foundation of liberal societies. This is why the stakes are high at Brown University. Its leaders must not allow any single politically charged issue—including gender dysphoria—from becoming the thin edge of a wedge that gradually undermines our precious, hard-won academic freedoms.

I certainly agree. There is a process for bringing research to the community of scholars and Littman followed it. Brown’s administrators should stand for the principle of academic freedom by leaving up the press release. The study can easily be criticized but at the same time it is similar to many pilot studies of hidden populations. Unless some kind of academic misconduct is found, Brown University should defend the work of this professor.

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Regret in Medical Transition: Research from the Amsterdam Gender Dysphoria Study

One of the significant issues in treating gender dysphoria is an examination of regret, if any, experienced by patients who engage in surgical interventions. In a remarkable paper published recently in The Journal of Sexual Medicine, a report of cases seen from 1972-2015 in the largest gender identity clinic in Amsterdam is presented. The sample was large and as a group showed very little regret.

6,793 people (4,432 birth-assigned male, 2,361 birth-assigned female) visited our gender identity clinic from 1972 through 2015. The number of people assessed per year increased 20-fold from 34 in 1980 to 686 in 2015. The estimated prevalence in the Netherlands in 2015 was 1:3,800 for men (transwomen) and 1:5,200 for women (transmen)*. The percentage of people who started HT within 5 years after the 1st visit decreased over time, with almost 90% in 1980 to 65% in 2010. The percentage of people who underwent gonadectomy within 5 years after starting HT remained stable over time (74.7% of transwomen and 83.8% of transmen). Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret.

The idea that regret is common is promoted by Christians who disapprove of gender transition.*** One such website “Sex Change Regret” (sexchangeregret.com) carries articles by Ryan Anderson, Walt Heyer, and Michelle Cretella.** Whether one agrees with transition or not, one should not promote a tendentious reading of research to promote one’s views. While a very small number of people have expressed regret, most don’t. In this study, some experienced social losses after transition, while others did not experience relief from their dysphoria.
If anything, the appropriate stance for a Christian is love and curiosity. Let’s keep our minds and hearts open.
**UPDATE:
After I published this post, Ryan Anderson took exception with my characterization of his position. See his tweet below:


Although Anderson quoted Walt Heyer’s article Regret Isn’t Rare in his new book When Harry Became Sally, I removed this phrase in the post:

all of whom promote the idea that regret is may be widespread

Anderson denies that he believes anything about regret. I also asked him to characterize his position which I will include in a separate post. There was no intent to misrepresent him. Given the section in his book on the subject of regret, his approving citation of Walt Heyer, and an essay in the Daily Signal, I felt I fairly and non-controversially represented his position.
 
*In the study, the authors defined “transwomen as having a male birth assignment and transmen as having a female birth assignment who might receive medical treatment to adapt their physical characteristics to their experienced gender.”
***edited to change “disapprove of transgender people” to “disapprove of gender transition.” To transgender people, there is little difference, but to be as fair as possible to those who have moral misgivings about transitioning, I made the change.

Some Reactions to the Nashville Statement

Nashville logoThis week the Council on Biblical Manhood and Womanhood released a series of affirmations and denials regarding human sexuality and gender. Titled the Nashville Statement, the document was signed by a group of conservative theologians, professors, and pastors. The statement trended on Twitter and has led to numerous blog posts and news articles.  In this post, I will link to three of them and then provide a few reactions to aspects of the statement. If you haven’t read the statement, you should do so before reading the rest of the post.

The Statement Gets Ahead of Science

Mark Yarhouse, my partner in the development of the sexual identity framework, weighed in and asserted that the dogmatic assertions in the statement are far ahead of the data on gender dysphoria. Here is a sample from his post, On the Nashville Statement:

When I wrote Understanding Gender Dysphoria, which was published in 2015, I noted that transgender presentations were a wave that was going to crest on evangelicals and that the church was not prepared for it. I noted that we needed to think deeply and well about gender identity and to engage with some humility what we know and do not know from the best of science, as well as learn from mistakes made in how evangelicals engaged the topic of sexual identity and especially how evangelicals treated the actual people who were navigating sexual identity and faith. I was suggesting we could learn from that experience and make some adjustments as we encounter the topic of gender identity.
I’m afraid the Nashville Statement, perhaps out of a desire to establish the parameters for orthodoxy on gender identity concerns, gets ahead of evangelicals because it doesn’t reflect the careful, nuanced reflection needed to guide Christians toward critical engagement of gender theory, while also aiding in the development of more flexible postures needed in pastoral care.

An Unhelpful Exclusive Statement

Historian Chris Gehrz had a somewhat stronger post at the Pietist Schoolman. He writes for those who feel in the middle on GLBT issues. Here is a sample:

But then the Nashville Statement doesn’t allow for the possibility of Christians disagreeing on such issues. I’m sure anyone paying any attention already knew what these authors and signers thought about sexuality and gender identity. If that’s all it addressed, I’d just try to ignore the statement. But then there’s Article 10…
We affirm that it is sinful to approve of homosexual immorality or transgenderism and that such approval constitutes an essential departure from Christian faithfulness and witness.
We deny that the approval of homosexual immorality or transgenderism is a matter of moral indifference about which otherwise faithful Christians should agree to disagree.
Wait, so… Is salvation at stake for queer Christians and their supporters? Is there to be any continuing communion or collaboration with those who have departed “from Christian faithfulness”? And are those of us who do think it’s possible to agree to disagree also making such a “departure”?

Gehrz also sees the statement as a Trump-like expression which trolls the gay affirming crowd and affirms those who oppose gay rights.

Nor that the authors have chosen to condemn “transgenderism” just days after Pres. Trump began to implement a ban on transgender persons serving in the military, only feeding the perception that whatever daylight separates Trumpism and evangelicalism is vanishing. (After all, that ban was reportedly discussed with Trump’s much-maligned evangelical advisers before he first tweeted his intentions last month.)
The Nashville Statement strikes me as theology for the Age of Trump because it’s being thrust into social media for little purpose other than to energize allies and troll enemies — distracting our attention from more pressing problems in order to demonize minorities whose existence causes anxiety among the many in the majority.

All Words and No Words-Made-Flesh

Although opposed to the statement, Jonathan Merritt doesn’t think it will have much effect. Writing at Religion News Service, Merritt says:

When it comes to issues of sexuality and gender, a statement like this is unlikely to move the needle with those who aren’t already in agreement. It is all head and no heart. It speaks to your mind but fails to look you in the eyes. It is intellectual, but not pastoral. It dialogues about people, rather than with them. It acknowledges the theology of these issues but never the humanity. It is all words and no word-made-flesh.
So progressives who hope for change should take a deep breath and stay the course. Keep comforting your friends. Keep making space for those whom others refuse to welcome. Keep loving your neighbors, and don’t forget that these signers are your neighbors, too.
Like so many before it, this statement won’t change anything. But if you keep leading with love, you can change everything. Proclamations don’t shape history; people do.

Bad Timing

Generally, I think the timing of the statement was poor. In the midst of an epic natural disaster and the national conversation on racism, a document which singles out a minority doesn’t seem wise. I suppose the reaction would have been negative at any time, but I think some of the intense negative reaction relates to increased awareness of the document this week.

Some Additional Reactions

While I don’t have reactions to all 14 articles, I will provide a few additional thoughts.
I was intrigued by the inclusion of Article VI:

WE AFFIRM that those born with a physical disorder of sex development are created in the image of God and have dignity and worth equal to all other image-bearers. They are acknowledged by our Lord Jesus in his words about “eunuchs who were born that way from their mother’s womb.” With all others they are welcome as faithful followers of Jesus Christ and should embrace their biological sex insofar as it may be known.
WE DENY that ambiguities related to a person’s biological sex render one incapable of living a fruitful life in joyful obedience to Christ.

I see it as a plus that the statement recognizes disorders of sex development (once commonly referred to as “intersex” conditions). However, I think the statement could have gone further to wrestle with the implications of what Jesus said as recorded in Matthew 19: 11-12.

11 Jesus replied, “Not everyone can accept this word, but only those to whom it has been given. 12 For there are eunuchs who were born that way, and there are eunuchs who have been made eunuchs by others—and there are those who choose to live like eunuchs for the sake of the kingdom of heaven. The one who can accept this should accept it.”

I realize I am a layman but this sounds like a recognition that the rules are different for some people. Not everybody is going to get married and not everyone has the requisite interests for heterosexual marriage. Jesus said so without condemning them. Some scholars have amassed linguistic evidence which suggests a eunuch could include persons who do not have inclination for opposite sex relations, such as gays and lesbians.
Practically, the Nashville signers don’t give us a clue how people Jesus referred to here can “embrace their biological sex.” Referring to GLBT people, I don’t know what that means. The Nashville statement certainly goes beyond Jesus’ words in Matthew 19. Given that the teaching from Jesus is pretty slim on this point and the Nashville Statement is vague in guiding “eunuchs,” I strongly disagree with the Nashville Statement’s Article 10 which states:

WE AFFIRM that it is sinful to approve of homosexual immorality or transgenderism and that such approval constitutes an essential departure from Christian faithfulness and witness.
WE DENY that the approval of homosexual immorality or transgenderism is a matter of moral indifference about which otherwise faithful Christians should agree to disagree.

As Mark Yarhouse said in his post, this statement is way out in front of what we know for sure. I will add that for “eunuchs” however defined, the statement is vague and severely limits sincere differences of interpretation and opinion among people who are orthodox. On that basis alone, I think the CBMW should go back to the drawing board.
Along similar lines, I think Articles 4, 12, and 13 may be at odds with existing research on gender differences and sexual orientation. For instance, Articles 12 and 13 sound like a theological statement of religiously-based reparative therapy which does not work to eradicate (“put to death”) attraction to the same sex.
Article 4 speaks of “divinely ordained differences between men and women.” What are those differences? While there are real differences which show up in research studies, the list of them would differ significantly from church to church and denomination to denomination. The lack of clarity invites abuse and misunderstanding.
Finally, I think Jonathan Merritt is probably correct that the conflict will die down and the statement will become a short hand for those who signed it but accomplish little else.
 
 

Information and Misinformation on Gender Dysphoria from Wallbuilders and the American College of Pediatricians, Part One

Tuesday on Wallbuilders Live, Dr. Michelle Cretella represented tiny pediatric breakaway group the American College of Pediatricians. She briefly discussed the organization’s position paper on responding to gender identity issues. In doing so, she said something which caught my irony sensor. It also occurred to me, as it repeatedly has in the discussion of gender dysphoria, how difficult it is to avoid taking extreme positions.
Listen to her response to a question from host Rick Green about how much harm gender dysphoria is causing.

I want to address two claims that came up in this segment. In this post, I address the claim that 80% of gender dysphoric children will accept their biological sex with therapy. In a future post, I will write about the claim about suicide rates.
Cretella says:

They’re [advocates for transgender children] cooperating with, at least, mental confusion.  You know, initially, we know that there is psychiatric literature that shows if you work with these children one on one and with their families, the vast majority, over 80% will come to accept their biological sex after puberty before adulthood. So yes, to put these children to reaffirm their confused thinking, to put them on puberty blockers, and then cross-sex hormones to make them quote unquote the other gender, you are permanently sterilizing children. It’s insanity.

Cretella is correct that persistence rates are low (gender dysphoria continuing into adulthood) among gender dysphoric children, but this is not the case with adolescents who remain gender dysphoric or those who experience it with an adolescent onset. In their paper, ACP uses the American Psychiatric Association’s DSM-V as an authority. The section of the DSM-V cited by ACP supports the claim about persistence but does not fully support Cretella’s claim about the role of therapy.

Rates of persistence of gender dysphoria from childhood into adolescence or adulthood vary. In natal males, persistence has ranged from 2.2% to 30%. In natal females, persistence has ranged from 12% to 50%. Persistence of gender dysphoria is modestly correlated with dimensional measures of severity ascertained at the time of a childhood baseline assessment. In one sample of natal males, lower socioeconomic background was also modestly correlated with persistence. It is unclear if particular therapeutic approaches to gender dysphoria in children are related to rates of long-term persistence. Extant follow-up samples consisted of children receiving no formal therapeutic intervention or receiving therapeutic interventions of various types, ranging from active efforts to reduce gender dysphoria to a more neutral, “watchful waiting” approach. It is unclear if children “encouraged” or supported to live socially in the desired gender will show higher rates of persistence, since such children have not yet been followed longitudinally in a systematic manner. For both natal male and female children showing persistence, almost all are sexually attracted to individuals of their natal sex. For natal male children whose gender dysphoria does not persist, the majority are androphilic (sexually attracted to males) and often self-identify as gay or homosexual (ranging from 63% to 100%). In natal female children whose gender dysphoria does not persist, the percentage who are gynephilic (sexually attracted to females) and self-identify as lesbian is lower (ranging from 32% to 50%). (APA, DSM-V, p. 455)

To the DSM-V, I can add the description of persistence developed by the World Professional Association for Transgender Health (WPATH) in their standards of care.

An important difference between gender dysphoric children and adolescents is in the proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood does not inevitably continue into adulthood.V Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6–23% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12–27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008).
In contrast, the persistence of gender dysphoria into adulthood appears to be much higher for adolescents. No formal prospective studies exist. However, in a follow-up study of 70 adolescents who were diagnosed with gender dysphoria and given puberty-suppressing hormones, all continued with actual sex reassignment, beginning with feminizing/masculinizing hormone therapy (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2010).
Another difference between gender dysphoric children and adolescents is in the sex ratios for each age group. In clinically referred, gender dysphoric children under age 12, the male/female ratio ranges from 6:1 to 3:1 (Zucker, 2004). In clinically referred, gender dysphoric adolescents older than age 12, the male/female ratio is close to 1:1 (Cohen-Kettenis & Pfäfflin, 2003). (WPATH, p. 11).

The irony of Cretella’s confidence in psychiatric intervention relates to the expulsion from ACP membership of George Rekers who was infamous for his own personal decline and his discredited treatment approach to what was then called gender identity disorder. In fact, we don’t know the role, if any, therapy plays in influencing the current persistence rates. While there is reason to think parental permission to transition in childhood might increase the persistence rates, there isn’t sufficient research to say for sure.
After listening to Cretella and reading the ACP paper, I wonder what the ACP recommends for the 10-20% of people with gender dysphoria persisting into the late teens. Do they favor reassignment for those persons? They focus on the data which make their point but don’t seem to have an answer for the rest of the people involved.
Another problem with ACP’s confidence in psychiatric interventions for gender dysphoria is that they also oppose a frequent end point in the trajectory of many gender dysphoric children: homosexuality (see image at the end of the post). One of the reasons George Rekers tried to re-orient gender dysphoria was to prevent homosexuality. Furthermore, one of the prime objectives of reparative therapists like Joseph Nicolosi is to prevent homosexuality via the alteration of parenting behaviors toward gender nonconforming children. ACP should stop pretending to sympathize with gender dysphoric children when they also write letters to school personnel promoting reparative change therapy for gay people.
Summary
Cretella is right that studies of gender dysphoric children (mostly with boys) find low rates of persistence of gender dysphoria into adulthood. However, she should have distinguished between prepubescent children and teens. The outcomes for these two groups do not appear to be the same. No doubt her listeners will not make that distinction.
Cretella was wrong to invoke psychiatric treatment as the reason for low persistence rates. If anything, some treatments have been shown to be harmful in some cases while others may not be harmful but may not cause a reduction in gender dysphoria. From her presentation, one could get the impression that advocates for gender dysphoric children know these treatments work but are motivated to undermine the natural family and therefore withhold appropriate medical care. While there is strong disagreement among experts and some advocates might oppose traditional families, it is simply not true that gender dysphoria could be easily treated if only activists would get out of the way.
Another important factor is that the treatment advocated by Cretella and the ACP is an outdated, discredited, psychoanalytically based approach which has not shown success. Even among those in the mainstream who are skeptical of puberty blocking drugs, the treatments advocated by ACP are rejected.
Gender Dysphoria After Childhood
The following image comes from a 2012 study by Devita Singh on gender dysphoric boys. Note the columns titled “sexual orientation in fantasy” and “sexual orientation in behavior.” By far, the most common end point for gender dysphoric children across studies is some level of same sex attraction. Gay advocates have in the past confided to me that they are ambivalent about supporting interruption of puberty because such interventions may interfere with a natural homosexual outcome. Please see this common sense article by Michael Bailey and Eric Vilain on the dilemma many parents of gender dysphoric children face.
Singh table