A Plea for Scholarly Dialogue
A Child Psychiatrist Speaks About "Gender Affirming Care"
My name is Kristopher Kaliebe.
I am a board-certified General, Forensic, and Child and Adolescent Psychiatrist and professor in the Psychiatry Department at the University of South Florida.
I have been trying to engage within my professional organizations to increase the rigor of our scholarly dialogue and clinical approach toward treating gender non-conforming and gender dysphoric youth. While psychiatric clinicians have a full range of viewpoints regarding this challenging clinical dilemma, professional organizations have rallied around a single politicized, low-quality approach to care.
They have been actively suppressive of scholarly dialogue, attempting to create a false appearance of consensus.
I am speaking out to inform the public of these realities.
I encourage other psychiatrists to speak up and prompt rigorous dialogue.
"Truth is the daughter of time, not of authority." Francis Bacon, 1620
The American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association years ago placed their institutional credibility behind the speculative concept that the medicalization and affirmation of youth with gender dysphoria is a sound medical practice. Their unwavering institution-wide support has come through press releases1, 2 , Amicus Briefs3, guidelines4, selective publication 5,6 dysfunctional peer review 7 ,8 9, and favorable editorial review in their medical journals10, 11.
These organizations formerly had built their reputations with quality peer review, cautious policy statements, and thoughtful practice guidelines. They had typically erred on the side of caution in the face of unproven novel treatments, such as miracle cures for autism, or areas of opaque risk, such as children’s adoption of new technologies.
The general public should know that these organizations' endorsement of medicalized and affirmative treatments for gender dysphoria in minors came without the knowledge or consent of most members. Articles from the Netherlands reporting positive results with rigorously selected cohorts in a multidisciplinary program prompted other groups to attempt puberty blockers in gender dysphoric youth 12, 13. Yet these studies have been heavily criticized for opaque presentation of data, loss to follow up, and methodological limitations, including lack of a control group14, 15.
Within these organizations' medical journals, there has never been open scholarly discussion detailing the most consequential and unsettled clinical questions regarding hormonal or surgical treatments for minors with gender dysphoria.
For instance, there have been no articles detailing what specific factors clinicians should use to determine the odds that an adolescent will continue to have gender dysphoria after completing puberty. Nor have these journals hosted details of why they believe they can generalize results from the narrow population treated in the Dutch protocol to the dissimilar cohort at gender clinics in America.
Concerns about the over-generalization of results to different populations are critical in light of England’s Tavistock clinic's failed attempt to replicate the Dutch studies 16 ,17.
The most likely explanation for these organizations’ missteps is that gender medicine enthusiasts convinced the already politicized leadership to support a simple, moralized narrative: medicalized and affirmative treatments are evidence-based and life-saving. The AAP policy statement frames resistance to puberty blockers, hormones, or surgeries as discrimination or adherence to disproven and outdated approaches such as watchful waiting. AAP ratifying this document indicated it was willing to tribalize a complex clinical dilemma and was not interested in engaging with good-faith scholarly skepticism.
These organizations enforced the gender dogma so rigidly that questioning or exploring a child’s newly adopted gender identity is demeaned as "reparative therapy" or "conversion therapy," terms previously understood to denote a discredited and often punitive attempt to change someone’s same-sex orientation to heterosexual. The organizations have repeatedly made claims that efforts to help youth come to accept their biological sex are harmful, but cite no research, only other authorities to make this claim18.
They can't cite such research because no such evidence of harm exists.
The medical organizations’ support for medicalization and mandatory gender affirmation occurred as the number of children reporting gender dysphoria exploded. Medical authority’s enthusiasm for medical treatment was likely one iatrogenic factor leading to the increased desire for hormones and surgeries.
Why did medical organizations exaggerate the evidence and adopt what now appear to be harmful policies?
Jonathan Haidt coined the apt term “structural stupidity.”
"In the 20th century, America built the most capable knowledge-producing institutions in human history… In the past decade, they got stupider en masse." 19
Haidt does not imply this “stupidity” is about individual intelligence but rather the dysfunctional group-think that results from the illiberal policies that squash scholarly dialogue and prioritize political advocacy over science.
Over the decades, academia has trended leftward.
The resultant hegemony within academia increased tribalism and enforced groupthink20. The dysfunction undermining the credibility of much of the social sciences has brought low-quality scholarship and culturally enforced adherence to political narratives into medicine. The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association have made no effort to hide they are openly political and skew leftward.
In my experience, this politicization originates more from the leadership than the busy and competent clinician members. The administration of professional organizations comes from academia or is run by professional bureaucrats. This leadership is out of touch with typical Americans and clinical medicine. They spend time in elite universities where cultivating a partisan progressive image can be perceived as virtuous and sophisticated.
Meanwhile, online gender activists have been able to weaponize harassment, which further distorts the academic dialogue by silencing the skeptical majority of clinicians. Trans activists accept no opposition as good faith, even as accusing the detransitioners of being "shills" and props for a right-wing agenda.
Dogma rather than nuance became the gender medicine story: pioneering physicians heroically saving transgender children. The story is also that evil transphobes want to restrict life-saving puberty blockers, hormones, and surgeries. Never mind the numerous feminists and left-wing physicians and therapists opposing affirmative care. The political left and much of the establishment media have fallen in love with this good vs. evil tribal story. It generates outrage, garners clicks, sells papers, and ramps up donations to activist causes. These various dynamics together enabled the structural stupidity that accomplished the ideological capture of the medical establishment.
This moralized fable regarding affirmative care for children and adolescents worked to silence debate within medicine for a few years. Over time, the story fell apart. No one who has read Jamie Reed's affidavit 21 or Hannah Barnes's "Time to Think” can deny harm has been done.
Many of us in medicine have been waiting for our professional organizations to self-correct. They seem to be digging in even more, refusing to platform free-thinking scholars or respond to member concerns (22,23). Professional medical organizations are destroying their reputations, which is terrible because of their essential role in our medical ecosystem. Their exaggerated support is consequential because they may have sponsored a medical scandal harming many children, adolescents, and young adults.
Yes, we need to change course regarding affirmative care based on wherever the evidence takes us. Yet the bigger problem is the structural stupidity in organized medicine. We need significant reforms to achieve the only proper solution: a culture and institutions prioritizing open, rigorous, and scholarly debate on the merits of medicalized and affirmative approaches to gender dysphoria in children and adolescents.
Until that debate occurs, the public should realize that these organizations are substituting their reputational authority for precise, compelling data supporting the most invasive intervention within mental health treatment. As Francis Bacon noted four centuries ago, time will expose the truth.
Kristopher Kaliebe MD is a Professor of Psychiatry at University of South Florida, in Tampa Florida. He is Board Certified in Psychiatry, Child and Adolescent Psychiatry and Forensic Psychiatry. He is a Distinguished Fellow at the American Academy of Child and Adolescent Psychiatry (AACAP). From 2013-2021 he served as co-chair of AACAP’s Media Committee.
His clinical work has been primarily in University clinics, Federally Qualified Health Centers and juvenile corrections. At USF Dr. Kaliebe instructs medical students, psychiatry residents and child and adolescent psychiatry fellows and forensic psychiatry fellows. Dr. Kaliebe co-leads the resident training track in Integrative Psychiatry in association with the Andrew Weil Center for Integrative Medicine.
Dr. Kaliebe’s publications and presentations include the effects of digital technologies, psychotherapy, mind-body medicine, nutrition, and mental health in primary care settings.
Dr. Kaliebe is a bibliophile and empirical skeptic. As such he is concerned about naïve interventionalism in medicine via over diagnosis and over-treatment. Dr. Kaliebe aspires to stay consistent with nutritious movement and spending time in nature.
Notes:
1
2, 3
American Academy of Pediatrics and other Amicus Briefs available online at https://downloads.aap.org/DOFA/AmicusBriefARtransgenderlaw.pdf
4
Rafferty J; Committee On Psychosocial Aspects Of Child And Family Health; Committee On Adolescence; Section On Lesbian, Gay, Bi-Sexual, And Transgender Health And Wellness. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018 Oct;142(4):e20182162. doi: 10.1542/peds.2018-2162. Epub 2018 Sep 17. PMID: 30224363. https://pubmed.ncbi.nlm.nih.gov/30224363/
5,6
Biggs, M. (2022). Turban et al.’s incredible assumptions about sex. file:///C:/Users/krisk/Downloads/Turban_jumps_the_shark%20(1).pdf
D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D. T., & Clarke, P. (2021). One size does not fit all: In support of psychotherapy for gender dysphoria. Archives of Sexual Behavior, 50(1), 7-16. https://pubmed.ncbi.nlm.nih.gov/33089441/
7,8
Bränström, R., & Pachankis, J. E. (2020). Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. American journal of psychiatry, 177(8), 727-734. https://pubmed.ncbi.nlm.nih.gov/31581798/
Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145, e20191725. https://pubmed.ncbi.nlm.nih.gov/31974216/
Turban, J. L., Dolotina, B., King, D., & Keuroghlian, A. S. (2022). Sex assigned at birth ratio among transgender and gender diverse adolescents in the United States. Pediatrics, 150(3), e2022056567. https://pubmed.ncbi.nlm.nih.gov/35918512/
9, 10
Dixon, M. et al. Let's Talk Gender: Ten Things Transgender and Nonbinary Youth Want All Researchers to Know Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 61, Issue 8, 960 – 96 (2022) https://pubmed.ncbi.nlm.nih.gov/34990762/
Turban, Jack et al. (2017) Ten Things Transgender and Gender Non-conforming Youth Want Their Doctors to Know. Journal of the American Academy of Child & Adolescent Psychiatry, Vol 56, Issue 4, 275 – 277 https://pubmed.ncbi.nlm.nih.gov/28335868/
11, 12, 13
de Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. The journal of sexual medicine, 8(8), 2276–2283. https://pubmed.ncbi.nlm.nih.gov/20646177/
de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704. https://pubmed.ncbi.nlm.nih.gov/25201798/
14, 15
Barnes, H. (2023). Time to Think: The Inside Story of the Collapse of the Tavistock's Gender Service for Children. Swift Press. https://www.amazon.com/Time-Think-Collapse-Tavistocks-Children-ebook/dp/B0BCL1T2XN
16,17
Abbruzzese, E., Levine, S. B., & Mason, J. W. (2022). The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed. Journal of Sex & Marital Therapy, 1-27. https://pubmed.ncbi.nlm.nih.gov/36593754/
Biggs, M. (2022). The Dutch protocol for Juvenile transsexuals: Origins and evidence. Journal of sex & marital therapy, 1-21. https://pubmed.ncbi.nlm.nih.gov/36120756/
18
AACAP policy statement on Conversion therapy. https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx
19
Jonathan Haidt, The Atlantic April 11, 2022 https://www.theatlantic.com/magazine/archive/2022/05/social-media-democracy-trust-babel/629369/
20
Bindewald, B., & Hawkins, J. (2021). Speech and inquiry in public institutions of higher education: Navigating ethical and epistemological challenges. Educational Philosophy and Theory, 53(11), 1074-1085. https://www.tandfonline.com/doi/full/10.1080/00131857.2020.1773794
21
https://ago.mo.gov/docs/default-source/press-releases/2-07-2023-reed-affidavit---signed.pdf
22, 23
Mason, Julia and Sapir, Leor. The American Academy of Pediatrics’ Dubious Transgender Science, Wall Street Journal, Aug. 17, 2022
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Wow. Bravo, Dr. Kaliebe! This a very thoughtful piece, and incredibly brave of you to write. (I wish that weren’t the case - it shouldn’t be.)
As someone who trained in child psychology 2002-2010 and then was out of practice for a decade, it’s been simply stunning (whiplash, really!), to see the changes in our professions on this particular issue. Diagnoses, formulations, and treatment approaches have always changed over time, of course (from Freud to behaviorism being the prototypical example!), but this has been a particularly rapid swing of the pendulum. I do hope we’ve reached peak and are beginning to swing back towards the moderate middle (where most all “right answers” regarding complex human beings reside, IMHO!)
Thank you for writing this!