Freedom of Speech and Gender-Affirming Care

Blue Hill is a small idyllic town a little less than two and a half hours Down East the coast from where I am sitting here in Harpswell. Thanks to gentrification it tends to lean left politically, but like the rest of Maine most folks in the surrounding communities often don’t know or care much about their neighbor’s party affiliation. Its library, founded in 1796, is well funded and a source of civic pride.

One day a couple of years ago, the library director received a donated book from a patron. Although he personally didn’t agree with the book’s message, he felt it deserved a space in their collection dealing with the subject. What happened in the wake of this donation is an ugly tale. Some community members objected to the book and asked that it be removed from the shelves, or at least kept under the desk and loaned out only on request.

The objectors, many of whom knew the director, were confrontational. The collections committee unanimously supported his decision. Some committee members also received similar responses from community members. Remember, this is a small town.

A request for support sent to the American Library Association was basically ignored. Over the next 2 years things have quieted, but fractured friendships and relationships in this quiet coastal Maine town have not been repaired. However, as the librarian has observed, “intellectual freedom or the freedom of speech isn’t there just to protect the ideas that we like.”

While the title of the book may feel inflammatory to some, every publisher hopes to grab the market’s attention with a hot title. The cause of this sad situation in Blue Hill was not a white supremacist’s polemic offering specific ways to create genocide. This was a book suggesting that gender dysphoria presenting in adolescence may have multiple causes and raises concerns about the wisdom of the pace of some gender-affirming care.

Clearly the topic of gender dysphoria in adolescence has become a third rail that must be approached with caution or completely avoided. A recent opinion piece in the New York Times provides even more concerning examples of this peril. Again, the eye-catching title of the article — As Kids, They Thought They Were Trans. They No Longer Do — draws in the audience eager to read about some unfortunate individuals who have regretted their decision to transition and are now detransitioning.

If you are interested in hearing anecdotal evidence and opinions supporting the notion that there is such a thing as rapid-onset gender dysphoria, I suggest you read the entire piece. However, the article’s most troubling message for me comes when I read about the professionals who were former gender-related care providers who left the field because of “pushback, the accusations of being transphobic, from being pro-assessment and wanting a more thorough process.”

One therapist trained in gender-affirming care who began to have doubts about the model and spoke out in favor of a more measured approach was investigated by her licensing board after transgender advocates threatened to report her. Ultimately, her case was dismissed, but she continues to fear for her safety.

Gender-related healthcare is another sad example of how in this country it is the noise coming from the advocates on the extremes of the issue that is drowning out the “vast ideological middle” that is seeking civil and rational discussions.

In this situation there are those who want to make it illegal for the healthcare providers to help patients who might benefit from transitioning. On the other end of the spectrum are those advocates who are unwilling to acknowledge that there may be some adolescents with what has been called by some “rapid-onset gender dysphoria.”

The landscape on which this tragedy is being played out is changing so quickly that there will be no correct answers in the short term. There just isn’t enough data. However, there is enough anecdotal evidence from professionals who were and still are practicing gender-related care to raise a concern that something is happening in the adolescent population that suggests some individuals with gender dysphoria should be managed in a different way than the currently accepted gender-affirming model. The size of this subgroup is up for debate and we may never learn it because of reporting bias and privacy concerns.

The American Academy of Pediatrics has recently authorized a systematic review of gender-affirming care. I hope that, like the librarian in Blue Hill, it will have the courage to include all the evidence available even though, as we have seen here in Maine, some of it may spark a firestorm of vehement responses.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Blue Hill is a small idyllic town a little less than two and a half hours Down East the coast from where I am sitting here in Harpswell. Thanks to gentrification it tends to lean left politically, but like the rest of Maine most folks in the surrounding communities often don’t know or care much about their neighbor’s party affiliation. Its library, founded in 1796, is well funded and a source of civic pride.

One day a couple of years ago, the library director received a donated book from a patron. Although he personally didn’t agree with the book’s message, he felt it deserved a space in their collection dealing with the subject. What happened in the wake of this donation is an ugly tale. Some community members objected to the book and asked that it be removed from the shelves, or at least kept under the desk and loaned out only on request.

The objectors, many of whom knew the director, were confrontational. The collections committee unanimously supported his decision. Some committee members also received similar responses from community members. Remember, this is a small town.

A request for support sent to the American Library Association was basically ignored. Over the next 2 years things have quieted, but fractured friendships and relationships in this quiet coastal Maine town have not been repaired. However, as the librarian has observed, “intellectual freedom or the freedom of speech isn’t there just to protect the ideas that we like.”

While the title of the book may feel inflammatory to some, every publisher hopes to grab the market’s attention with a hot title. The cause of this sad situation in Blue Hill was not a white supremacist’s polemic offering specific ways to create genocide. This was a book suggesting that gender dysphoria presenting in adolescence may have multiple causes and raises concerns about the wisdom of the pace of some gender-affirming care.

Clearly the topic of gender dysphoria in adolescence has become a third rail that must be approached with caution or completely avoided. A recent opinion piece in the New York Times provides even more concerning examples of this peril. Again, the eye-catching title of the article — As Kids, They Thought They Were Trans. They No Longer Do — draws in the audience eager to read about some unfortunate individuals who have regretted their decision to transition and are now detransitioning.

If you are interested in hearing anecdotal evidence and opinions supporting the notion that there is such a thing as rapid-onset gender dysphoria, I suggest you read the entire piece. However, the article’s most troubling message for me comes when I read about the professionals who were former gender-related care providers who left the field because of “pushback, the accusations of being transphobic, from being pro-assessment and wanting a more thorough process.”

One therapist trained in gender-affirming care who began to have doubts about the model and spoke out in favor of a more measured approach was investigated by her licensing board after transgender advocates threatened to report her. Ultimately, her case was dismissed, but she continues to fear for her safety.

Gender-related healthcare is another sad example of how in this country it is the noise coming from the advocates on the extremes of the issue that is drowning out the “vast ideological middle” that is seeking civil and rational discussions.

In this situation there are those who want to make it illegal for the healthcare providers to help patients who might benefit from transitioning. On the other end of the spectrum are those advocates who are unwilling to acknowledge that there may be some adolescents with what has been called by some “rapid-onset gender dysphoria.”

The landscape on which this tragedy is being played out is changing so quickly that there will be no correct answers in the short term. There just isn’t enough data. However, there is enough anecdotal evidence from professionals who were and still are practicing gender-related care to raise a concern that something is happening in the adolescent population that suggests some individuals with gender dysphoria should be managed in a different way than the currently accepted gender-affirming model. The size of this subgroup is up for debate and we may never learn it because of reporting bias and privacy concerns.

The American Academy of Pediatrics has recently authorized a systematic review of gender-affirming care. I hope that, like the librarian in Blue Hill, it will have the courage to include all the evidence available even though, as we have seen here in Maine, some of it may spark a firestorm of vehement responses.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Blue Hill is a small idyllic town a little less than two and a half hours Down East the coast from where I am sitting here in Harpswell. Thanks to gentrification it tends to lean left politically, but like the rest of Maine most folks in the surrounding communities often don’t know or care much about their neighbor’s party affiliation. Its library, founded in 1796, is well funded and a source of civic pride.

One day a couple of years ago, the library director received a donated book from a patron. Although he personally didn’t agree with the book’s message, he felt it deserved a space in their collection dealing with the subject. What happened in the wake of this donation is an ugly tale. Some community members objected to the book and asked that it be removed from the shelves, or at least kept under the desk and loaned out only on request.

The objectors, many of whom knew the director, were confrontational. The collections committee unanimously supported his decision. Some committee members also received similar responses from community members. Remember, this is a small town.

A request for support sent to the American Library Association was basically ignored. Over the next 2 years things have quieted, but fractured friendships and relationships in this quiet coastal Maine town have not been repaired. However, as the librarian has observed, “intellectual freedom or the freedom of speech isn’t there just to protect the ideas that we like.”

While the title of the book may feel inflammatory to some, every publisher hopes to grab the market’s attention with a hot title. The cause of this sad situation in Blue Hill was not a white supremacist’s polemic offering specific ways to create genocide. This was a book suggesting that gender dysphoria presenting in adolescence may have multiple causes and raises concerns about the wisdom of the pace of some gender-affirming care.

Clearly the topic of gender dysphoria in adolescence has become a third rail that must be approached with caution or completely avoided. A recent opinion piece in the New York Times provides even more concerning examples of this peril. Again, the eye-catching title of the article — As Kids, They Thought They Were Trans. They No Longer Do — draws in the audience eager to read about some unfortunate individuals who have regretted their decision to transition and are now detransitioning.

If you are interested in hearing anecdotal evidence and opinions supporting the notion that there is such a thing as rapid-onset gender dysphoria, I suggest you read the entire piece. However, the article’s most troubling message for me comes when I read about the professionals who were former gender-related care providers who left the field because of “pushback, the accusations of being transphobic, from being pro-assessment and wanting a more thorough process.”

One therapist trained in gender-affirming care who began to have doubts about the model and spoke out in favor of a more measured approach was investigated by her licensing board after transgender advocates threatened to report her. Ultimately, her case was dismissed, but she continues to fear for her safety.

Gender-related healthcare is another sad example of how in this country it is the noise coming from the advocates on the extremes of the issue that is drowning out the “vast ideological middle” that is seeking civil and rational discussions.

In this situation there are those who want to make it illegal for the healthcare providers to help patients who might benefit from transitioning. On the other end of the spectrum are those advocates who are unwilling to acknowledge that there may be some adolescents with what has been called by some “rapid-onset gender dysphoria.”

The landscape on which this tragedy is being played out is changing so quickly that there will be no correct answers in the short term. There just isn’t enough data. However, there is enough anecdotal evidence from professionals who were and still are practicing gender-related care to raise a concern that something is happening in the adolescent population that suggests some individuals with gender dysphoria should be managed in a different way than the currently accepted gender-affirming model. The size of this subgroup is up for debate and we may never learn it because of reporting bias and privacy concerns.

The American Academy of Pediatrics has recently authorized a systematic review of gender-affirming care. I hope that, like the librarian in Blue Hill, it will have the courage to include all the evidence available even though, as we have seen here in Maine, some of it may spark a firestorm of vehement responses.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.