FPA and APA Div 44 Position Statement on Recent Guidance from FL DOH Regarding Care for Transgender and Gender-Diverse Youth
The Florida Psychological Association (FPA) is an organization of psychologists serving Floridians. FPA and the American Psychological Association Division 44, value evidence-based treatments that rely on a solid foundation of high-quality, recent, peer-reviewed scientific research. As psychologists, we are trained to filter and disregard outdated, poor-quality research that misguides treatment protocols and may cause harm to our patients. We uphold our professional ethical standards that call us very clearly to do no harm. After a careful review of all high-quality, recent research on the topics of evidence-based practice for the treatment of gender dysphoria in children and youth, FPA supports the guidance from the American Psychological Association ( APA), the National Association of School Psychologists (NASP ), the U.S. Department of Health and Human Services , the World Professional Association for Transgender Health (WPATH), and GLMA: Health Professionals Advancing LGBTQ Equality (previously known as the Gay & Lesbian Medical Association–GLMA) amongst many other reputable organizations, and concludes that transgender and gender diverse youth are best served with gender-affirming care. As an organization, we stand united with these organizations and with our transgender and nonbinary patients in denouncing the recent statement issued by the Florida Department of Health (DOH).
The statement issued by the Florida DOH raises a number of concerns for members of the FPA. The research that is cited in the guidelines released by the Florida DOH is inaccurately reported, from studies with small sample sizes, relies on methodologically flawed research, and is from articles published in low-impact journals.
Contrary to the Florida DOH’s claims that “evidence regarding their psychosocial and cognitive impact is generally lacking,” there is, in fact, a fair amount of empirical data that contradicts the DOH’s recommendations. Several professional organizations in the United States have published well-respected and widely used guidelines, which are based on peer-reviewed research (APA, American Counseling Association, Endocrine Society, American Academy of Pediatrics, the American Academy of Child & Adolescent Psychiatry, and the World Professional Association for Transgender Health). Even the Merck Manual, cited in the DOH document, states that “while there is no clinical consensus on the treatment of prepubertal gender dysphoric children, it is recognized that attempts to force the child to accept the birth-assigned gender role is usually traumatic and unsuccessful” and recommends “using a gender-affirmative model as opposed to a gender-pathologizing model. This affirmative approach supports the child in the gender expressed, sometimes including social transition prior to puberty. Prior to puberty, there is no current indication for either medical or surgical intervention with gender-dysphoric children.” Instead, it would be useful and valuable for both, policymakers and psychological practitioners, to follow APA’s carefully researched ‘Guidelines for Psychological Practice With Transgender and Gender Nonconforming People,’ which call for ‘culturally competent, developmentally appropriate, and trans-affirmative psychological practice’ with such individuals, including minors.
Research on the benefits of puberty-blocking medications (fully reversible interventions which are also used to treat precocious puberty) has demonstrated that beginning GnRH analogues shortly after the onset of puberty can prevent distressing secondary sex characteristics from developing, and therefore ease transition later in life for those who may later seek to take steps toward transition. Puberty-blockers have also been shown to decrease distress related to gender dysphoria and experiencing gender mis-aligned puberty, correlates with decreases in risk-taking behaviors, and contributes to improved family functioning and school performance (Stewart Adelson, MD; Joanna Olsen, MD).
Gender-affirming care leads to positive education, social and cognitive outcomes for transgender and nonbinary youth and allows parents to make a fully informed decision about the medical and psychological care of their children. We support the President of the American Psychological Association, Dr. Frank Worrell, in his statement recommending that “psychologists follow APA’s carefully researched Guidelines for Psychological Practice with Transgender and Gender Non-Conforming People which call for culturally competent, developmentally appropriate, and trans affirmative psychological practice with such individuals, including minors.” These guidelines are currently under revision but are founded on years of research and provide clinicians with tools to be culturally competent in working with this very vulnerable population. We believe the fact sheet released by the U.S. Department of Health and Human Services provides guidance on treating gender dysphoria for children and adolescents that more closely aligns with the majority of current research. While the document is not comprehensive of all the nuances of working with such a vulnerable population, it provides a good starting point and is informed by reputable research.
REFERENCES:
Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.
Adelson S. L., (2012) American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry 51:957.
Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302.
American Psychological Association (2015) . Guidelines for Psychological Practice with Transgender and Gender Non-Conforming People. https://www.apa.org/practice/guidelines/transgender.pdf
De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.
National Association of School Psychologists. (2019). Prejudice, discrimination, and racism [Position Statement]. https://www.nasponline.org/x26830.xml
Olson K.R., Durwood L., DeMeules M., McLaughlin K. A. (2016) Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics, 137(3):e20153223. doi: 10.1542/peds.2015-3223. Epub 2016 Feb 26. Erratum in: Pediatrics, 2018 Aug;142(2): PMID: 26921285; PMCID: PMC4771131
Safe and Supportive Schools for LGBTQ+ Youth [Position Statement],
https://www.nasponline.org/x26826.xml
Tordoff, D. M., Wanta, J. W., Collin, A., Stephney, C., Inwards-Breland, D. J., Ahrens, K. (2022) Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Network Open, 5(2), e220978.
World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7th Version]. https://www.wpath.org/publications/soc
Guidelines and Standards of Care:
WPATH Standards of Care v7 http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3926
UCSF Center for Excellence of Transgender Health http://www.transhealth.ucsf.edu/
UCSF Primary Care Protocol for Transgender Patient Care - http://transhealth.ucsf.edu/trans?page=protocol-00-00
Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline - file:///C:/Users/Resident.CPANCF/Downloads/Endocrine-Treatment-of-Transsexual-Persons%20(1).pdf
APA Guidelines for Working with Transgender, Gender-Nonconforming People - http://www.apa.org/practice/guidelines/transgender.pdf
National LGBT Health Education Center at Fenway Institute http://www.lgbthealtheducation.org/
The Joint Commission: Advancing Effective Communication, Cultural Competence and Patient-and-Family Centered Care for the Lesbian, Gay, Bisexual and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL, Oct. 2011. http://www.jointcommission.org/lgbt/