Commentary From the Section on Lesbian, Gay, Bisexual, Transgender Health and Wellness
The Section on Lesbian, Gay, Bisexual, Transgender Health and Wellness (SOLGBTHW) was formed in 2016, after groups of pediatricians met at the American Academy of Pediatrics (AAP) National Conference & Exhibition and at other conferences devoted to LGBTQ+ health care. Further, the AAP’s policy statements on adoption by same sex parents and the benefits of marriage for children led to recognition that these issues needed a home. The work of the section has focused on education along with advocacy, especially around trans health issues.
Pediatrics: Coming Out and Moving Forward
Christopher Harris, MD, FAAP
Affiliation: Medical Director, Enanta Pharmaceuticals
Highlighted Articles From Pediatrics
- Green R, Money J. Effeminacy in prepubertal boys. Summary of eleven cases and recommendations for case management. Pediatrics. 1961;27:286-291
- Bakwin H. Deviant gender-role behavior in children: relation to homosexuality. Pediatrics. 1968;41(3):620-629
- Committee on Youth. Sexual problems in children and adolescents. Pediatrics. 1968;42(4):697-699
- McKinnish T, Hunt C, Weinberg S, et al. A quality improvement approach to enhance LGBTQ+ inclusivity in pediatric primary care. Pediatrics. 2022;150(2):e2021052125. 10.1542/peds.2021-052125
- Katz-Wise SL, Gordon AR, Sharp KJ, Johnson NP, Hart LM. Developing parenting guidelines to support transgender and gender diverse children’s well-being. Pediatrics. 2022;150(3):e2021055347. 10.1542/peds.2021-055347
Throughout the 75 years since the inauguration of Pediatrics as the official publication of the AAP, the journal has consistently sought to publish works of great contemporary interest and relevance to its readership. Over its 3 quarter centuries, Pediatrics has catalogued many advances in our understanding of disease and social phenomena. This has never been more evident than in the context of our evolving understanding of human sexuality. We now understand that variations in sexual orientation and gender identity are not manifestations of significant psychopathology but represent the continuity of the normal biological spectrum of human sexual and gender expression.
In the early half of the 20th century, pediatricians were heavily influenced by Freud’s multiple explanations of homosexuality. His earliest thesis was that males became attracted to the same gender due to a developmental arrest. In other words, gay and lesbian individuals had not completed the normal progression of sexual maturation. Later, he theorized that “...homosexual men experienced an especially strong fixation on their mother…” which then led to an overly strong attachment and identification that caused them to seek objects of affection similar to themselves so as to continue the maternal bond. Other theories developed by Freud invoked an inverted Oedipal complex, with male children assuming feminine characteristics to gain favor with a father figure. Although these concepts were wildly disparate and had no objective basis, they unfortunately colored the understanding of human sexuality for decades.
In the course of reviewing what has been published in Pediatrics over the decades, several articles stood out that espoused now antiquated viewpoints on sexuality and behavior. First, we highlight the publication “Effeminacy in Prepubertal Boys: Summary of Eleven Cases and Recommendations for Case Management” by Richard Green and John Money.1 Published in 1961, this article described 11 effeminate boys who were followed for 1 to 5 years. Behaviors that initiated referral included “excessive and persistent attempts to dress in the clothes of the opposite sex, constant display of gestures and mannerisms of the opposite sex, preference for play…of the opposite sex or a stated desire to be a member of the opposite sex.” The boys were initially evaluated at a mean age of 8 years (range, 3 to 12 years of age). The authors attempted to explore the family dynamics and acknowledged that “gender-role seems to get established early in life by some as yet unascertained process” and “gender-role behavior in any of its manifestations is not present at birth.” They attempted to draw parallels with sex assignment of “hermaphrodites.” They also used animal experiments of bird imprinting to ascribe a “gender-role disorder” to these boys but could not identify a “simple point-for-point correlation of cause and effect.” They postulated that factors such as the “infrequency of forceful paternal dominance…frequency with which the mother viewed the son’s behavioral anomalies in a more serious light than did the father, and the relative fragile body build of many of the boys” contributed to behaviors, but notably did not document growth parameters. Recommendations included to “illustrate to parents the inescapability of some handicaps…he will not be helped in the least by constant disapproval…” and to “ascertain how much time father and son spend doing things together.” A similar recommendation was made to engage the child with others in his own age group. Parents were encouraged to avoid “insidious and irrational ways of encouraging girlishness” and offer “whole-hearted approval of his present and future masculine behavior and sexuality.” Finally, the authors advised referral to psychiatry if “problems…are multiple and severe” but they also stated “the boy who is stuck with the handicap of effeminacy is still capable of leading a stable and productive life…there have been many illustrious homosexuals in the history of civilization.”
A second similarly wayward article entitled, “Deviant Gender-Role Behavior in Children: Relation to Homosexuality,” written by Henry Bakwin, was published in 1968.2 It covered many of the topics covered by Green and Money but in addition it reported on 3 masculine-behaving girls. These authors described as “deviant” behaviors some that dated back to earliest childhood such as preference for boy clothes and haircuts, non-interest in playing with dolls, and resentment of “feminine activities like housework and sewing.” One of the original subjects “showed an active interest in her sex-appropriate dress—high heels and the like…married at 27 years of age and had six children in rapid succession”. Importantly, in describing the etiology of gender-role, the author did distinguish between gender-role and gender-identity (how a person feels). Transgender people are briefly described as those who “changed their sex of rearing…and functioned seemingly normally thereafter.” Finally, the authors stated that “in children with readily recognizable deviant gender-role behavior…the risk of homosexuality is high” and they counseled prevention for these children.
Finally, the AAP’s Committee on Youth published a policy statement “Sexual Problems in Children and Adolescents” in 1968.3 Fortunately, the statement begins with a call for more research on the sexual behavior of adolescents, especially because available information at the time was judged to be “based on folklore, prejudiced moral judgments, and retrospective anecdotal reporting.” Comprehensive sex education was also highlighted as key for young people, although they cautioned the pediatrician not “to educate the child simply because he has been called on to do so by the parent. This is a job for the parent.” Finally, the authors devoted much attention to “deviant” behaviors. The policy statement stated that environments with large numbers of one sex require special attention as these might be associated with increased risk of deviant behavior. Recommended management plans included a holistic approach to the adverse childhood experiences that might have occurred in a child’s life. Consultation with a multi-disciplinary team was suggested. They suggested that pediatricians provide education about adolescent pregnancy and have conversations with patients with the goal of pointing out the harms associated with “increased sexual freedom and stimulation, abuse of drugs, illegitimate pregnancies, deviant sexual behavior, protest movements, and pornography.”
Read through today’s lens, these 3 articles are startling in their approach to what are now understood as normal variants in sexual behavior and gender development. Beginning with the groundbreaking psychology study by Evelyn Hooker in the 1950s, which showed that homosexuality was not associated with psychopathology, further research has also documented that transgender individuals are healthy and well-adjusted. Reading these articles was difficult and nearly heartbreaking, especially with the very frequent use of terms such as “deviant,” “abnormal,” and “inappropriate.” Setting the dominant heteronormative family structure as the desired ideal was also striking and alarming. Today we, as pediatricians, recognize that other family structures are just as nurturing and loving as a straight couple. In retrospect, the observations were faulty, the conclusions were biased, and the management recommendations were harmful.
This commentary has shown that the early history of publications within Pediatrics related to LGBT children mirrored the social conventions of the time. However, Pediatrics has recognized the unique needs of LGBT children through recent articles such as “A Quality Improvement Approach to Enhance LGBTQ+ Inclusivity in Pediatric Primary Care”4 and “Developing Parenting Guidelines to Support Transgender and Gender Diverse Children’s Well-being.”5 Together, these articles show that compassion combined with rigorous science have improved the care of the diverse populations that we see in our clinics.
References
- Green R, Money J. Effeminacy in prepubertal boys. Summary of eleven cases and recommendations for case management. Pediatrics. 1961;27:286-291
- Bakwin H. Deviant gender-role behavior in children: relation to homosexuality. Pediatrics. 1968;41(3):620-629
- Committee on Youth. Sexual problems in children and adolescents. Pediatrics. 1968;42(4):697-699
- McKinnish T, Hunt C, Weinberg S, et al. A quality improvement approach to enhance LGBTQ+ inclusivity in pediatric primary care. Pediatrics. 2022;150(2):e2021052125. 10.1542/peds.2021-052125
- Katz-Wise SL, Gordon AR, Sharp KJ, Johnson NP, Hart LM. Developing parenting guidelines to support transgender and gender diverse children’s well-being. Pediatrics. 2022;150(3):e2021055347. 10.1542/peds.2021-055347
