Letters from Maine

The tale of two scenarios of gender dysphoria


In a recent column, I cautiously discussed what has been called gender-affirming or transgender care.

In the days following the appearance of that Letters From Maine column on this topic, I received an unusual number of responses from readers suggesting I had touched on a topic that was on the minds of many pediatricians.

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.

Dr. William G. Wilkoff

Since then, the Florida Board of Medicine and Osteopathic Medicine voted to forbid physicians from prescribing puberty blockers and hormones and/or performing surgeries in patients under age 18 who were seeking transgender care. Children already receiving treatments were exempt from the ruling. The osteopathic board added a second exception in cases where the child was a participant in a research protocol. The board of medicine inexplicably did not include this exception.

Regardless of how one feels about the ethics and the appropriateness of transgender care, it is not an issue to be decided by a politically appointed entity.

As I look back over what I have learned by watching this tragic drama play out, I am struck by a distinction that has yet to receive enough attention. When we are discussing gender dysphoria we are really talking about two different pediatric populations and scenarios. There is the child who from a very young age has consistently preferred to dress and behave in a manner that is different from the gender he or she was assigned at birth. The management of this child is a challenge that requires a careful balance of support and protection from the harsh realities of the gender-regimented world.

The second scenario stars the adolescent who has no prior history of gender dysphoria, or at least no outward manifestations. Then, faced by the challenges of puberty and adolescence, something or things happen that erupt into a full-blown gender-dysphoric storm. We currently have very little understanding of what those “things” are.

Each population can probably be further divided into subgroups – and that’s just the point. Every gender-dysphoric child, whether their dysphoria began at age 2 or 12, is an individual with a unique family dynamic and socioeconomic background. They may share some as yet unknown genetic signature, but in our current state of ignorance they deserve, as do all of our patients, to be treated as individuals by their primary care physicians and consultants who must at first do no harm. One size does not fit all and certainly their care should not be dictated by a politically influenced entity.

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.

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