Gender Dysphoria in Children: summary points

The American College of Pediatricians urges health professionals, educators and legislators to reject all policies that condition children to accept a life of chemical and surgical impersonation of the opposite sex as normal and healthful. Facts – not ideology – determine reality. All references are found within the text of the full statement.

1. Gender dysphoria (GD) of childhood describes a psychological condition in which children experience a marked incongruence between their experienced gender and the gender associated with their biological sex. They often state that they are the opposite sex. Prevalence rates among children are estimated to be less than 1%.

2. It is false that brain differences observed in some studies between transgender adults and non-transgender adults prove that GD is innate. If differences do exist in brain structures of transgender adults, these differences are more likely to be the result of transgender identification and behavior, not the cause of transgender identification and behavior. This is because thinking and behavior is known to shape brain microstructure through a process called neuroplasticity.

3. When GD occurs in the pre-pubertal child, it resolves in 80-95 percent of patients by late adolescence after they naturally pass through puberty. This is consistent with studies of identical twins that prove no one is born hard-wired to develop GD.

4. All complex behaviors are due to a combination of nature (biology), nurture (environmental factors) and free will choices. Studies of identical twins prove that GD is predominately influenced by non-shared post-natal events. The largest study of twin transsexual adults found that only 20 percent of identical twins were both trans-identified. Since identical twins contain 100 percent of the same DNA from conception, and develop in exactly the same prenatal environment where they are exposed to the same prenatal hormones, if genes and/or prenatal hormones contributed significantly to transgenderism, the concordance rates would be close to 100 percent. Instead, 80 percent of identical twin pairs were discordant for transgenderism. This means that at least 80 percent of what contributes to transgenderism in one adult co-twin consists of one or more non-shared post-natal experiences.

5. There is no single family dynamic, social situation, adverse event, or combination thereof that has been found to destine any child to develop GD. This fact, together with twin studies, suggests that there are many paths that may lead to GD in certain vulnerable children. Clinical case studies suggest that social reinforcement, parental psychopathology, family dynamics, and social contagion facilitated by mainstream and social media, all contribute to the development and/or persistence of GD in some vulnerable children. There may be other as yet unrecognized contributing factors as well.

6. There is a suppressed debate among physicians, therapists, and academics regarding the recent trend to quickly affirm gender dysphoric youth as transgender. Many health professionals are deeply concerned because affirming youth as transgender sends them down the path of medical transition (a sex change) which requires the use of toxic hormones and unnecessary surgeries. Healthcare professionals opposed to affirming a child’s gender dysphoria based upon the medical ethics principle of “First do no harm” are being silenced. This is true among  left-leaning youth trans critical professionals as well as those who are traditionally more conservative.

7. Human sexuality is an objective biological binary trait: “XY” and “XX” are genetic markers of sex, male and female respectively – not genetic markers of a disorder. The norm for human design is to be conceived either male or female. Human sexuality is binary by design with the obvious purpose being the reproduction and flourishing of our species. This principle is self-evident. The exceedingly rare disorders of sex development (DSDs), including but not limited to androgen insensitivity syndrome and congenital adrenal hyperplasia, are all medically identifiable deviations from the sexual binary norm, and are rightly recognized as disorders of human design. Individuals with DSDs do not constitute a third sex.

8. Human beings are born with a biological sex. Gender (an awareness and sense of oneself as male or female) is a psychological concept; not an objective biological entity. No one is born with an awareness of being male or female; this awareness develops over time and, like other aspects of one’s self-awareness, may be derailed by a child’s subjective perceptions, relationships, and adverse experiences from infancy forward. People who identify as “feeling like the opposite sex” or “somewhere in between” do not comprise a third sex. They remain biological men or biological women.

9. A person’s belief that one is something one is not is, at best, a sign of confused thinking; at worst it is a delusion.

10. Cross-sex hormones (estrogen for boys and testosterone for girls) are associated with dangerous health risks. Oral estrogen administration to boys may place them at risk for experiencing: thrombosis/thromboembolism; cardiovascular disease; weight gain; hypertrigyceridemia; elevated blood pressure; decreased glucose tolerance; gallbladder disease; prolactinoma; and breast cancer. Similarly, girls who receive testosterone may experience an elevated risk for: low HDL and elevated triglycerides (cardiovascular risk); increased homocysteine levels; hepatotoxicity; polycythemia; increased risk of sleep apnea; insulin resistance; and unknown effects on breast, endometrial and ovarian tissues.

11. Puberty is not a disorder and therefore should not be arrested as though it is a disease. Puberty-blocking hormones induce a state of disease – the absence of puberty. Puberty blocking hormones (gonadotropin releasing hormone agonists or GnRH agonists) arrest bone growth, decrease bone density, prevent the sex-steroid dependent organization and maturation of the adolescent brain, and inhibit fertility by preventing the development of gonadal tissue and mature gametes for the duration of treatment.

12. Pre-pubertal children who receive puberty-blocking hormones (GnRH agonists) followed by cross-sex hormones are permanently sterilized. Pre-pubertal children who bypass pubertal suppression and are placed on cross-sex hormones directly are also permanently sterilized.

13. At least one prospective study demonstrates that all pre-pubertal children placed on puberty blocking drugs eventually choose to begin sex reassignment with cross-sex hormones. This suggests that impersonation of the opposite sex and pubertal suppression, far from being fully reversible and harmless as proponents claim, sets into motion a single inevitable outcome (transgender identification) that requires lifelong use of toxic cross-sex hormones, resulting in infertility and other serious health risks.

14. Adolescent girls with GD who have taken testosterone daily for one year may obtain a double mastectomy as young as age 16. This is not a reversible procedure.

15. A thirty year follow up study found rates of suicide are nearly twenty times greater among adults who undergo sex reassignment in Sweden which is among the most LGBTQ – affirming countries. This demonstrates that while sex-reassignment eases some of the gender dysphoria in adulthood, it does not result in levels of health on par with that of the general population. It also suggests that the mental health disparities are not primarily due to social prejudice, but to whatever pathology has precipitated the transgender feelings in the first place and/or the transgender lifestyle itself.

16. Conditioning children to believe the absurdity that they or anyone could be “born into the wrong body,” and that a lifetime of chemical and surgical impersonation of the opposite sex is normal and healthful is child abuse. Affirming gender dysphoria via public education and legal policies will confuse children and parents, leading more children to present to “gender clinics” where they will be given puberty-blocking drugs. This, in turn, virtually ensures that they will “choose” a lifetime of sterility, toxic cross-sex hormones, and likely consider unnecessary surgical mutilation of their healthy body parts as young adults.

17. There is a serious ethical problem with allowing irreversible, life-changing procedures to be performed on minors who are too young to give valid consent themselves. Children and adolescents do not have the cognitive maturity or experiential capacity to understand the magnitude of such decisions. Ethics alone demands an end to the use of pubertal suppression, cross-sex hormones, and sex reassignment surgeries in children and adolescents.

Gender Dysphoria in Children

American College of Pediatricians – August 2016

ABSTRACT: Gender dysphoria (GD) of childhood describes a psychological condition in which children experience a marked incongruence between their experienced gender and the gender associated with their biological sex. When this occurs in the pre-pubertal child, GD resolves in the vast majority of patients by late adolescence. Currently there is a vigorous, albeit suppressed, debate among physicians, therapists, and academics regarding what is fast becoming the new treatment standard for GD in children. This new paradigm is rooted in the assumption that GD is innate, and involves pubertal suppression with gonadotropin releasing hormone (GnRH) agonists followed by the use of cross-sex hormones—a combination that results in the sterility of minors. A review of the current literature suggests that this protocol is founded upon an unscientific gender ideology, lacks an evidence base, and violates the long-standing ethical principle of “First do no harm.”

Gender Dysphoria in Children: This Debate Concerns More than Science

Gender is a term that refers to the psychological and cultural characteristics associated with biological sex.1 It is a psychological concept and sociological term, not a biological one. Gender identity refers to an individual’s awareness of being male or female and is sometimes referred to as an individual’s “experienced gender.” Gender dysphoria (GD) in children describes a psychological condition in which they experience marked incongruence between their experienced gender and the gender associated with their biological sex. They often express the belief that they are the opposite sex.2 The prevalence rates of GD among children has been estimated to be less than 1%.3 Sex differences in rate of referrals to specialty clinics vary by age. In pre-pubertal children, the ratio of boys to girls ranges from 2:1 to 4.5:1. In adolescents, the sex ratio is close to parity; in adults, the ratio of males to females range from 1:1 to 6.1:1.2

The debate over how to treat children with GD is primarily an ethical dispute; one that concerns physician worldview as much as science. Medicine does not occur in a moral vacuum; every therapeutic action or inaction is the result of a moral judgment of some kind that arises from the physician’s philosophical worldview. Medicine also does not occur in a political vacuum and being on the wrong side of sexual politics can have severe consequences for individuals who hold the politically incorrect view.

As an example, Dr. Kenneth Zucker, long acknowledged as a foremost authority on gender identity issues in children, has also been a lifelong advocate for gay and transgender rights. However, much to the consternation of adult transgender activists, Zucker believes that gender-dysphoric pre-pubertal children are best served by helping them align their gender identity with their anatomic sex. This view ultimately cost him his 30-year directorship of the Child Youth and Family Gender Identity Clinic (GIC) at the Center for Addiction and Mental Health in Toronto.4,5

Many critics of pubertal suppression hold a modernist teleological worldview. They find it self-evident that there is a purposeful design to human nature, and that cooperation with this design leads to human flourishing. Others, however, identify as post-modernists who reject teleology. What unites the two groups is a traditional interpretation of “First do no harm.” For example, there is a growing online community of gay-affirming physicians, mental health professionals, and academics with a webpage entitled “First, do no harm: youth trans critical professionals.” They write:

We are concerned about the current trend to quickly diagnose and affirm young people as transgender, often setting them down a path toward medical transition…. We feel that unnecessary surgeries and/or hormonal treatments which have not been proven safe in the long-term represent significant risks for young people. Policies that encourage—either directly or indirectly—such medical treatment for young people who may not be able to evaluate the risks and benefits are highly suspect, in our opinion.6

Advocates of the medical interventionist paradigm, in contrast, are also post-modernists but hold a subjective view of “First do no harm.” Dr. Johanna Olson-Kennedy, an adolescent medicine specialist at Children’s Hospital Los Angeles, and leader in pediatric gender transitioning, has stated that “[First do no harm] is really subjective. [H]istorically we come from a very paternalistic perspective… [in which] doctors are really given the purview of deciding what is going to be harmful and what isn’t. And that, in the world of gender, is really problematic.”7 Not only does she claim that “First do no harm” is subjective, but she later also states that it should be left to the child decide what constitutes harm based upon their own subjective thoughts and feelings.7 Given the cognitive and experiential immaturity of the child and adolescent, the American College of Pediatricians (the College) finds this highly problematic and unethical.

Gender dysphoria as the result of an innate internal sexed identity

Professor of social work, Dr. William Brennan, has written that “[t]he power of language to color one’s view of reality is profound.”8 It is for this reason that linguistic engineering always precedes social engineering — even in medicine. Many hold the mistaken belief that gender once meant biological sex. Though the terms are often used interchangeably they were never truly synonymous.9,10 Feminists of the late 1960’s and 1970’s used gender to refer to a “social sex” that could differ from one’s “biological sex” in order to overcome unjust discrimination against women rooted in sex stereotypes. These feminists are largely responsible for mainstreaming the use of the word gender in place of sex. More recently, in an attempt to eliminate heteronormativity, queer theorists have expanded gender into an excess of 50 categories by merging the concept of a social sex with sexual attractions.9 However, neither usage reflects the original meaning of the term.

Prior to the 1950s, gender applied only to grammar not to persons.9,10 Latin based languages categorize nouns and their modifiers as masculine or feminine and for this reason are still referred to as having a gender. This changed during the 1950s and 1960s as sexologists realized that their sex reassignment agenda could not be sufficiently defended using the words sex and transsexual. From a purely scientific standpoint, human beings possess a biologically determined sex and innate sex differences. No sexologist could actually change a person’s genes through hormones and surgery. Sex change is objectively impossible. Their solution was to hijack the word gender and infuse it with a new meaning that applied to persons. John Money, PhD was among the most prominent of these sexologists who redefined gender to mean ‘the social performance indicative of an internal sexed identity.10 In essence, these sexologists invented the ideological foundation necessary to justify their treatment of transsexualism with sex reassignment surgery and called it gender. It is this man-made ideology of an ‘internal sexed identity’ that now dominates mainstream medicine, psychiatry and academia. This linguistic history makes it clear that gender is not and never has been a biological or scientific entity. Rather, gender is a socially and politically constructed concept.

In their “Overview of Gender Development and Gender Nonconformity in Children and Adolescents,” Forcier and Olson-Kennedy dismiss the binary model of human sexuality as “ideology” and present an “alternate perspective” of “innate gender identity” that presents along a “gender continuum.” They recommend that pediatricians tell parents that a child’s “real gender” is what he or she feels it to be because “a child’s brain and body may not be on the same page.”11

Forcier and Olson-Kennedy’s claim of an innate discordance between a child’s brain and body derives from diffusion-weighted MRI scans that demonstrate the pubertal testosterone surge in boys increases white matter volume, as well as from brain studies of adults who identify as transgender. A study by Rametti and colleagues found that the white matter microstructure of the brains of female-to-male (FtM) transsexual adults, who had not begun testosterone treatment, more closely resembled that of men than that of women.12 Other diffusion-weighted MRI studies have concluded that the white matter microstructure in both FtM and male-to-female (MtF) transsexuals falls halfway between that of genetic females and males.13 These studies, however, are of questionable clinical significance due to the small number of subjects and the existence of neuroplasticity. Neuroplasticity is the well-established phenomenon in which long-term behavior alters brain microstructure. There is no evidence that people are born with brain microstructures that are forever unalterable, but there is significant evidence that experience changes brain microstructure.14 Therefore, if and when valid transgender brain differences are identified, these will likely be the result of transgender behavior rather than its cause. More importantly, however, is the fact that the brains of all male infants are masculinized prenatally by their own endogenous testosterone, which is secreted from their testes beginning at approximately eight weeks’ gestation. Female infants, of course, lack testes, and therefore, do not have their brains masculinized by endogenous testosterone.15,16,17 For this reason, barring one of the rare disorders of sex development (DSD), boys are not born with feminized brains, and girls are not born with masculinized brains.

Behavior geneticists have known for decades that while genes and hormones influence behavior, they do not hard-wire a person to think, feel, or behave in a particular way. The science of epigenetics has established that genes are not analogous to rigid “blueprints” for behavior. Rather, humans “develop traits through the dynamic process of gene-environment interaction… [genes alone] don’t determine who we are.”18 Regarding the etiology of transgenderism, twin studies of adult transsexuals prove definitively that prenatal genetic and hormone influence is minimal.

The largest study of twin transsexual adults found that only 20 percent of identical twins were both trans-identified.19 Since identical twins contain 100 percent of the same DNA from conception, and develop in exactly the same prenatal environment where they are exposed to the same prenatal hormones, if genes and/or prenatal hormones contributed significantly to transgenderism, the concordance rates would be close to 100 percent. Instead, 80 percent of identical twin pairs were discordant. This means that at least 80 percent of what contributes to transgenderism in one adult co-twin consists of one or more non-shared post-natal experiences including but not limited to non-shared family experiences. This is consistent with the dramatic rates of resolution of gender dysphoria documented among children when they are not encouraged to impersonate the opposite sex. These results also support the theory that persistent GD is due predominately to the impact of non-shared environmental influences upon certain biologically vulnerable children. To be clear, twin studies alone establish that the “alternate perspective” of an “innate gender identity” arising from prenatally “feminized” or “masculinized” brains trapped in the wrong body is in fact an ideological belief that has no basis in rigorous science.

A teleological binary view of human sexuality, in contrast, is compatible with biological reality. The norm for human design is to be conceived either male or female. Sex chromosome pairs “XY” and “XX” are genetic determinants of sex, male and female, respectively. They are not genetic markers of a disordered body or birth defect. Human sexuality is binary by design with the purpose being the reproduction of our species. This principle is self-evident. Barring one of the rare disorders of sex development (DSD), no infant is “assigned” a sex or a gender at birth; rather birth sex declares itself anatomically in utero and is clearly evident and acknowledged at birth.

The exceedingly rare DSDs, including but not limited to androgen insensitivity syndrome and congenital adrenal hyperplasia, are all medically identifiable deviations from the human binary sexual norm. Unlike individuals with a normal genotype and hormonal axis who identify as “transgender,” those with DSD have an innate biological condition. Sex assignment in individuals with DSDs is complex and dependent on a variety of genetic, hormonal, and physical factors. Nevertheless, the 2006 consensus statement of the Intersex Society of North America did not endorse DSD as a third sex.20

Post-natal Factors Predominate in the Development and Persistence of GD

Identical twin studies demonstrate that non-shared post-natal events (environmental factors) predominate in the development and persistence of gender dysphoria. This is not surprising since it is well accepted that a child’s emotional and psychological development is impacted by positive and negative experiences from infancy forward. Family and peer relationships, one’s school and neighborhood, the experience of any form of abuse, media exposure, chronic illness, war, and natural disasters are all examples of environmental factors that impact an individual’s emotional, social, and psychological development. There is no single family dynamic, social situation, adverse event, or combination thereof that has been found to destine any child to develop GD. This fact, together with twin studies, suggests that there are many paths that may lead to GD in certain biologically vulnerable children. The literature regarding the etiology and psychotherapeutic treatment of childhood GD is heavily based upon clinical case studies. These studies suggest that social reinforcement, parental psychopathology, family dynamics, and social contagion facilitated by mainstream and social media, all contribute to the development and/or persistence of GD in some vulnerable children. There may be other as yet unrecognized contributing factors as well.

Most parents of children with GD recall their initial reactions to their child’s cross-sex dressing and other cross-sex behaviors to have been tolerance and/or encouragement. Sometimes parental psychopathology is at the root of the social reinforcement. For example, among mothers of boys with GD who had desired daughters, a small subgroup experienced what has been termed “pathologic gender mourning.” Within this subgroup the mother’s desire for a daughter was acted out by the mother actively cross-dressing her son as a girl. These mothers typically suffered from severe depression that was relieved when their sons dressed and acted in a feminine manner.21

A large body of clinical literature documents that fathers of feminine boys report spending less time with their sons between the ages of two and five as compared with fathers of control boys. This is consistent with data that shows feminine boys feel closer to their mothers than to their fathers. In his clinical studies of boys with GD, Stoller observed that most had an overly close relationship with their mother and a distant, peripheral relationship with their father. He postulated that GD in boys was a “developmental arrest … in which an excessively close and gratifying mother-infant symbiosis, undisturbed by father’s presence, prevents a boy from adequately separating himself from his mother’s female body and feminine behavior.”21

It has also been found that among children with GD, the rate of maternal psychopathology, particularly depression and bipolar disorder is “high by any standard.” Additionally, a majority of the fathers of GD boys are easily threatened, exhibit difficulty with affect regulation, and possess an inner sense of inadequacy. These fathers typically deal with their conflicts by overwork or otherwise distance themselves from their families. Most often, the parents fail to support one another, and have difficulty resolving marital conflicts. This produces an intensified air of conflict and hostility. In this situation, the boy becomes increasingly unsure about his own self-value because of the mother’s withdrawal or anger and the father’s failure to intercede. The boy’s anxiety and insecurity intensify, as does his anger, which may all result in his inability to identify with his biological sex.22

Systematic studies regarding girls with GD and the parent-child relationship have not been conducted. However, clinical observations suggest that the relationship between mother and daughter is most often distant and marked by conflict, which may lead the daughter to disidentify from the mother. In other cases, masculinity is praised while femininity is devalued by the parents. Furthermore, there have been cases in which girls are afraid of their fathers who may exhibit volatile anger up to and including abuse toward the mother. A girl may perceive being female as unsafe, and psychologically defend against this by feeling that she is really a boy; subconsciously believing that if she were a boy she would be safe from and loved by her father.21

There is evidence that psychopathology and/or developmental diversity may precipitate GD in adolescents, particularly among young women. Recent research has documented increasing numbers of adolescents who present to adolescent gender identity clinics and request sex reassignment (SR). Kaltiala-Heino and colleagues sought to describe the adolescent applicants for legal and medical sex reassignment during the first two years of an adolescent gender identity clinic in Finland, in terms of sociodemographic, psychiatric, and gender identity related factors and adolescent development. They conducted a structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013. They found that the number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding the onset of GD was common. Many youth were on the autism spectrum. These findings do not fit the commonly accepted image of a gender dysphoric child. The researchers conclude that treatment guidelines need to consider GD in minors in the context of severe psychopathology and developmental difficulties.23

Anecdotally, there is also an increasing trend among adolescents to self-diagnose as transgender after binges on social media sites such as Tumblr, Reddit, and YouTube. This suggests that social contagion may be at play. In many schools and communities, there are entire peer groups “coming out” as trans at the same time.6 Finally, strong consideration should be given to investigating a causal association between adverse childhood events, including sexual abuse, and transgenderism. The overlap between childhood gender discordance and an adult homosexual orientation has long been acknowledged.24 There is also a large body of literature documenting a significantly greater prevalence of childhood adverse events and sexual abuse among homosexual adults as compared to heterosexual adults. Andrea Roberts and colleagues’ published a study in 2013 that found “half to all of the elevated risk of childhood abuse among persons with same-sex sexuality compared to heterosexuals was due to the effects of abuse on sexuality.”25 It is therefore possible that some individuals develop GD and later claim a transgender identity as a result of childhood maltreatment and/or sexual abuse. This is an area in need of research.

GD as an Objective Mental Disorder

Psychology has increasingly rejected the concept of norms for mental health, focusing instead on emotional distress. The American Psychiatric Association (APA), for example, explains in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) that GD is listed therein not due to the discrepancy between the individual’s thoughts and physical reality, but due to the presence of emotional distress that hampers social functioning. The DSM-V also notes that a diagnosis is required for insurance companies to pay for cross-sex hormones and sex reassignment surgery (SRS) to alleviate the emotional distress of GD. Once the distress is relieved, GD is no longer considered a disorder.2

There are problems with this reasoning. Consider the following examples: a girl with anorexia nervosa has the persistent mistaken belief that she is obese; a person with body dysmorphic disorder (BDD) harbors the erroneous conviction that she is ugly; a person with body integrity identity disorder (BIID) identifies as a disabled person and feels trapped in a fully functional body. Individuals with BIID are often so distressed by their fully capable bodies that they seek surgical amputation of healthy limbs or the surgical severing of their spinal cord.26 Dr. Anne Lawrence, who is transgender, has argued that BIID has many parallels with GD.27 The aforementioned false beliefs, like GD, are not merely emotionally distressing for the individuals but also life-threatening. In each case, surgery to “affirm” the false assumption (liposuction for anorexia, cosmetic surgery for BDD, amputation or surgically induced paraplegia for BIID, sex reassignment surgery for GD) may very well alleviate the patient’s emotional distress, but will do nothing to address the underlying psychological problem, and may result in the patient’s death. Completely removed from physical reality, the art of psychotherapy will diminish as the field of psychology increasingly devolves into a medical interventionist specialty, with devastating results for patients.

Alternatively, a minimal standard could be sought. Normality has been defined as “that which functions according to its design.”28 One of the chief functions of the brain is to perceive physical reality. Thoughts that are in accordance with physical reality are normal. Thoughts that deviate from physical reality are abnormal—as well as potentially harmful to the individual or to others. This is true whether or not the individual who possesses the abnormal thoughts feels distress. A person’s belief that he is something or someone he is not is, at best, a sign of confused thinking; at worst, it is a delusion. Just because a person thinks or feels something does not make it so. This would be true even if abnormal thoughts were biologically “hardwired.”

The norm for human development is for an individual’s thoughts to align with physical reality; for an individual’s gender identity to align with biologic sex. People who identify as “feeling like the opposite sex” or “somewhere in between” or some other category do not comprise a third sex. They remain biological men or biological women. GD is a problem that resides in the mind not in the body. Children with GD do not have a disordered body—even though they feel as if they do. Similarly, a child’s distress over developing secondary sex characteristics does not mean that puberty should be treated as a disease to be halted, because puberty is not, in fact, a disease. Likewise, although many men with GD express the belief that they are a “feminine essence” trapped in a male body, this belief has no scientific basis.

Until recently, the prevailing worldview with respect to childhood GD was that it reflected abnormal thinking or confusion on the part of the child that may or may not be transient. Consequently, the standard approach was either watchful waiting or pursuit of family and individual psychotherapy.1,2 The goals of therapy were to address familial pathology if it was present, treat any psychosocial morbidities in the child, and aid the child in aligning gender identity with biological sex.21,22 Experts on both sides of the pubertal suppression debate agree that within this context, 80 percent to 95 percent of children with GD accepted their biological sex by late adolescence.29 This worldview began to shift, however, as adult transgender activists increasingly promoted the “feminine essence” narrative to secure social acceptance.10 In 2007, the same year that Boston Children’s Hospital opened the nation’s first pediatric gender clinic, Dr. J. Michael Bailey wrote:

Currently the predominant cultural understanding of male-to-female transsexualism is that all male-to-female (MtF) transsexuals are, essentially, women trapped in men’s bodies. This understanding has little scientific basis, however, and is inconsistent with clinical observations. Ray Blanchard has shown that there are two distinct subtypes of MtF transsexuals. Members of one subtype, homosexual transsexuals, are best understood as a type of homosexual male. The other subtype, autogynephilic transsexuals, are (sic) motivated by the erotic desire to become women. The persistence of the predominant cultural understanding, while explicable, is damaging to science and to many transsexuals.30

As the “feminine essence” view persisted, the suffering of transgender adults was invoked to argue for the urgent rescue of children from the same fate by early identification, affirmation, and pubertal suppression. It is now alleged that discrimination, violence, psychopathology, and suicide are the direct and inevitable consequences of withholding social affirmation and puberty blockers or cross-sex hormones from a gender dysphoric child.31 Yet, the fact that 80 percent to 95 percent of gender-dysphoric youth emerge physically and psychologically intact after passing through puberty without social affirmation refutes this claim.29 Furthermore, over 90 percent of people who die of suicide have a diagnosed mental disorder.32 There is no evidence that gender-dysphoric children who commit suicide are any different. Therefore, the cornerstone for suicide prevention should be the same for them as for all children: early identification and treatment of psychological co-morbidities.

Nevertheless, there are now 40 gender clinics across the United States that promote the use of pubertal suppression and cross-sex hormones in children. The rationale for suppression is to allow the gender-dysphoric child time to explore gender identity free from the emotional distress triggered by the onset of secondary sex characteristics. The standards followed in these clinics are based on “expert opinion.” There is not a single large, randomized, controlled study that documents the alleged benefits and potential harms to gender-dysphoric children from pubertal suppression and decades of cross-sex hormone use. Nor is there a single long-term, large, randomized, controlled study that compares the outcomes of various psychotherapeutic interventions for childhood GD with those of pubertal suppression followed by decades of toxic synthetic steroids. In today’s age of “evidence-based medicine,” this should give everyone pause. Of greater concern is that pubertal suppression at Tanner Stage 2 (usually 11 years of age) followed by the use of cross-sex hormones will leave these children sterile and without gonadal tissue or gametes available for cryo-preservation.33,34,35

Neuroscience clearly documents that the adolescent brain is cognitively immature and lacks the adult capacity needed for risk assessment prior to the early to mid-twenties.36 There is a serious ethical problem with allowing irreversible, life-changing procedures to be performed on minors who are too young to give valid consent themselves. This ethical requirement of informed consent is fundamental to the practice of medicine, as emphasized by the U.S. Department of Health & Human Services website: “The voluntary consent of the human subject is absolutely essential.”37 Moreover, when an individual is sterilized, even as a secondary outcome of therapy, lacking full, free, and informed consent, it is a violation of international law.38

Transgender-Affirming Protocol: What Is the Evidence Base?

Over the past two decades, Hayes, Inc. has grown to become an internationally recognized research and consulting firm that evaluates a wide range of medical technologies to determine the impact on patient safety, health outcomes, and resource utilization. This corporation conducted a comprehensive review and evaluation of the scientific literature regarding the treatment of GD in adults and children in 2014. It concluded that although “evidence suggests positive benefits” to the practice of using sex reassignment surgery in gender dysphoric adults, “serious limitations [inherent to the research] permit only weak conclusions.”39 Similarly, Hayes, Inc. found the practice of using cross-sex hormones for gender dysphoric adults to be based on “very low” quality of evidence:

Statistically significant improvements have not been consistently demonstrated by multiple studies for most outcomes. Evidence regarding quality of life and function in male-to-female (MtF) adults was very sparse. Evidence for less comprehensive measures of well-being in adult recipients of cross-sex hormone therapy was directly applicable to GD patients but was sparse and/or conflicting. The study designs do not permit conclusions of causality and studies generally had weaknesses associated with study execution as well. There are potentially long-term safety risks associated with hormone therapy but none have been proven or conclusively ruled out.40

Regarding treatment of children with GD using gonadotropin releasing hormone (GnRH) agonists and cross-sex hormones, Hayes, Inc. awarded its lowest rating indicating that the literature is “too sparse and the studies [that exist are] too limited to suggest conclusions.”40

Gender Clinics Proliferate Across United States Despite Lack of Medical Evidence

In 2007 Dr. Norman Spack, a pediatric endocrinologist and founder of the nation’s first gender clinic at Boston Children’s Hospital, launched the pubertal suppression paradigm in the United States.41 It consists of first affirming the child’s false self-concept by instituting name and pronoun changes, and facilitating the impersonation of the opposite sex within and outside of the home. Next, puberty is suppressed via GnRH agonists as early as age 11 years, and then finally, patients may graduate to cross-sex hormones at age 16 in preparation for sex-reassignment surgery as an older adolescent or adult.42 Endocrine Society guidelines currently prohibit the use of cross-sex hormones before age 16 but this prohibition is being reconsidered.43 Some gender specialists are already bypassing pubertal suppression and instead putting children as young as 11 years old directly onto cross-sex hormones.44 The rationale is that the child will experience the pubertal development of the desired  sex  and thereby avoid the iatrogenic emotional distress from maintaining a pre-pubertal appearance as peers progress along their natural pubertal trajectory.

In 2014 there were 24 gender clinics clustered chiefly along the East Coast and in California; one year later there were 40 across the nation. Dr. Ximena Lopez, a pediatric endocrinologist at Children’s Medical Center Dallas, and a member of that program’s GENder Education and Care, Interdisciplinary Support program (Genecis) stated, “[Use of this protocol is] growing really fast. And the main reason is [that] parents are demanding it and bringing patients to the door of pediatric endocrinologists because they know this is available.”45 Notice, the main reason for the protocol’s increased use is parent demand; not evidence-based medicine. 

Risks of GnRH Agonists

The GnRH agonists used for pubertal suppression in gender dysphoric children include two that are approved for the treatment of precocious puberty: leuprolide by intramuscular injection with monthly or once every three month dosing formulations, and histrelin, a subcutaneous implant with yearly dosing.34 In addition to preventing the development of secondary sex characteristics, GnRH agonists arrest bone growth, decrease bone accretion, prevent the sex-steroid dependent organization and maturation of the adolescent brain, and inhibit fertility by preventing the development of gonadal tissue and mature gametes for the duration of treatment. If the child discontinues the GnRH agonists, puberty will ensue.34,42 Consequently, the Endocrine Society maintains that GnRH agonists, as well as living socially as the opposite sex, are fully reversible interventions that carry no risk of permanent harm to children.42 However, social learning theory, neuroscience, and the single long-term follow-up study of adolescents who have received pubertal suppression described below challenge this claim.

In a follow-up study of their first 70 pre-pubertal candidates to receive puberty suppression, de Vries and colleagues documented that all subjects eventually embraced a transgender identity and requested cross-sex hormones.46 This is cause for concern. Normally, 80 percent to 95 percent of pre-pubertal youth with GD do not persist in their GD. To have 100 percent of pre-pubertal children choose cross-sex hormones suggests that the protocol itself inevitably leads the individual to identify as transgender. There is an obvious self-fulfilling nature to encouraging a young child with GD to socially impersonate the opposite sex and then institute pubertal suppression. Given the well-established phenomenon of neuroplasticity, the repeated behavior of impersonating the opposite sex will alter the structure and function of the child’s brain in some way—potentially in a way that will make identity alignment with the child’s biologic sex less likely. This, together with the suppression of puberty that prevents further endogenous masculinization or feminization of the brain, causes the child to remain either a gender non-conforming pre-pubertal boy disguised as a pre-pubertal girl, or the reverse. Since their peers develop normally into young men or young women, these children are left psychosocially isolated. They will be less able to identify as being the biological male or female they actually are. A protocol of impersonation and pubertal suppression that sets into motion a single inevitable outcome (transgender identification) that requires lifelong use of toxic synthetic hormones, resulting in infertility, is neither fully reversible nor harmless.

GnRH Agonists, Cross-sex Hormones, and Infertility

Since GnRH agonists prevent the maturation of gonadal tissue and gametes in both sexes, youth who graduate from pubertal suppression at Tanner Stage 2 to cross-sex hormones will be rendered infertile without any possibility of having genetic offspring in the future because they will lack gonadal tissue and gametes for cryo-preservation. The same outcome will occur if pre-pubertal children are placed directly upon cross-sex hormones. Older adolescents who declined pubertal suppression are advised to consider cryo-preservation of gametes prior to beginning cross-sex hormones. This will allow them to conceive genetic offspring in the future via artificial reproductive technology. While there are documented cases of transgendered adults who stopped their cross-sex hormones in order to allow their bodies to produce gametes, conceive, and have a child, there is no absolute guarantee that this is a viable option in the long term. Moreover, transgendered individuals who undergo sex reassignment surgery and have their reproductive organs removed are rendered permanently infertile.34,35,36

Additional Health Risks Associated with Cross-sex Hormones

Potential risks from cross-sex hormones to children with GD are based on the adult literature. Recall that regarding the adult literature, the Hayes report states: “There are potentially long-term safety risks associated with hormone therapy but none have been proven or conclusively ruled out.”40 For example, most experts agree that there is an increased risk of coronary artery disease among MtF adults when placed on oral ethinyl estradiol; therefore, alternative estrogen formulations are recommended. However, there is one study of MtF adults using alternative preparations that found a similar increased risk. Therefore, this risk is neither established nor ruled out.47,48,49 Children who transition will require these hormones for a significantly greater length of time than their adult counterparts. Consequently, they may be more likely to experience physiologically theoretical though rarely observed morbidities in adults. With these caveats, it is most accurate to say that oral estrogen administration to  boys may place them at risk for experiencing: thrombosis/thromboembolism; cardiovascular disease; weight gain; hypertrigyceridemia; elevated blood pressure; decreased glucose tolerance; gallbladder disease; prolactinoma; and breast cancer.47,48,49 Similarly, girls who receive testosterone may experience an elevated risk for: low HDL and elevated triglycerides; increased homocysteine levels; hepatotoxicity; polycythemia; increased risk of sleep apnea; insulin resistance; and unknown effects on breast, endometrial and ovarian tissues.47,48,49 In addition, girls may legally obtain a mastectomy as early as 16 years of age after receiving testosterone therapy for at least one year; this surgery carries its own set of irreversible risks.34

 The Post-Pubertal Adolescent with GD

As previously noted, 80 percent to 95 percent of pre-pubertal children with GD will experience resolution by late adolescence if not exposed to social affirmation and medical intervention. This means that 5 percent to 20 percent will persist in their GD as young adults. Currently, there is no medical or psychological test to determine which children will persist in their GD as young adults. Pre-pubertal children with GD who persist in their GD beyond puberty are more likely to also persist into adulthood. The Endocrine Society and others, including Dr. Zucker, therefore regard it reasonable to affirm children who persist in their GD beyond puberty, as well as those who present after puberty, and to proceed with cross-sex hormones at age 16 years.42

The College disagrees for the following reasons. First, not all adolescents with GD inevitably go on to trans-identification, but cross-sex hormones inevitably result in irreversible changes for all patients. Second, the young adolescent is simply not sufficiently mature to make significant medical decisions.  The adolescent brain does not achieve the capacity for full risk assessment until the early to mid-twenties. There is a significant ethical problem with allowing minors to receive life-altering medical interventions including cross-sex hormones and, in the case of natal girls, bilateral mastectomy, when they are incapable of providing informed consent for themselves. As stated earlier, the College is also concerned about an increasing trend among adolescents to self-diagnose as transgender after binges on social media sites. While many of these adolescents will seek out a therapist after self-identifying, many states have been forced by non-scientific political pressure to ban so-called “conversion therapy.” These bans prevent therapists from exploring not only a young person’s sexual attractions and identity, but also his or her gender identity. Therapists are not allowed to ask why an adolescent believes he or she is transgender; may not explore underlying mental health issues; cannot consider the symbolic nature of the gender dysphoria; and may not look at possible confounding issues such as social media use or social contagion.6

Impact of sex reassignment in adults as it relates to risk in children

Surveys suggest that transgender adults express a sense of “relief” and “satisfaction” following the use of hormones and sex reassignment surgery (SRS). However, SRS does not result in a level of health equivalent to that of the general population. 50

For example, a 2001 study of 392 male-to-female and 123 female-to-male transgender persons found that 62 percent of the male-to-female (MtF) and 55 percent of the female-to-male (FtM) transgender persons were depressed. Nearly one third (32 percent) of each population had attempted suicide.51 Similarly, in 2009, Kuhn and colleagues found considerably lower general health and general life satisfaction among 52 MtF and 3 FtM transsexuals fifteen years after SRS when compared with controls.52 Finally, a thirty-year follow-up study of post-operative transgender patients from Sweden found that the rate of suicide among post-operative transgender adults was nearly twenty times greater than that of the general population. To be clear, this does not prove that sex reassignment causes an increased risk of suicide or other psychological morbidities. Rather, it indicates that sex reassignment alone does not provide the individual with a level of mental health on par with the general population. The authors summarized their findings as follows:

Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, though alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.50

It is noteworthy that these mental health disparities are observed in one of the most lesbian, gay, bisexual and transgender (LGBT) affirming nations of the world. It suggests that these health differences are not due primarily to social prejudice, but rather due to the adult transgender condition or lifestyle. This is also consistent with an American study published in the Journal of LGBT Health in 2008 that found discrimination did not account for the mental health discrepancies between LGBT-identified individuals and the heterosexual population.53

Absent hormonal and surgical intervention, only 5-20 percent of pre-pubertal children with GD will face a transgender adulthood which seems to predispose them to certain morbidities and an increased risk of early death. In contrast, the single study of pre-pubertal children with GD who received pubertal suppression makes clear that 100 percent of these children will face a transgender adulthood. Therefore, the current transgender affirming interventions at pediatric gender clinics will statistically yield this outcome for the remaining 80 to 95 percent of pre-pubertal children with GD who otherwise would have identified with their biological sex by adulthood.

Recommendations for research

Identical twin studies establish that post-natal environmental factors exert a significant influence over the development of GD and transgenderism. Data also reflects a greater than 80% resolution rate among pre-pubertal children with GD. Consequently, identification of the various environmental factors and pathways that trigger GD in biologically vulnerable children should be one focus of research. Particular attention should be given to the impact of childhood adverse events and social contagion. Another area of much needed research is within psychotherapy. Large long term longitudinal studies in which children with GD and their families are randomized to treatment with various therapeutic modalities and assessed across multiple measures of physical and social emotional health are desperately needed and should have been launched long ago. In addition, long term follow-up studies that assess objective measures of physical and mental health of post-surgical transsexual adults must include a matched control group consisting of transgender individuals who do not undergo SRS. This is the only way to test the hypothesis that SRS itself may cause more harm to individuals than they otherwise would experience with psychotherapy alone.


Gender dysphoria (GD) in children is a term used to describe a psychological condition in which a child experiences marked incongruence between his or her experienced gender and the gender associated with the child’s biological sex. Twin studies demonstrate that GD is not an innate trait. Moreover, barring pre-pubertal affirmation and hormone intervention for GD, 80 percent to 95 percent of children with GD will accept the reality of their biological sex by late adolescence.

The treatment of GD in childhood with hormones effectively amounts to mass experimentation on, and sterilization of, youth who are cognitively incapable of providing informed consent. There is a serious ethical problem with allowing irreversible, life-changing procedures to be performed on minors who are too young to give valid consent themselves; adolescents cannot understand the magnitude of such decisions.

Ethics alone demands an end to the use of pubertal suppression with GnRH agonists, cross-sex hormones, and sex reassignment surgeries in children and adolescents. The College recommends an immediate cessation of these interventions, as well as an end to promoting gender ideology via school curricula and legislative policies. Healthcare, school curricula and legislation must remain anchored to physical reality. Scientific research should focus upon better understanding the psychological underpinnings of this disorder, optimal family and individual therapies, as well as delineating the differences among children who resolve with watchful waiting versus those who resolve with therapy and those who persist despite therapy.

Primary author: Michelle Cretella, MD
August 2016

The American College of Pediatricians is a national medical association of licensed physicians and healthcare professionals who specialize in the care of infants, children, and adolescents. The mission of the College is to enable all children to reach their optimal, physical and emotional health and well-being.

A printable Adobe Acrobat (pdf) copy of this position is available by clicking here: Gender Dysphoria in Children



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The Impact of Media Use and Screen Time on Children, Adolescents, and Families

American College of Pediatricians – July 2016

ABSTRACT: The media, and especially visual media in recent years, are playing an increasing role in the lives of children, adolescents, and families in the United States.  While the limited use of high-quality and developmentally appropriate media may have a positive influence, excessive or developmentally inappropriate use carries grave health risks for children and their families. Excessive exposure to screens (television, tablets, smartphones, computers, and video game consoles), especially at early ages, has been associated with lower academic performance, increased sleep problems, obesity, behavior problems, increased aggression, lower self-esteem. depression, and increased high risk behaviors, including sexual activity at an earlier age.  The American College of Pediatricians encourages parents to become media literate and limit all screen time for their children.  Parents, too, must limit their own screen time, especially the use of smartphones, to improve their interaction and engagement with their children, as well as to assure the physical safety of their children.  The College encourages pediatricians to discuss the impact of media with all families, and calls upon the media industry, sponsors, educators, and policymakers to act responsibly to protect the physical and emotional health of children and families.

The term media commonly refers to mass communication through the use of newspapers, books, magazines, television, radio, film, Internet-enabled devices, or video games. There is abundant research evaluating the impact of various media on children and adolescents; however, television watching, video game playing, and electronic screen time have received a great deal of attention in recent years because of their popularity among youth.  While not exhaustive, this position paper reviews key medical and social science research findings, and provides a summary of the major known adverse effects of screen time in particular.


Time spent using media

Children and adolescents’ use of media has greatly increased in the past 5 – 10 years, which has been documented in numerous Kaiser Family Foundation Studies.  The most recent 2010 report regarding   behavior of two thousand 8 – 18 year olds showed that the average child spent 7.5 hours each day using media.  However, because of multi-tasking, children actually crammed 10.75 hours of media use into that 7.5-hour period of time.  On a typical day, this study also revealed that, 8 – 18 year olds spent approximately 4.39 hours viewing television, 2.31 hours listening to music, 1.29 hours using computers, and 1.13 hours playing video games.  It is important to note that print media, such as books or magazines, and movies, are also consumed on a daily basis but the least amount of time is spent with these media.1 Another study found 18 year olds in America spent nearly 40 hours each week accessing the Internet from their home computers.2

As part of the International Study of Asthma and Allergies in Children Phase Three, adolescents between 12 and 15 years of age from 37 countries provided information on television viewing habits.  Eighty-nine percent of adolescents reported more than one hour of television viewing daily.3

Media exposure of younger children

Younger children are increasingly exposed to screen time opportunities, with one study showing 18 percent of children 0 – 2 years old had a television in their bedroom. Sixty-three percent of children between birth and two years of age had watched television in the day prior to the survey, and the mean television viewing time was 75 minutes.4

A more recent study in Singapore evaluated 725 children aged two years and below.  Of 93 children who were between 18 and 24 months of age, 88.2 percent were allowed daily screen time, with television and mobile devices being the most commonly used.5

Various forms of media

Although there are other media readily available, television is still the predominant medium accessed today.  However, television shows may now be downloaded onto computers, smartphones, and tablets.  As reported in 2010, approximately 60 percent of viewing by adolescents is done via television, with the remaining 40 percent occurring via alternative devices.1

Another development over the past 25 years has been the increased access children have to the Internet and video games. Children using the Internet and video games add, at a minimum, one hour more daily to time spent engaged in media use.   In addition, the use of social media contributes greatly to increased screen time.  In 2011, the American Academy of Pediatrics reported 75 percent of adolescents owned a cell phone, 25 percent use the phone for accessing social media, and 22 percent of adolescents log on to social media more than 10 times a day.7 Adolescents use their cell phones more for texting rather than for live conversation.  In one survey, teens 13 to 17 years of age were noted to send an average of 3364 texts per month, with one-third of adolescents stating they sent more than 100 texts per day.2

Parental rules regarding media

Most children and adolescents live in homes where there are no parental rules regarding screen time.  In one study, less than 30 percent of children and adolescents 8 – 18 years of age stated there were household rules regarding time spent viewing television. Parents were more likely to have rules regarding programs viewed—but even so, only 46 percent of these children and adolescents stated there were such rules in their home.   In this same study, 64 percent of those surveyed stated the television in their homes was left on during meals, and 45 percent stated the television was left on most of the time.1

Even more significant, parental television viewing time is more closely associated with children’s viewing time—and impacts the screen time of their children more than household rules.  So parents should be encouraged to decrease their own viewing time in order to impact that of their children.7

Media use decreases time spent in more healthful activities

Time spent with ‘screen use’ must be taken from other more potentially beneficial activities of the day—personal ‘face-to-face’ communication and interaction with family and friends, outdoor play (with its associated benefits of creativity, problem solving, and exercise), reading, homework, doing chores, and sleeping.


As younger children are increasingly exposed to screen time through the use of parental cell phones, researchers are beginning to evaluate the impact of this on the preschooler.  In one study by a global security software maker 2200 mothers from 10 developed nations, including the United States and Canada, who had children between two and five years of age were surveyed.  The study reported that more of these preschool children could use technology than could demonstrate ‘life skills’ such as tying their shoes, riding a bike, or swimming.  For example, 58 percent of the preschool children knew how to play a computer game versus only 9 percent who could tie their shoes.  (Mothers aged 35 and older were slightly better at teaching their children ‘life skills’.) 8

The Association of Teachers and Lecturers in the United Kingdom warned that as preschool children spend more time using screen technology they become less able to perform basic tasks such as using building blocks.  Older children were less able to utilize pen and pencil for school tasks.9 Two small studies suggest the importance of traditional toys in the language development of young children. One study of toddlers (between 18 and 30 months of age) found improved language scores among the children whose parents engaged them in play with building blocks. Another study of 26 parent-infant dyads found that during play with electronic toys, there was less vocalization – both by the parent and their infants (age 10-16 months).10,11

Adults tend to absorb information from television, even though they forget the source, and sometimes cannot recall whether the events were real or simulated12 Children also learn from what they view.  Significantly, even toddlers have been shown to imitate behaviors they have viewed on a screen.13 More importantly, young children pay greater attention to visual images rather than the plot, so they are often unable to understand the storyline or moral lesson and are less able to separate reality from fiction.

Visual images can also be frightening for the young child—and these images can remain in the child’s sub conscious for a long time, causing nightmares and other sleep disturbances.


Screen time likely impacts children’s behavior and capacity to pay attention via several mechanisms as it leads to sleep disturbances and adversely impacts brain development.   A 2016 study linked increased screen time with poor sleep quality and behavior problems.14

The number of hours spent viewing television at a young age has also been linked with future attention difficulties.  An analysis using the National Longitudinal Survey of Youth found “hours viewed per day at both ages one and three was associated with attentional problems at age seven.”15

Similar results are available for the adverse effect on attention in older children and adolescents.  A study of 1323 middle school children and 210 late adolescents/early adult participants found a relationship between time spent viewing television and playing video games with difficulties paying attention. This study is significant because its longitudinal design for the children in middle school which allowed the researchers to control for previous attention difficulties.  In addition, the researchers documented the contribution of video game playing to the development of attention problems as assessed by teachers.16


Inaccurate Sexual Information

Sexual messages are prevalent in film, television, and music, and are often explicit but also inaccurate and misleading.  Unfortunately, however, these messages are frequently accepted as truth by young people. Both programming and advertising are highly sexualized in their content. Teens rank the media as the second leading source of information about sexual behavior (The first is school sex education).17 

Earlier Sexual Debut

Studies reveal that the more an adolescent watches television programming featuring sexual content, the more likely that adolescent is to prematurely initiate sexual activity. Teens exposed to a high level of sexual content were also twice as likely to experience a pregnancy within the next three years as compared to those teens who viewed less sexualized programming.18,19 These studies also documented that teens who were exposed to talk about sex on television experienced risks similar to those teens who viewed actual sexual behavior.18

Additionally, a 2012 longitudinal study of 6522 adolescents in the U.S., ages 10 to 14, found that early exposure to sexual content in popular, mainstream movies was predictive of an earlier age of sexual debut and engagement in risky sexual behaviors.  The findings suggested that exposure to sexual content in movies may promote sexual risk taking by changing actual sexual behaviors and also by accelerating the normal rise in sensation seeking in teens.20 Similarly, research on 1058 youth between 14 and 21 years of age found “more frequent exposure to sexual media was related to ever having had sex, coercive sex victimization, and attempted /completed rape but not risky sexual behavior.”21  However another longitudinal study of adolescents in the United States found sexual exposure through movies predicted the age of sexual debut, as well as engagement in risky sexual behaviors.20

Pornography via Internet

In the Internet era, pornography has become easily accessible to people of all ages, including children and adolescents.  In recent years, there has been an increase in empirical research examining the impact of pornography use among minors.  A recent and systematic examination of the peer-reviewed research spanning years 1995 to 2015 indicated that pornography use among adolescents is prevalent, mainly accessed via the Internet, and first exposure often occurs unintentionally. Although there are many variables impacting this research, pornography is associated with more permissive sexual attitudes and stronger gender-stereotypical sexual beliefs.  Additionally, the same review found pornography use to be associated with early sexual intercourse, greater experience with casual sex behavior, and increased sexual aggression both as perpetrators and victims.22

Pornography via Social Media

Social media sites also contribute to the early exposure of sexually explicit material via shared nude photographs (“selfies”).  In her book, American Girls: Social Media and the Secret Lives of Teenagers, Nancy Jo Sales reports on her interviews with 200 teenagers and documents the intense pressure they experience to send and receive sexually-explicit photographs.  Cybersex is impacting even middle school students as they are sending and receiving sexually-explicit photos of themselves via their cell phones,  photos which are often widely distributed and used to bully, degrade, and demean.  In one study, 22 percent of teen girls said they have sent partially nude or fully nude photos of themselves, and 18 percent of boys have done so.22 Adolescents adversely impacted by cybersex/bullying often suffer from lower school grades, anxiety, alcohol and drug use, depression, and rarely, suicidal ideation and suicide.

Adolescents sharing such photographs could be prosecuted for being in possession of child pornography—and indeed some attempts have been made to curb this epidemic by doing so. In 2014, law enforcement in Fayetteville, North Carolina, were investigating a suspected statutory rape case and found an explicit photograph of a 16-year-old girl on a 16-year-old boy’s cell phone.  Both the male and female were charged with multiple counts but most charges were dismissed as the County District Attorney Cumberland stated, “…the consequences were much too serious for the conduct.”24    This case demonstrates the difficulties law enforcement encounters as it seeks to decrease the possession and distribution of sexually-explicit material among minors, and several states have responded by decreasing the penalties for minors convicted of sexting.

Pornography via High School Literature Classes

Common Core standards influence the selection of books utilized in United States high school English literature classes, and some books listed in the Appendix B of the standards include pornographic sections containing graphic depictions of consensual and, more disturbingly, illegal sexual behavior (e.g., rape, incest, abuse, bestiality, pedophilia). The likelihood of adolescents encountering violent or pornographic literature at school is increasing in part due to the fact that Advanced Placement English classes, by nature, lend themselves toward more mature content.  The number of students enrolling in Advanced Placement classes in the United States has nearly doubled in the last decade and more than quadrupled among low-income students. (“10 Years of Advanced Placement Exam Data Show Significant Gains in Access and Success; Areas for Improvement.”) 25

Although the majority of research conducted on the effects of reading are positive, studies have almost exclusively focused on the amount of time engaged in reading as an activity, or the level of reading ability. The impact of different types of content in literature is a newer arena of examination, but one that has been initiated in recent years.  For example, research examining the effects of reading physical and relational aggression in literature has revealed a correlation between reading aggressive content in literature and subsequent increases in actual aggressive behavior.26 Additionally, neuroscience is beginning to evaluate, via functional MRI scans, the way in which literature impacts the brain. Changes in the connectivity between various regions of the brain have been documented after a study subject read a novel, and some of the changes persisted for several days after the reading was completed.27

See College statement, The Impact of Pornography on Children, for additional information: 

Sexual Exploitation

Pornography is often viewed as a ‘victimless’ crime, but its relation to sex trafficking and cybersex clearly demonstrate the harm associated with it.  Pornography fuels the demand for sex trafficking as men develop a sense of ‘entitlement’ and women are portrayed as objects of sexual satisfaction.  Mary Layden, co-director of the Sexual Trauma and Psychopathology Program at the University of Pennsylvania, found that men who visited prostitutes were twice as likely to view pornography as men who did not engage with prostitutes.28 

A related and serious challenge facing children, adolescents, and their parents is cybersex. Cybersex or Internet sex is a virtual sex encounter between persons remotely connected via a computer network. It is a form of role-playing; the participants pretend they are having sexual relations. These computer sites are available to all who desire access, including children. The Internet also plays a growing role in sex crimes committed against children. These crimes range from sexual exploitation, such as child pornography, to actual assault against a victim identified through the Internet.29


Excessive viewing of television, movies, computer, and video games also results in increased tobacco and alcohol use.17,30 A recent study documented that when parents restrict viewing of R-rated movies, children have a reduced risk of experimenting with cigarettes in the future.31


Media use may interfere with adequate quantity (duration) and quality (nighttime waking, nightmares, irregular bedtimes) of sleep. In addition to the well-known problems associated with inadequate sleep, poor quantity or quality of sleep is associated with impaired immune function, and impaired regulation of metabolism.32

Parents of 495 children in kindergarten through fourth grade were surveyed regarding their children’s sleep habits as well as their television viewing. Twenty-five percent of the children had a television in their bedroom.  The authors note, “The television-viewing habits associated most significantly with sleep disturbance were increased daily television viewing amounts and increased television viewing at bedtime, especially in the context of having a television set in the bedroom.”33

Sleep deprivation has also been reported to be associated with obesity, diabetes, school failure, and behavior problems including hyperactivity.32 Demonstrating the impact of night-time use of electronic devices on sleep and obesity, researchers in Alberta, Canada, surveyed 3398 fifth grade children and found 64 percent of parents stated their children had access to one or more electronic devices in their bedroom.  The study found a relationship between night-time use of electronic devices and shortened sleep duration, increased body weight, and lower levels of physical activity.34

In a study of over 207,000 adolescents from 37 countries, researchers found that increased hours spent watching television were associated with higher BMI in adolescents with an apparent dose response effect.3


The negative associations between excessive media exposure and academic performance has been well documented.36 Zimmerman and Christakis evaluated young children up to seven years of age regarding the impact of television viewing on cognitive development.  Controlling for parental cognitive stimulation and maternal education, the researchers found “each hour of average daily television viewing before age three years was associated with deleterious effects” in several scales evaluating reading recognition and comprehension.35

Children with a television in their bedroom are known to score 7 to 8 points lower on standardized tests for mathematics and reading than those without a television in their bedroom.36

If instant messaging via electronic devices is considered, research notes there may be a negative impact on academic performance when messaging interferes with sleep.  A study of 1537 students from three high schools in New Jersey found those students who reported more use of instant messaging after ‘lights out’ were more likely to report fewer hours of sleeping and lower academic performance.37


Internet bullying (cyber bullying) is common and has serious consequences.  Over half of today’s adolescents state they have been bullied online, and over 25 percent of adolescents state they have been bullied repeatedly through the Internet or on cell phones.  However, only 1 in 10 teens tell a parent about the bullying.38

Sadly, some victims of cyber bullying resort to suicide to escape the embarrassment. A review of 37 studies found a definite relationship between cyber bullying and suicidal ideation and behavior.39


Several studies demonstrate the relationship between increased use of screen time and depression.  One longitudinal study in Denmark followed a cohort of 435 adolescents into young adulthood and found “each additional hour/day spent watching television or screen viewing in adolescence was associated with …greater odds of prevalent depression in young adulthood, and dose-response relationships were indicated.”40

Another study from Canada evaluated 2482 youth in grades 7 – 12 and concluded, “Video game playing and computer use but not TV viewing were associated with more severe depressive symptoms…Screen time may represent a risk factor or marker of anxiety and depression in adolescents.”41

A study of 8256 Australian adolescents utilizing self-report surveys found a relationship between increased leisure time screen use and depressive symptoms in the younger (12 – 14-year-old) adolescents.


Aggressive Behavior

Also of grave concern is the association between viewing media violence and increased real-life aggression.  The American Academy of Pediatrics, in its policy statement on Media Education, documents, “Results of more than 2000 scientific studies and reviews have shown that significant exposure to media violence increases the risk of aggressive behavior in certain children and adolescents, desensitizes them to violence, and makes them believe that the world is a ‘meaner and scarier’ place than it is.”43

A 2010 research paper entitled Health Effects of Media on Children and Adolescents, poignantly states:

“The relationship between media violence and real-life aggression is nearly as strong as the impact of cigarette smoking on lung cancer: Not everyone who smokes will get lung cancer, and not everyone who views media violence will become aggressive themselves.  However, the connection is significant.  The most problematic forms of media violence include attractive and unpunished perpetrators, no harm to victims, realism, and humor.”45

Violence in Television

Of concern, nearly two-thirds of all TV programs contain violent scenes, including so-called children’s programs, and it is well documented that children imitate behavior seen on television, including such media violence.45,46

Numerous studies have now documented the link between viewing violence and future aggressive behavior. One such study evaluated 430 third, fourth, and fifth graders and their teachers and found children’s exposure to media violence predicted higher verbal, as well as higher physical, aggressive behavior.47

More concerning is the fact that not only is violence depicted frequently in media, but it is depicted in ways that reinforce aggressive behavior in viewers—it is shown as justifiable, realistic, and without adverse consequences.

Violence in Video Games

Video games deserve special mention; as even parents of toddlers are utilizing the games on their smartphones to entertain their young children.  Children and adolescents who spend time playing video games (especially violent games) are more likely to have difficulties paying attention in school; act aggressively toward others; interpret others’ behaviors more negatively; have decreased empathy; have less pro-social behavior; and respond more violently when confronted.48,49,50

Half of all video games contain violence, and 90 percent of video games marketed to children age 10 years and older have violent content.  Unfortunately, the top selling video games are those that are the most violent, and parents provide less oversight for video games than they do for television viewing.  Ninety percent of adolescents in grades 8 – 12 reported their parents never check the ratings of video games prior to purchase and 89 percent stated their parents never limited time playing video games.50

Violence in Literature

There is less research on the impact of reading violence, but one study indicates the possible adverse effects of reading literature that depicts physical and relational aggression.  Using undergraduate college students, one study evaluated the impact of reading selections with either physical or relational aggression and the impact on subsequent behavior.  Although a small study, the authors did find “exposure to aggression in literature showed a specific effect on subsequent aggressive behavior.”25


Mirror neurons are cells in the brain that appear to be involved in the development of empathy and compassion. They allow an individual to have ‘cognitive empathy’—the mental ability to take another’s perspective—and these mirror neurons are undergoing dramatic changes during adolescence, as are other areas of the brain.

A study from UCLA demonstrated the impact of media via cell phones on the ability of sixth graders to recognize people’s emotions in photos and videos.  Students attending a nature camp who went without screen time for five days were compared with students who would attend the camp later.  Each set of students were evaluated at the beginning and end of the week, with the students who attended camp and went without screen time improving in their emotional cognition after only five days of non-use.  The authors stated, “Decreased sensitivity to emotional cues—losing the ability to understand the emotions of other people—is one of the costs.  The displacement of in-person social interaction by screen interaction seems to be reducing social skills.”51


The amount of time a parent views television can influence the amount of screen time a child experiences.  A 2013 study of 1550 parents with children less than 18 years of age found the amount of time a parent watched television was a better indicator of the children’s viewing time than were rules about time limits or even whether the child had a television in the bedroom.7 So, it is important to encourage parents to limit their television viewing to maintain healthy habits in their homes.

The impact of cell phone use on parenting is a new area of research, but the data that is surfacing is concerning.  An online survey52 of 6000 children and parents found 54 percent of children said their parents checked their smartphones too often, and 32 percent felt they were unimportant when parents were distracted.

Parents agreed.  Over half of the parents said they probably checked their smartphones too frequently and 28 percent felt they did not set a good example for their children. In addition, 25 percent stated they wanted their children to use their smartphones less.52

A study from Boston Medical Center evaluated parent-child interactions at fast food restaurants. Fifty-five caregivers were observed, and children were between infancy and 10 years of age. Forty of the caregivers used a cell phone during the meal and 16 used it throughout the entire meal.53

Since young children learn more from face-to-face encounters, and older children feel unimportant when parents are using cell phones, parents must be encouraged to turn off their cell phones when interacting with their children.


Adolescent drivers are known to be at increased risk for accidents due to distracted driving and inexperience, so all 50 states in America have implemented Graduated Driver’s Licenses.  Several national surveys have demonstrated the widespread use of cell phones while driving, including texting.  In a 2013 study of 3000 people aged 16 years and older, 58 percent of the 16 – 18-year-old drivers stated they had talked on a cell phone, 39 percent said they had read texts or emails, and 31 percent said they had sent emails or texts while driving within the last month.54

Another study of 8500 high school students aged 16 and up found 45 percent of drivers said they had texted while driving within the preceding month.55

Since even experienced drivers are at risk for distracted driving and show slower responses to hazards when talking on a cell phone, it is important for inexperienced adolescent drivers to be encouraged to avoid all technology while operating a vehicle.56


It is also important to mention the impact not only of media content but also of sponsors (i.e., advertisers). Advertising is a powerful force in American culture. The preeminent advertising medium is television. The principal goal of most children’s television is to sell products to children and their families. The television commercial is likely the single most influential source of information to which the young are exposed. The average American child will have viewed approximately 500,000 television commercials by the end of high school. Numerous studies have documented that the young child is often unable to understand the intent of advertising and usually accepts the advertising claim as true.57

Among products seen on television, food is the most widely advertised. In children’s shows, 50 percent of advertisement time is devoted to foodstuffs. Most of these ads are for products that nutritionists agree should be consumed occasionally and/or in small portions. Only 15 percent of food ads targeting children include reference to an active lifestyle. Public Service Announcements (PSAs) on fitness and nutrition are very few. TV stations dedicate an average of only 17 seconds per hour to PSAs; moreover, 46 percent of all PSAs air after midnight. Children under eight years old see one PSA on fitness and nutrition for every 26 food-related advertisements.58,59 Young children (at the mean age of eight) have been shown to select food products that they have seen advertised over those that were not.60

In addition, the sedentary hours spent viewing media take away from outdoor activities that might promote a healthy lifestyle and counter the rising incidence of obesity.

IMPORTANCE of MEDIA EDUCATION – for parents, children, and adolescents

The College emphasizes the positive and critical role of media education (defined as learning how to analyze the underpinnings and influence of mass media). A media-educated public is better able to understand mass media messages and their purposes. A media-educated person understands that all media messages are constructed, that media messages shape our understanding of the culture, and that mass media has powerful economic implications. It is crucial that all parents become media educated. Parents should be aware of program ratings and monitor programs that their children watch.61 Software that allows the adult to block undesirable programs is also a helpful tool. The mass media must be held accountable to the principles of the Children’s Television Acts of 1990 and 1996. Enforcement of the Children’s Television Acts will help to ensure that children’s programs are truly designed for them. Media education of children has been accomplished as early as elementary school. It has been incorporated into school curricula in Canada, Australia, and Brazil. As a result of this intervention, children have demonstrated the ability to evaluate programs and advertising more critically.62

In summary, the media have a substantial influence on today’s children and adolescents.  At the current time, disappointingly, parents cannot confidently look to the media for a consistent menu of high-quality programming.   Pediatricians and parents must do their part, ideally working with the media, to secure opportunities for educating children that facilitates the best outcomes for children.  We urge them to do so.


  • Discourage TV viewing and all screen exposure (including on smartphones and iPads) for all children under the age of two.63
  • Discourage use of electronic toys for younger children.
  • Encourage use of toys fostering creativity, such as blocks and crayons.
  • Have a goal of limiting all media exposure for entertainment purposes (television, movies, computer/video games, and music) to one hour or less per day for children over two years of age, and avoid developmentally inappropriate content all together.
    • Turn the television off during mealtimes.
    • Do not allow your child or adolescent to have a television, computer, or Internet access in       the bedroom, including Internet-enabled game consoles and phones.
    • Determine appropriate time limits for use of social media with adolescents.
  • Although teens have a need to develop and practice independence and separation from their parents, it is important to encourage alternate forms of entertainment, especially those involving physical activity with participation of all family members.63 
  •  Parents should screen and monitor the media viewing of their children and adolescents.
    • Watch television with your children so you know what programs they are watching and what lessons they are receiving.  Every television program and video game will teach your children something. Choose programs and games that support your family’s values.
    • Ask your children questions while watching the program.  Do they understand what is happening?  Do they think what is happening is real or possible?  (Young children often cannot understand the story’s idea–they just see the action.)
    • Explain commercials to your children.  Commercials are made to encourage us to spend money.  Children can understand that we do not need a certain product to really be happy.  Ask your children questions that stimulate conversations about the commercials.
  • Parents should also be aware of the video game rating system–and know the rating of the games their children play.  Pornography is embedded and accessed through a variety of games aimed at youth.
    • Video games often become more violent and more sexual at higher levels.  Parents need to check the levels of the games their children have access to and remove any inappropriate games from these devices.
    • Set limits on video game play just as with television viewing.
    • Disallow play of video games on the Internet with unknown players.
  • Pediatricians and parents should become media literate—and should be good role models in their use of media.
    • Parents should limit their own use of media – turn off the television, smartphones, and computers during mealtimes.
    • Don’t text or talk on cell phones while driving.
    • Think of other ways to entertain your child while traveling, such as listening to or singing songs together, making up stories, and bringing books for your child to read.
    • Parents should be encouraged to consider utilizing Internet or router filters such as “Covenant Eyes” or “Router Limits”, or Internet provider services such as “Integrity Online” to decrease the likelihood of inappropriate access to obscenity or high-risk online activities.
    • Parents should maintain awareness of literature children are reading in school, especially in high school. Be aware of the increasing use of sexually explicit material in high school literature classes.
  • Pediatricians should routinely provide anticipatory guidance that addresses media exposure as a part of the health maintenance visit.
  • Pediatricians and parents should discuss the profound influence the mass media has on a child’s well-being and actively work together towards improving the overall quality of media content as well as reducing the child’s exposure to cyber bullying.
    • Encourage parents to discuss this topic with their children and adolescents.
    • Limit younger adolescents’ access to social media.
    • Encourage parents to monitor social media sites.
  • Educators are encouraged to only use high-quality and developmentally-appropriate media, including books, in the classroom.  Additionally, educators are encouraged whenever possible to model and teach principles of media literacy, digital citizenship, and Internet safety.  We encourage educators to maximize the benefits of mass media and technology while at the same time minimizing the risks when children and adolescents are in their care.
  • The media industry should consider the substantial influence that programming and advertising have on children and adolescents. The College calls upon the media industry and their sponsors to act responsibly. This would include limiting the portrayal of unhealthy behaviors including violence, smoking, overeating, eating high sugar/high fat foods, sexual behavior between unmarried individuals, and sexual innuendos or frank references. Instead, increase portrayals of healthy behavior to include families engaging in physical activities together, healthy eating, and respectful dialogue between individuals.

Originally posted as Children, Adolescents, and the Media, October 2005
Revised February 2014 by Jane Anderson, MD

Revised July 2016 by Jane Anderson, MD

The American College of Pediatricians is a national medical association of licensed physicians and healthcare professionals who specialize in the care of infants, children, and adolescents. The mission of the College is to enable all children to reach their optimal, physical, and emotional health and well-being.



For an exhaustive review, see:   Strasburger VC, Jordan AB, and Donnerstein E.  Children, Adolescents, and the Media:  Health Effects.  Pediatric Clinics of North America. 2012; 59:533-587.

American Medical Association, Physician Guide to Media Violence, 1996

Neil Postman, Amusing Ourselves to Death, Penguin Books USA Inc., 1985

Neil Postman and Steve Powers, How to Watch TV News, Penguin Books USA Inc., 1992.


Policy Statement – Media Violence.   Council on Communications and Media.  American Academy of Pediatrics.  2009; 124(5):1495.

Policy Statement – Media Education.  Council on Communications and Media.  American Academy of Pediatrics.  2010; 126:1012.

A PDF of this statement The Impact of Media Use and Screen Time on Children.



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