AAP calls for “systematic review of evidence,” yet reaffirms 2018 gender-affirming care policy
August 28, 2023
by Andrè Van Mol, MD
The American Academy of Pediatrics (AAP) announced on AAP News on August 4, 2023, “AAP reaffirms gender-affirming care policy, authorizes systematic review of evidence to guide update.”
Referring to AAP CEO/Executive Vice President Mark Del Monte, JD, it explained, “He emphasizes that policy authors and AAP leadership are confident the principles presented in the original policy, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, remain in the best interest of children.” That is an impressively expectation-lowering presuppositional admission in light of how the original 2018 policy was generated, to which I shall return.
The press release noted, “The decision to authorize a systematic review reflects the board’s concerns about restrictions to access to health care with bans on gender-affirming care in more than 20 states.” There are two problems here. First, what constitutes appropriate and evidence-based healthcare for the gender dysphoric is precisely the issue, and the 2018 AAP policy statement is the most aggressively pro-transition of any medical organization, yet it lacked any manner of adequate literature review (and worse, as we will see). Secondly, these restrictions on gender transition procedures in more than 20 states constitute remarkably socio-politically diverse, hands-across-the-aisle efforts that bring together people of stunningly varied political, spiritual, professional and sexual perspectives. I’ve been involved in several, as have other members of the CMDA Sexual and Gender Identity Task Force—we’ve seen it firsthand.
The press release continues, “The AAP and other major medical organizations—including the American Medical Association, the American College of Obstetricians and Gynecologists and the World Health Organization—support giving transgender adolescents access to the health care they need.” But many others do not—a point which seems ignored. To name a few gender-critical medical and mental health organizations:
- Society of Evidence Based Gender Medicine
- Do No Harm Medicine
- Association of American Physicians and Surgeons
- American College of Pediatricians
- Christian Medical & Dental Associations
- Catholic Medical Association
- Alliance for Therapeutic Choice
- The International Federation for Therapeutic and Counselling Choice (IFTCC)
One can also take issue with the AAP’s use of the phrase “transgender adolescents.”
Transgenderism is an ideology. Gender dysphoria is a diagnosis. Recall University of Toronto’s Ken Zucker’s statement, “The term ‘transgender identity’ is hardly an objective label for a child’s gendered subjectivity.” Beware loaded language.
The press statement continues, “The AAP opposes any laws or regulations that discriminate against transgender and gender-diverse individuals, or that interfere in the doctor-patient relationship.” Au contraire, twice. It is both non-discriminatory and professionally appropriate to withhold unproven interventions that are not demonstrated to be safe, effective or of greater benefit than harm. Gender transition procedures are shown to lead to considerable harm. We medical professionals take an oath to do no harm. It is also non-discriminatory in that there exist mental health alternatives to gender transition procedures, which are at least as effective and without their physical harms.
Furthermore, the AAP’s alleged non-interference in the doctor-patient relationship brings to mind Dr. Leonard Sax’s critique of the 2018 AAP policy in which he observed, “The AAP would not allow a five-year-old to veto the parent’s decision regarding whether to be vaccinated against diphtheria, which is today a very rare disease. Why is the AAP giving five-year-olds supreme authority for this much more profound decision?” I would add, if the hypothetical doctor and minor patient both desired simple counseling to help deal with undesired sexual attractions and/or behavior, would the AAP refuse to “interfere in the doctor-patient relationship,” or would they condemn the alleged “conversion therapy?” And what is more conversionary than the chemical sterilization and surgical mutilation of a minor for a mental health issue, of which the natural course of which is desistance by adulthood?,,,
The New York Times coverage of the AAP decision to reaffirm its pro-transition position while calling for a “systematic review” included a statement from McMaster University epidemiologist Dr. Gordon Guyatt, credited as a developer of the field of evidence-based medicine. Dr. Guyatt was not laudatory, referring to the AAP plan as “very clearly putting the cart before the horse.” That New York Times piece added, “Based on previous systematic reviews, Dr. Guyatt said, the A.A.P.’s report will most likely find low-quality evidence for pediatric gender care. ‘The policies of the Europeans are much more aligned with the evidence than are the Americans,’ he said.”
But the AAP has not been warmly welcoming of those with contrary opinions and evidence.
In 2022, Resolution 27 was submitted with pediatrician Dr. Julia Mason as lead author. It asked the AAP to “undertake a rigorous systematic review of available evidence regarding the safety, efficacy, and risks of childhood social transition, puberty blockers, cross sex hormones and surgery” and to “update the 2018 guidelines for the care of gender dysphoric youth, based on the results of this evidence review, and in consultation with a range of stakeholders…” In 2023, another attempted submission was made. It resolved, “that the Academy commit to the principles of evidence-based medicine by eschewing narrative and other types of non-systematic reviews as the basis for its recommendations, and either use existing high quality systematic reviews from public health authorities, or commission its own…” and “that the Academy issue an urgent statement to all pediatricians treating young gender dysphoric patients to exercise extreme caution in transitioning minors with hormones and surgeries pending the results of systematic reviews and a subsequent update of treatment guidelines based on the findings from such review of evidence.”
Dr. Mason told the United Kingdom’s Daily Mail, “I’m really disappointed the AAP is being driven by ideology, rather than evidence. They’ve suppressed my efforts and come up with new rules to hide what we’re trying to say from rank and file pediatricians.” Additional reporting concurs the AAP ignored, suppressed and buried Resolution 27 and its concerns prior to their August press release.,
And what of the 2018 AAP Policy Statement, “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents”? It was the work of Dr. Jason Rafferty and states on page 1, “Dr. Rafferty conceptualized the statement, drafted the initial manuscript, reviewed and revised the manuscript, approved the final manuscript as submitted, and agrees to be accountable for all aspects of the work.” A one-dude show.
The policy statement also cautions, “The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.” That message seems altogether lost on the pro-transition crowd. It further clarifies, “All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.” And the clock running out is at least in part of what brought the AAP to the current decision.
Among the 2018 recommendations were: “1. that youth who identify as TGD have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space;” “4. that insurance plans offer coverage for health care that is specific to the needs of youth who identify as TGD, including coverage for medical, psychological, and, when indicated, surgical gender-affirming interventions;” and
“5. that provider education, including medical school, residency, and continuing education, integrate core competencies on the emotional and physical health needs and best practices for the care of youth who identify as TGD and their families.”
Rafferty’s 2018 AAP policy drew prompt criticism, the most blistering and discrediting being that of University of Toronto’s James Cantor. Dr. Cantor declared, “But any assertion that their policy is based on evidence is demonstrably false…” Regarding the AAP policy statement that ““[C]onversion” or “reparative” treatment models are used to prevent children and adolescents from identifying as transgender or to dissuade them from exhibiting gender-diverse expressions,” Cantor responds, “These claims struck me as odd because there are no studies of conversion therapy for gender identity. Studies of conversion therapy have been limited to sexual orientation—specifically, the sexual orientation of adults—not gender identity, and not children in any case.”
Dr. Cantor went over AAP citation after citation and concluded, “Rather, AAP’s statement is a systematic exclusion and misrepresentation of entire literatures. Not only did AAP fail to provide extraordinary evidence, it failed to provide the evidence at all. Indeed, AAP’s recommendations are despite the existing evidence.” He added, “In fact, the references that AAP cited as the basis of their policy instead outright contradicted that policy, repeatedly endorsing watchful waiting;” and “The AAP statement was also remarkable in what it left out—namely, the outcomes research on GD children…every follow-up study of GD children, without exception, found the same thing: Over puberty, the majority of GD children ceased to want to transition.”
In an August 17, 2022 article in the Wall Street Journal, pediatrician Dr. Julia Mason and Leor Sapir brought the hammer down on the AAP. They declared, “The AAP has ignored the evidence that has led Sweden, Finland and most recently the U.K. to place severe restrictions on medical transition for minors…Medical societies in France, Belgium and Australia have also sounded the alarm. The U.S. is an outlier on pediatric gender medicine.”
Mason and Sapir stingingly concluded, “The AAP has stifled debate on how best to treat youth in distress over their bodies, shut down efforts by critics to present better scientific approaches at conferences, used technicalities to suppress resolutions to bring it into line with better-informed European countries, and put its thumb on the scale at Pediatrics in favor of a shoddy but politically correct research agenda. Its preference for fashionable political positions over evidence-based medicine is a disservice to member physicians, parents and children.”
The article brought a quick rebuttal by AAP President Moira Szilagyi, who ironically wrote this: “Gender-affirming care can be lifesaving. It doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.” Her words contradict the affirmation-on-demand AAP policy. Dr. Szilagyi then stumbled by stating,
“No European country has categorically banned gender-affirming care when medically appropriate. Contrary to what Dr. Mason and Mr. Sapir claim, the U.K. isn’t moving away from gender-affirming care. It is moving toward a more regional, multidisciplinary approach, similar to what is practiced in the U.S.” But Mason and Sapir said that several European countries now “place severe restrictions on medical transition for minors,” not the “categorically banned,” as Dr. Szilagyl conflated. For instance, recent guidance from British National Health Service prioritizes psychological intervention over gender transition procedures: “The primary intervention for children and young people who are assessed as suitable for The Service is psychosocial (including psychoeducation) and psychological support and intervention; the main objective is to alleviate distress associated with gender incongruence and promote the individual’s global functioning and wellbeing.” Dr. Szilagyl’s description of the UK’s policy change—which included closing the world’s largest pediatric gender clinic—as mirroring what she describes as being U.S. practices is baffling, illusionary and unsupportable, both regarding UK policy and U.S. practices.
The AAP has been subpoenaed, first by Florida followed by some other states, to defend the evidence upon which they make their policy. They have yet to do so, finding judges to grant them stays. Why? Why not dazzle the courts with the crushing weight of the proof? A systematic literature review is precisely what they and the United States need. Now, will there be one, or will it be something more cherry-picked and self-serving? They will be watched.
 Singh D, Bradley SJ and Zucker KJ (2021) A Follow-Up Study of Boys With Gender Identity Disorder. Front. Psychiatry 12:632784. doi: 10.3389/fpsyt.2021.632784
 Hembree, W., Cohen-Kettenis, et al., (2017) Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab,102:1–35.
 Ristori J, Steensma TD. Gender dysphoria in childhood. Int Rev Psychiatry. 2016;28(1):13-20.
 Zucker, K. J. (2018). The myth of persistence: response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al. International Journal of Transgenderism, 19(2), 231–245. Published online May 29, 2018. http://doi.org/10.1080/15532739.2018.1468293