The American Academy of Pediatrics sidelines formal proposal to revise Pediatric Medical Transition policy for the 4th consecutive year

Unfortunately, it seems that U.S. medical organizations have allowed politics to overshadow their commitment to evidence-based medicine.

The American Academy of Pediatrics (AAP) has, once again, overlooked a formal proposal—its fifth iteration for the fourth year running—intended to amend its stance on pediatric medical transitions. This proposal, known as Resolution #37, was co-authored by 24 pediatricians who are also AAP members. It called for the AAP to align its policy with findings from systematic evidence reviews, universally considered the gold standard of evidence-based medicine.

Resolution #37, titled "Align the AAP Treatment Recommendations for Gender Incongruence and Gender Dysphoria with Findings from Systematic Reviews of Evidence," was submitted on April 1, 2023. The resolution sought a comprehensive review and update of the AAP's current policy on gender-affirming care for trans-identified youth, as stated in the 2018 AAP position paper titled "Ensuring Comprehensive Care and Support for Transgender and Gender Diverse Children and Adolescents." The existing policy endorses the view that immediate affirmation through psychosocial and medical interventions is the only appropriate approach for youth experiencing gender dysphoria, a stance that Resolution #37 argues requires reevaluation.

Despite assurances from the AAP in February 2023 that policy statements undergo a review every five years, and thus an update of the 2018 statement is already underway, Resolution #37 states that the AAP is proceeding with the update without conducting a systematic review of the evidence. No AAP committees working on these policy updates plan to perform such a review, and there's no indication that a systematic review related to treatments for gender dysphoria is even being considered.

The resolution urges the AAP to either utilize existing high-quality systematic reviews from public health authorities or commission its own, and not to base its recommendations on poorer quality reviews with known biases. It further asks the AAP to promptly issue a statement advising pediatricians to exercise extreme caution when transitioning minors with hormones and surgeries pending the results of systematic reviews and subsequent guideline updates.

Despite its poor evidence base, the gender-affirming model of care has gained wide acceptance across the United States, largely due to endorsements from major medical organizations like the AAP. This approach discourages healthcare professionals from questioning a patient's self-identified transgender status or investigating potential underlying causes of gender dysphoria. The standard protocol for minors involves the initial use of puberty blockers, followed by cross-sex hormones and sometimes surgery.

Dr. Julia Mason, a pediatrician and AAP member who is the lead author on 4 of the 5 resolutions submitted in the last 4 years, shared the Resolution #37 document on Twitter. It provided extensive background on the evolving state of gender medicine, including how many countries, such as those in Europe that have conducted systematic reviews, are now adopting a more cautious approach towards pediatric transgender healthcare than the US. These countries prioritize psychotherapy and restrict hormonal interventions for clinical research. This approach differs significantly from the AAP’s stance, which encourages clinicians to immediately affirm patients' identities and views alternative approaches as forms of "conversion therapy."

The 2018 policy statement, authored by Dr. Jason Rafferty, represents the official viewpoint of the AAP. However, the statement did not undergo a comprehensive review by other members of the organization. In fact, Rafferty alone was responsible for conceptualizing, drafting, revising, and approving the document. This paper inappropriately equated “watchful waiting,” a clinical approach that involves not rushing into medical interventions, to the widely discredited practice of “conversion therapy” without an evidential basis for this comparison. It also overlooked the findings of 11 desistance studies, which consistently show that 60-90% of trans-identified youth who do not socially and medically transition grow up to no longer identify as transgender and instead often become gay, lesbian or bisexual adults. Rafferty was quoted recently as saying that a "child's sense of reality" is the "navigational beacon to orient treatment around."

In 2022, the AAP leadership introduced a new rule that specifically prevented pediatricians from commenting on “unsponsored” resolutions. This rule wasn't in place in 2021 when an “unsponsored” resolution calling for a revision of the pediatric gender care policy received significant support in the form of votes and comments from pediatricians. With the advent of this rule, the resolution submitted in 2022 (#27) was omitted from the list of resolutions emailed to members for commentary. The AAP's maneuver appears to be a calculated attempt to suppress debate by disallowing comments on “unsponsored” resolutions.

Reacting to these restrictions, dozens of AAP members took an unprecedented step by voicing their concerns in the comments section of a separate resolution on the AAP's members-only website. Despite these efforts, Resolution #27 failed to progress at the leadership meeting in Chicago last year. Due to the new rule introduced that year, it was the only resolution out of 45 to be suppressed.

Last month, on June 30, the AAP announced a new set of resolutions that were ready for member review and commentary in preparation for the annual AAP Leadership Conference in August. However, Resolution #37 remains barred from receiving comments, as no chapter or committee within the AAP was willing to act as a sponsor.

In an attempt to dissuade members from commenting on Resolution #37 within the comment sections of other resolutions, as was done the previous year, the AAP included a proviso stating: "Members should focus their comments on the content of the resolution itself. Submitted comments will be reviewed before public posting. The comments contained in the report are for members only and should not be shared outside the AAP."

Despite the Academy's internal debates, their public face is still steadfast in endorsing gender-affirming care. This stance was particularly evident when Dr. Benjamin Hoffman, the president-elect of the AAP, recently appeared on an ABC special called "The Freedom to Exist," which featured transgender actor Elliot Page. During the show, Hoffman forwarded the common claim that gender-affirming care plays a vital role in preventing suicides. However, no study to date has consistently shown that gender transition reduces either completed suicides or serious suicide attempts.

Hoffman stated that, “We know the risks associated with not accessing essential care,” which included heightened levels of depression and anxiety, increased self-harm, and elevated suicidality. While it is true that suicidal ideation is more prevalent among trans-identified youth, the actual rate of suicide in this group remains comparatively low. Significantly, there's no substantial evidence to suggest that interventions such as puberty blockers, cross-sex hormones, or surgeries decrease these rates.

When studies compared trans-identified youth to non-trans-identified youth with similar mental health conditions, the rates of suicidal behaviors were almost equivalent between the two groups. This parity suggests that mental health issues, not lack of gender affirmation, is likely to be the primary cause of suicidal behavior.

Proponents of gender-affirming care typically believe in the existence of an innate and immutable “gender identity," despite the lack of empirical evidence to substantiate this view. This belief was evident when Hoffman discussed the increasing restrictions on pediatric transition services across the United States, asserting that, “If you’ve got a law in your state that says you’re wrong for being who you know you are, that’s going to deeply impact your sense of self.”

The notion of an intrinsic "gender identity" suggests that individuals possess a profound sense of being male, female, or another gender, that can be known from a very young age. However, research attempting to link neurological factors with "gender identity" have failed to materialize, once confounding factors like sexual orientation are controlled for.

In reality, outcomes for gender dysphoria — a recognized psychiatric condition — vary widely, with the majority resolving or desisting over time. The growing number of individuals detransitioning serves as clear evidence that gender dysphoria can be temporary and that "gender identity" is not an innate condition solidified at birth.

Despite the United States becoming an outlier in pediatric medical transition, the American Medical Association (AMA) recently restated its commitment to the affirmative model of care. By announcing the approval of the Endocrine Society's resolution by its House of Delegates, the AMA seeks to safeguard access to what it inaccurately describes as "evidence-based" gender-affirming care.

Jesse Singal, a journalist who first brought attention to the surge in trans-identification among teenagers in 2018, debunked many of the false claims made in the AMA's announcement on his Substack Singal Minded. He reminded readers that these highly esteemed institutions are acting as political entities that represent specific interest groups that invest heavily in lobbying.

Unfortunately, it seems that U.S. medical organizations have allowed politics to overshadow their commitment to evidence-based medicine. They remain stubbornly attached to the affirming model of care despite emerging evidence indicating significant risks. Instead of undertaking transparent, rigorous, and long-term research on children to inform effective policy and practice around medical transition, these organizations appear to prioritize maintaining a "politically correct" image. If U.S. medical organizations continue to take politically-driven rather than science-based positions, they risk damaging their credibility and inflicting serious harm on the children they have a duty to care for.