'Gagging' the debate
The American Academy of Pediatrics is accused of trying to suppress discussion of a request to rethink gender dysphoria care
The American Academy of Pediatrics has reportedly gagged debate on a resolution calling for an independent and rigorous review of the evidence on treatment of youth gender dysphoria.
The five paediatricians behind the resolution highlight an international shift away from the hormonal and surgical interventions recommended by the AAP in its contentious 2018 policy endorsing the “gender-affirming” treatment model.
In the lead-up to an annual meeting in August, the AAP leadership invoked a “new rule” that resolutions not sponsored by a chapter or committee cannot be opened to members for comment, according to the international parents’ group Genspect.
“It is alarming that not a single chapter or committee within the AAP was willing to sponsor a resolution that asks to conduct a non-partisan and systematic review of evidence in paediatric gender medicine – something the AAP has never done,” Genspect says in an open letter to the academy.
“It is even more alarming that the AAP appears to be preemptively suppressing debate by not allowing comments on ‘unsponsored’ resolutions, a rule that did not exist last year when a similar ‘unsponsored’ resolution got many supportive paediatrician votes and comments.”
The AAP’s policy endorsement of medicalised gender change for minors has been cited by the Biden administration, gender clinicians, trans rights activists and journalists as a sign that puberty blockers, opposite-sex hormones and surgery are mainstream medicine supported by evidence.
However, several recent systematic reviews of the medical literature internationally have confirmed the very weak evidence base for medicalised gender change with minors, raising questions about treatment recommendations by the AAP and other medical societies.
Critics of health professional organisations which have pledged allegiance to the gender-affirming worldview say this may represent capture of policy-making by small groups of activist clinicians unrepresentative of the broad membership.
The March 31 resolution of the five paediatricians was devised to be put to the AAP’s August 4-7 Leadership Conference in Itasca, Illinois, assuming the usual ability for members to comment online on important topics before the meeting.
The resolution cites new statements, reviews or more cautious policies on youth gender dysphoria in the United Kingdom, Sweden, Iceland, France, Australia and New Zealand.
It asks 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”.
It requests a thorough and transparent update of the AAP’s 2018 policy in line with the results of the systematic review and “in consultation with a range of stakeholders, including mental health and medical clinicians, parents and patients, with diverse views and experiences. (Policies automatically expire after five years.)
“Given the increasing numbers of children and young people identifying as transgender — as many as 9 per cent [according to one study] — and the near unified movement away from hormonal and surgical interventions as first-line treatment in multiple countries, a review of the evolving evidence is imperative.”
The resolution notes that puberty blockers followed by opposite-sex hormones “compromise future fertility and sexual function — two fundamental human rights that should not be compromised except in exceptional circumstances”.
It says that “no clear diagnostic criteria exist which can reliably identify which young people will persist in a transgender identification, and there is increasing evidence of regret and detransition”.
A July 1 news item on the AAP website — headed “AAP members encouraged to comment on 2022 resolutions” — says that “An important aim of the Leadership Conference is to incorporate diverse perspectives in the discussion and debate of leading paediatric issues”.
The AAP’s 2018 policy has been the subject of a withering critique by clinical psychologist James M. Cantor, an authority on the evidence base for youth gender dysphoria.
In a 2019 peer-reviewed “fact check”, Dr Cantor claimed that the AAP document systematically misrepresented the evidence, which in fact contradicted the academy’s embrace of gender affirmation and its rejection of the more cautious approach known as “watchful waiting”.
“[The] AAP is advocating for something far in excess of mainstream practice and medical consensus,” Dr Cantor said. The academy has failed to take up several opportunities to defend the policy in the media.
Suppress the science
In current litigation over Alabama’s criminal law against medicalised gender change for anyone under age 19, a federal appeal court has been told there is “a suppression of evidence-based research and discourse” around youth gender dysphoria.
“Scientific inquiry is stunted when activists, clinicians, or medical associations attempt to silence or punish those who question medicalised transition, produce research that does not align with favoured conclusions, or caution against rushing children into transitioning treatments without adequate psychological assessments,” says a brief filed in support of Alabama’s law by the Ethics & Public Policy Center of Washington, DC.
“For example, Dr Kenneth Zucker, a highly regarded researcher, clinician, and journal editor, was de-platformed at several national transgender health conferences after activists denounced his caution regarding transitioning treatments for minors as ‘transphobic’. Zucker’s emphasis on psychotherapy for minors was demonised as ‘conversion therapy’ and his gender clinic shuttered. (Zucker later prevailed in a defamation claim against his former employer.)
“Similarly, when Brown University physician-researcher Dr Lisa Littman published a study describing how peers and social media might influence the onset of gender dysphoria in adolescent females (a phenomenon dubbed ‘rapid onset gender dysphoria’), activists sought to silence her and discredit her work. Her published study was withdrawn and subject to additional scrutiny before being republished; her research contract was not renewed.
“A recent New York Times article highlights growing divisions among gender clinicians over the appropriate care for adolescents seeking transitioning treatments.
“[Two veteran gender clinicians, Dr Erica Anderson and Dr Laura Edwards-Leeper, who have warned that some adolescents receive ‘sloppy care’ from clinicians who start them on transitioning treatments with minimal psychological assessments], are applauded by colleagues who share their concerns, but other clinicians deride their emphasis on pre-transition psychological assessments as ‘discriminatory’ and ‘reek[ing] of some old kind of conversion-therapy-type things’.
“The toxic climate that seeks to impose a false medical consensus regarding the appropriate standard of care for gender dysphoria or transitioning treatments impedes quality research and undermines sound clinical practice.”
In another reversal for scientific freedom, the AAP last year refused to grant exhibitor status to the Society for Evidence-Based Gender Medicine at the academy’s annual conference in Philadelphia. (SEGM is an international group of clinicians and researchers advocating for safe and effective treatment of youth gender dysphoria.)
The decision not to allow SEGM to present its assessment of the latest evidence followed strong positive feedback from AAP members on a resolution entitled “Addressing alternatives to the use of hormone therapies for gender dysphoric youth”.
In a statement at the time, SEGM said the rejection of its request “sends a strong signal that the AAP does not want to see any debate on what constitutes evidence-based care for gender-diverse youth”.
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In its open letter to the AAP, Genspect says it is “very concerned” that the academy “is currently representing only one set of views on how best to help our children thrive [namely, by social and medical transition].
“Many of our children have received this care and are anything but thriving”.
The group represents parents of gender dysphoric children, adolescents and young adults including detransitioners and trans people. It was founded by Stella O’Malley, an Irish psychotherapist, and draws on the expertise of other clinicians and professional people.
Genspect’s letter says the AAP resolution is timely because “thousands of young adults are coming forward on the Detrans subreddit and other social media platforms describing their regret. Why is this happening?
“Many of our children suffer from psychological comorbidities (including anxiety, ASD, ADHD, depression, trauma, eating disorders, and more – while many others are trying to understand their sexual orientation), which [shows] the need for differential diagnoses and appropriate therapeutic support, including exploratory therapy,” the letter says.
“Having a combative teenager who urgently insists on something or makes risky choices is not a new development for any parent of an adolescent. What is new is that professionals to whom we have entrusted our kids, rather than safeguarding them from harm and helping heal parental-child rifts so common in teen years, are encouraging our kids to act on their risky, impulsive decisions with irreversible consequences.”
Genspect urges the AAP to open up comments on the paediatricians’ resolution, and to update its policy, which “incorrectly promulgates the notion that ‘gender affirmative’ psychosocial and medical interventions are the only acceptable treatment for gender dysphoric youth”.
Florida v the AAP
“Those who rely on the AAP’s endorsement as a basis for gender-affirming treatments are practising eminence-based medicine as opposed to evidence-based medicine,” says a June Medicaid report from the Florida Agency for Health Care Administration.
“Eminence-based medicine refers to clinical decisions made by relying on the opinions of prominent health organisations rather than relying on critical appraisals of scientific evidence.
“While it is true that the AAP has more knowledge than a lay person and a degree of credibility in the medical community, the opinions of such organisations are not valid unless they are based on quality evidence.”
The Florida report says that despite the need for stronger studies, “many practitioners stand by the recommendations of the AAP, Endocrine Society, and [the World Professional Association for Transgender Health]”.
It cites the example of an open letter from 300 Florida health care professionals deploring April’s state health guidance which warns against medicalised gender change for minors.
The letter, published in the Tampa Bay Times, says this guidance “directly contradicts existing guidelines from the American Academy of Pediatrics, the Endocrine Society, the American Academy of Child and Adolescent Psychiatry and the World Professional Association for Transgender Health.
“These national and international guidelines are the result of careful deliberation and examination of the evidence by experts including paediatricians, endocrinologists, psychologists and psychiatrists.”
The Florida Medicaid report, which draws on five expert papers on the evidence and ethics of hormonal and surgical treatments for youth gender dysphoria, says its evaluations refute the claim that these guidelines and policies amount to “careful deliberation and examination of the evidence by experts”.
GCN sought comment from the AAP and Dr Jason Rafferty, who was lead author on the academy’s 2018 policy. Any responses will be added as they arrive.