The American Academy of Pediatrics (AAP) Board of Directors made an announcement last week that they will be maintaining their 2018 policy statement on gender-affirming care (GAC). This policy recommends a process of social transition for gender dysphoric minors, which may include adopting new names and pronouns, followed by medical interventions like puberty blockers, cross-sex hormones, and surgery to address gender-related distress. Although the AAP’s words may seem confident, their other announcement suggests a hint of uncertainty. In addition to reaffirming their existing policy, the AAP revealed their intention to conduct a systematic review of the evidence for pediatric GAC.
This move has left many perplexed. How can the AAP support GAC without even conducting a review, especially when reviews in Sweden, Finland, and the U.K. have found insufficient evidence to support the benefits of GAC, leading them to prioritize psychotherapy over social, hormonal, and surgical transition procedures?
The AAP’s decision to review Gender Affirming Care comes as they acknowledge their support for medical interventions for gender dysphoric children. What’s even more eyebrow-raising is the fact that the AAP’s sudden interest in conducting the review is driven by the numerous “restrictions” and “bans on gender-affirming care recently enacted in some 20 states.” These revelations, laden with political implications, raise concerns about potential biases and the overall integrity of the impending review.
While it may be comforting for GAC critics that the AAP is finally conducting a review, it is important for them to stay engaged and not passively wait for up to 18 months for the review to conclude. A biased or poorly executed systematic review can be worse than having no review at all. It is imperative for organizations critical of GAC, such as Genspect, the Society for Evidence-Based Gender Medicine (SEGM), and Do No Harm, to closely monitor and collaborate with the AAP to ensure that the review maintains transparency and an unbiased scientific process.
Systematic reviews are the epitome of evidence-based medicine. Although they follow strict protocols to prevent biases, they still have vulnerabilities. Some vulnerabilities, like eliminating conflicts of interest and including diverse viewpoints on GAC in the review team, are obvious. However, others are subtler, such as how the central questions of the review are framed. The AAP’s review of Gender Affirming Care may take up to 18 months and must include rigorous defenses against bias or political interference, according to GAC critics. Health officials in Europe have conducted similar reviews of GAC and have determined that surgical interventions are not the best course of action.
In shaping these core questions, systematic reviews often use the “PICO” framework (Population, Intervention, Comparator, Outcome), but none of these components are immune to bias. The measurement of “outcomes” is likely the most vulnerable avenue for GAC proponents to manipulate the system in their favor. This vulnerability arises mainly from GAC’s focus on evaluating short-term feelings rather than long-term objective measures of mental health. The AAP has a history of suppressing dissent on GAC, which is why concerns about them tipping the scales in their favor are valid.
For instance, “gender-affirming” double mastectomies are often evaluated by comparing patients’ attitudes before and after the procedure. This approach is significantly different from evaluating these procedures against objective measures of long-term improvement in anxiety, depression, suicidal ideation, and overall quality of life. It would logically be challenging to remain dysphoric about having breasts after they have been removed. Extraordinary interventions like mastectomies require extraordinary evidence of benefit.
Moreover, GAC is increasingly sidelining medical professionals in favor of allowing patients unrestricted access to cosmetic procedures to achieve their own personal goals of embodiment. This shift raises the question of clinical benefit. As the Journal of Medical Ethics reports, “Medically transitioning is not all about gender dysphoria,” but can include achieving “gender euphoria and creative transfiguration.”
The debate over surgical interventions for gender dysphoric minors is happening amidst new laws across the country targeting the transgender community. Given this context, it is crucial for the AAP’s systematic review to uphold strict standards that prioritize objective and measurable long-term physical and mental health outcomes. Does GAC significantly alleviate symptoms of depression, anxiety, suicidal ideation, and actual suicides in gender dysphoric youth compared to non-gender dysphoric youth with similar mental health issues? These are the fundamental questions that a systematic review of GAC should address.
By adhering strictly to an impartial and transparent process, the AAP can ensure that its decisions regarding patient care are based on sound scientific understanding rather than being influenced by external political pressures. Failing to do so would damage their credibility and put the lives and well-being of gender-distressed youth at risk. Dr. Colin Wright, an evolutionary biologist and fellow at the Manhattan Institute, brings attention to these concerns.
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