The American Academy of Pediatrics (AAP) Board of Directors announced last week they are maintaining their 2018 policy statement on gender-affirming care (GAC).
That policy recommends that gender dysphoric minors begin a process of social transition, which can include new names and pronouns – followed by medical interventions such as puberty blockers, cross-sex hormones, and surgery, to resolve a child’s gender-related distress.
While their words may sound confident and considered, the AAP Board’s other announcement actually suggests an undercurrent of uncertainty. Along with reaffirming that existing policy, the AAP revealed its intention to carry out a systematic review of the evidence for pediatric GAC.
This move has perplexed many; how can the AAP endorse GAC before such a review has even taken place, especially when reviews conducted in Sweden, Finland, and the U.K. have found insufficient evidence to support the benefits of GAC, causing them to prioritize psychotherapy over social, hormonal, and surgical transition procedures.
Even more eyebrow-raising was the AAP’s admission that their sudden itch to conduct their GAC review stems from the dozens of “restrictions” and “bans on gender-affirming care recently enacted in some 20 states.” Laden with political implications, such revelations raise concerns over potential biases and the overall integrity of the impending review.
While “better late than never” may capture the attitude that many GAC critics have regarding the AAP review, it’s essential to stay engaged and not wait passively for up to 18 months while the review runs its course. Because the only thing worse than no systematic review is a biased or poorly executed systematic review.
This is why it’s 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 the review maintains the most transparent and unbiased scientific process possible.
Systematic reviews epitomize the pinnacle of evidence-based medicine. Although they employ stringent protocols to prevent biases, they nevertheless have their own vulnerabilities.
Some are obvious, such as the need to eliminate conflicts of interest and enlist an impartial review team with diverse viewpoints on GAC. Other vulnerabilities are subtler, such as the process of framing the central questions the review hopes to answer.
In shaping these core questions, systematic reviews commonly utilize the “PICO” framework (Population, Intervention, Comparator, Outcome). Though none of these components are immune to bias, the ways in which the “outcomes” are measured are likely the most vulnerable avenue for GAC proponents to manipulate the system to their advantage.
This vulnerability arises largely from GAC’s emphasis on evaluating short-term feelings over long-term objective measures of mental health. The AAP has a history of suppressing dissent on GAC, which is why concerns that they might try to tip the scales in their favor are valid.
For instance, outcomes of “gender-affirming” double mastectomies are often evaluated by asking patients to contrast their before-and-after attitudes to having their breasts removed. This approach is vastly different from evaluating such procedures against objective measures of long-term improvement in anxiety, depression, suicidal ideation, and overall quality of life.
Logically, it would be rather difficult, for example, to remain dysphoric about having breasts after they’ve been removed. Extraordinary interventions, such as mastectomies require extraordinary evidence of benefit.
Moreover, GAC is increasingly ignoring the question of clinical benefit altogether in favor of sidelining the medical “gatekeepers”—otherwise known as “doctors” and other medical professionals—to allow patients unfettered access to cosmetic procedures in order to achieve their personal “embodiment goals.”
As reported in the Journal of Medical Ethics, “Medically transitioning is not all about gender dysphoria,” but can include achieving “gender euphoria and creative transfiguration.”
Given this trajectory, it is vital that the AAP’s systematic review upholds strict standards emphasizing objective and measurable long-term physical and mental health outcomes.
For instance, does GAC significantly alleviate symptoms of depression, anxiety, suicidal ideation, and actual suicides in gender dysphoric youth compared to youth with similar levels of depression, anxiety, and other mental health issues who are not gender dysphoric?
These are the basic questions a systematic review of GAC should be able to address.
By adhering strictly to an impartial and transparent process, the AAP can ensure that its decisions on patient care are anchored in sound scientific understanding rather than wavering under external political pressures.
A failure to do so would be ruinous to their credibility and put the lives and well-being of gender-distressed youth at risk of serious harm.
Dr. Colin Wright is an evolutionary biologist and a fellow at the Manhattan Institute.
