U.S. Medical Groups Get The Science Wrong On Pediatric ‘Gender Affirming’ Care

Medical organizations in the U.S. that endorse the “gender affirming” model of care lack evidence to substantiate the medical treatment of trans-identified minors.

Activists often point to the authority of medical institutions that support “gender-affirming” care for minors to dismiss any and all criticism. A close inspection in the form of a new resource guide by Manhattan Institute fellow Leor Sapir found that the most prominent organizations in favor of “gender-affirming” care lack evidence to back up their position and depart from a growing international consensus.

“While it is understandable that doctors and their patients should want to follow guidelines issued by professional medical groups, it is important to recognize that these groups don’t always get the science right,” said Sapir.

“Gender-affirming” care discourages medical professionals from questioning a minor’s self-reported transgender identity or exploring possible underlying factors that may be causing their dysphoria. The standard protocol for gender affirmation is administering puberty blockers, followed by cross-sex hormones, and then surgery, if desired. Proponents generally argue that parental approval should not be a requirement and reject medical “gatekeeping.”

The three most influential medical organizations to have released guidelines recommending “gender-affirming” care for minors are the American Academy of Pediatrics (AAP), the Endocrine Society (ES), and the World Professional Association for Transgender Health (WPATH). The American Medical Association, as well as other organizations, have made public statements supporting the “affirming” model without citing evidence, or have deferred to one or more of these three, Sapir noted.

“On the issue of medical treatment for youth gender dysphoria in particular, American medical organizations have demonstrated a preference for ideologically driven conclusions over cautious review of the available research,” Sapir said.

According to Sapir, the AAP’s central conclusion is negated by its citations and flawed logic. The AAP’s position is based on a 2018 policy statement, authored by Dr. Jason Rafferty and published in Pediatrics.

“Rafferty’s central claim in that article is that ‘watchful waiting,’ a therapeutic approach in which clinicians delay social and medical transition as long as possible in order to exhaust all efforts to help youth in distress feel comfortable in their bodies, is a form of ‘conversion therapy,’” said Sapir. The citations used to defend this claim had nothing to do with gender self-identification and were all based on the discredited practice of trying to get gay and lesbian adults to “convert” to heterosexuality.

Rafferty argued that clinicians should always “affirm” the gender self-declarations of their pediatric patients. In 2020, Dr. James Cantor of the Toronto Sexuality Centre published a thorough fact-check of Rafferty’s article in another journal. The fact-check revealed that the AAP policy contained “egregious omissions and misrepresentations of the available research on youth gender dysphoria,” said Sapir.

In 2017, the Endocrine Society published guidelines that invalidate their own strength of evidence by rating the guidelines as being “weak recommendations” and citing the quality of evidence for hormonal interventions for minors as being “low” or “very low.”

The World Professional Association for Transgender Health (WPATH) recently published the 8th edition of their Standards of Care, notably removing their minimum age recommendations for minors to receive medical interventions, their guidance on ethics, and adding a chapter on “eunuchs” that has alarmed medical professionals.

“WPATH is an explicitly ideological organization that now includes ‘eunuch’ as a valid ‘gender identity’ that children can supposedly know they have at a very early age,” Sapir said.

Their guidance for adolescents seeking hormones are based largely on a single study from the Netherlands, often referred to as the “Dutch study,” and related, the Dutch protocol. Aside from its “biased methodology” and “unimpressive results,” which have been the subject of widespread criticism, it does not apply to the vast majority of teenagers in the West seeking hormonal interventions today.

The Dutch study and its “protocol” selects candidates who must fulfill certain criteria to be eligible. Data shows the majority of youth seeking hormonal interventions in recent years are adolescent girls with no prior history of dysphoria and very high rates of mental health comorbidities, that would automatically disqualify them from the Dutch protocol, rendering the WPATH’s application of it practically worthless.

Additional studies cited by the WPATH “all suffer from methodological shortcomings, most commonly lack of adequate controls for confounding factors like psychotherapy and very short follow-up times,” said Sapir.

None of these U.S.-based organizations have done systematic reviews of the evidence, while arguably more progressive European countries like Sweden, Finland, and England have. After reviewing the evidence for the use of puberty blockers and cross-sex hormones in treating pediatric gender dysphoria, health authorities in all three countries have decided to abandon the “gender-affirming” model, finding the costs outweigh the benefits.

“The main purpose of systematic reviews is to prevent cherry-picking of studies to produce desirable conclusions,” said Sapir. “Neither the AAP, nor the ES, nor WPATH have conducted systematic reviews of the research. Indeed, in its latest Standards of Care