August 26, 2022 - 11:28am

The American Academy of Pediatrics has a gender problem. But it really doesn’t want to talk about it. And it doesn’t want its 67,000 members to talk about it eitherThe Academy, the top professional organisation for paediatricians in the United States, has gone all in on “gender-affirming care” in recent years, publishing “evidence-based” guidance on pubertal suppression (which the Academy describes as “reversible”), cross-sex hormones, and “gender-affirming surgeries”. It has condemned alternative perspectives and approaches as bigoted, harmful, and futile. 

There were good reasons to question this approach back when it became official policy in 2018. There’s even more cause for concern now, with dissidents within the field raising concerns about affirmative care and calling for a systematic review of the evidence. Rather than listen, however, the AAP has bent and broken its own rules in order to enforce the party line. So much for “evidence-based”. 

But the Academy may not be able to contain the issue for much longer, as frustrated critics have started to take their concerns public. Last week, the controversy broke out on the editorial pages of the Wall Street Journal, where paediatrician Julia Mason and researcher Leor Sapir charged the AAP with “ignor[ing] the evidence that has led Sweden, Finland and most recently the U.K. to place severe restrictions on medical transition for minors” and with “stifl[ing] debate on how best to treat youth in distress over their bodies”.

Academy President Moira Szilagyi responded that the AAP takes an open, “developmentally appropriate” approach to gender-questioning children that “allows questions and concerns to be raised in a supportive environment.” “This is what it means to ‘affirm’ a child or teen,” Szilagyi insists: “it means destigmatising gender variance and promoting a child’s self-worth. Gender-affirming care can be lifesaving. It doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.” On Twitter, the Academy’s social media team went further: gender affirmation “has never been about pushing medicines or surgery. Medicines or surgery are options that may be considered by families and their care team on a case-by-case basis, but are not the goal of gender-affirming care, contrary to how critics have often mischaracterized the AAP’s recommendations.” 

There may be compelling strategic reasons to take the AAP at its word when it insists that gender-affirming care recommends “the opposite” of drugs and surgery. Doing so might require them to explain why so many American paediatricians, inspired by AAP guidelines, are rushing gender-distressed youth into social and medical transition. But Szilagyi’s defensive statement doesn’t mark a “reversal”, as Mason and Sapir claim in a follow-up letter. Rather, it’s just the latest move by affirming advocates to shut down debate by pretending there’s nothing to talk about. Drugs and surgery are “not the goal of gender-affirming care”, the Academy insists. But of course drugs and surgery aren’t the goal. The goal is to “affirm” a child’s gender-variant identity. Drugs and surgery are just the means by which this identity can be affirmed. 

The playbook is familiar by now. Advocates for a more cautious, exploratory approach want to talk about specifics: what is the relationship between social transition and medical interventions? How does the AAP square its condemnation of “watchful waiting” with Szilagyi’s call for “developmentally appropriate care that is oriented toward understanding and appreciating the youth’s gender experience”? Rather than answering these questions, proponents of affirmative care retreat behind abstractions like “promoting a child’s self-worth”.

What the AAP can’t and won’t engage with is the possibility that their recommendations around gender-affirming care aren’t neutral, that affirmation may solidify a child’s sense that they really are in the wrong body, and that the cascade of interventions that often follow a youthful self-declaration amount to an unregulated medical experiment on underage patients, with unknown consequences for cognitive, psychosocial, physical, and sexual development. When professional associations like the AAP dismiss good-faith critics as “anti-transgender activists” and bend or break their own rules to prevent open dialogues from taking shape, entire fields can lose their way and harm in the name of healing. 

Eliza Mondegreen is a graduate student in psychiatry and the author of Writing Behavior on Substack.