On ‘Gender’ the AAP Has Chosen Ideology Over Science

The AAP no longer views itself as a professional organization of physicians and gatekeeper of medical knowledge, but as an agent of radical social reform.

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The American Academy of Pediatrics (AAP) has come under intense scrutiny of late after members and scholars exposed the organization’s politicized inner workings and the lack of standards at its flagship journal, Pediatrics. AAP leadership must also be feeling the heat as European countries begin to restrict the use of hormones to treat teenagers in distress over their bodies and as families in the U.K. look to sue the Tavistock clinic for fast-tracking their children to cross-sex hormones.

On Wednesday, AAP president Dr. Moira Szilagyi published a press release explaining why her organization has thus far been unwilling to conduct a thorough “systematic review” of the evidence for “gender-affirming care”—a gold standard review methodology which assesses the entire body of the evidence instead of cherry-picking individual studies that are often deeply flawed and unreliable. A systematic review hasn’t been necessary, Szilagyi told pediatrician members frustrated with the organization’s lack of transparency on this issue, because critics of the AAP’s current stance are operating from the false assumption that “gender-affirming care” involves “pushing medical or surgical treatments on youth.” What it really means, Szilagyi insists, is “the opposite: a holistic, collaborative, compassionate approach to care with no end goal or agenda.”

Szilagyi’s statement is disingenuous. The AAP has in fact endorsed the meaning of “affirmative care” imputed to it by critics but is now seemingly trying to walk back that endorsement by burying it under mushy therapeutic jargon (“holistic, collaborative, compassionate approach”). By doing so, the organization is sowing yet more confusion at a time when precise language and bold leadership are badly needed. The AAP has a responsibility to tell its member physicians and the families that rely on them that the only ethical approach to managing gender-related distress in minors is one that prioritizes counseling and resorts to medical interventions only in the most extreme situations, if at all (whether and under what conditions minors should be able to consent to puberty blockers is subject to debate).

Szilagyi’s claim that “care” has no defined “end goal or agenda” echoes a central theme in the 2018 Pediatrics article in which the AAP advertised its novel approach to pediatric gender medicine. But as you’ll see, that claim, when properly understood, is itself evidence for “pushing medical or surgical treatments on youth.” Unfortunately, this is a nuance that most media outlets and policymakers, especially those sympathetic to “gender affirming care,” are likely to miss.

The 2018 article, whose lead author was Dr. Jason Rafferty, had one central purpose: to equate a clinical approach known as “watchful waiting” with “conversion therapy,” a reference to the discredited practice of trying to get gays and lesbians to “convert” to heterosexuality. As Dr. James Cantor demonstrated in his thorough fact-checking of Rafferty’s article shortly after it came out, there is no evidence to support this equation and much to discredit it. I won’t rehearse the arguments here because any reader who is even remotely interested in this topic should really read the Rafferty article and then Cantor’s devastating point-by-point rebuttal. That Rafferty’s article could survive the peer-review process at a high-impact journal like Pediatrics is a damning statement on the condition of peer-review in medical research. Sadly, it is also indicative of a broader corruption of medicine through infiltration, especially at medical schools and professional organizations, of woke ideology.

By equating watchful waiting and conversion therapy, Rafferty effectively rejects the Dutch protocol. The authors of that protocol recognized that because the vast majority of children with “gender identity disorder” desist from the condition around puberty, it is best to avoid medical or even social transition (use of a child’s preferred name and pronouns) until it is clear that the child’s dysphoria persists into adolescence. According to Rafferty, however, once children begin to clearly and consistently express a “gender identity” other than that which matches their sex, they can be assumed to “know,” and should thus be “affirmed” in, their claimed gender. The only adolescents the Dutch thought were eligible for hormonal interventions were those whose dysphoria began prior to and persisted into puberty. They had little to say about adolescents whose dysphoria occurred for the first time after the onset of puberty; such presentations were rare and were not usually considered eligible for medical interventions. But today, reports from gender clinics around the world reveal that they represent the majority of minors declaring themselves trans and seeking medical transition.

Rafferty gives three reasons for rejecting watchful waiting. First, “watchful waiting is based on binary notions of gender in which gender diversity and fluidity is pathologized.” Second, watchful waiting presupposes that “notions of gender identity become fixed at a certain age.” Third, the studies that show high rates of desistence are flawed, while newer studies demonstrate that, “rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience.”

Regarding the first reason, it is hard to know what exactly Rafferty has in mind here, as the terms he uses are slippery. Is a 5-year-old boy who claims he is girl because he feels more comfortable playing with girls and likes stereotypically feminine toys being “gender diverse”? Wouldn’t “gender diversity” actually require acknowledging that, no, boys can play with girls and with “girl” toys and still be boys? And what does “gender fluidity” even mean? If it means a boy identifying as a girl and then again as a boy—one obvious interpretation of “fluid”—then that is in fact what happens in most cases and why the Dutch experts recommended watchful waiting. The fact that Rafferty resorts to such abstractions and cliches where precision and clarity are required is a first clue that what Rafferty is doing is not exactly “science.”

A look at Rafferty’s sources sheds light on the meaning of his argument. He provides two citations for his claim that the desistence literature is flawed. Neither, however, refutes or even weakens that literature. One of the studies Rafferty cites is by Diane Ehrensaft, the controversial Bay Area child psychologist who has made such baseless claims as that gender transition can “cure” autism. In the study in question, Ehrensaft claims that earlier research on desistence failed to take into account that gender in children is “an evolutionary process in which there may be several iterations throughout development.” Because these studies coded only male and female as gender options, they apparently failed to capture the degree of “fluidity” children express when trying out or moving between these categories. The important thing, Ehrensaft says here and in her other writings, is that children as young as three know their “true gender self” and it is up to us, the adults, to learn from them. Because watchful waiting regards childhood expressions of incongruent gender as only presumptively true, Ehrensaft says that approach should be avoided, and that clinicians and parents should instead to follow the children’s lead, always deferring to their avowed gender.

Ehrensaft bases her rejection of the desistence literature in part on a 2013 study by Thomas Steensma and colleagues on the factors associated with gender dysphoria desistence/persistence in childhood. In that article Steensma et al indeed write that “Childhood social transitions were important predictors of persistence, especially among natal boys.” But they emphasize that social transitions “have never been independently studied regarding the possible impact of the social transition itself on cognitive representation of gender identity or persistence.” In other words, it is not clear whether the intensity and persistence of GD is a cause or a consequence of social transition.

While adults may believe that they are merely giving emotional support to a child’s inner authentic voice, they might actually be locking in what would otherwise prove to be a transitory stage of identity consolidation. Experts have since urged caution when using social transition due to its iatrogenic effects (i.e. the condition being caused by its treatment) and called for more research. Steensma himself would later say that American gender-affirmers are “blindly adopting” the pediatric gender transition model he and his Dutch colleagues developed several years earlier.

In short, Rafferty ignores the consistent findings of 11 studies about desistance and, as revealed through an archeological dig through his sources, provides no serious evidence to support his preference for “affirmation” in childhood. His equation of “watchful waiting” with “conversion therapy,” as James Cantor notes, is premised entirely on studies done on homosexuality. Worse, some of the sources Rafferty cites in support of affirmation explicitly endorse “watchful waiting.”  

Earlier this year, Kristina Olson published a study in Pediatrics finding that 94 percent young children who received “support” for their transgender self-identification (i.e., social transition) persisted in their trans identification five years later. To advocates of “gender affirming care,” this came as good news. It underscored that “transgender children” exist and deserve to be supported in their “authentic” identity. To the more critical reader, however, it was further confirmation of social transition’s iatrogenic risks. “Affirm” a child with his preferred name and pronouns and you greatly increase the chance that an otherwise temporary phase will congeal into an “identity,” sending the child on a path toward hormones and surgeries. Virtually all children who are socially affirmed persist in their identity, and many resort to puberty blockers. Virtually all who use puberty blockers continue to cross-sex hormones.

The key to unlocking Rafferty’s full position, and to understanding why the AAP has put its thumb on the scale in favor of medicalization, lies in his assumptions about human nature. Watchful waiting is inappropriate, Rafferty suggests, because it contains an implicit preference for a “cisgender” over a transgender outcome in clinical treatment of youth with gender-related distress. This preference stems from and in turn fortifies the belief that transgenderism is a pathological condition, an abnormality of human development, whereas alignment of sex and “gender identity” is the natural and normal human condition. For Rafferty and the AAP, “variations in gender identity and expression are normal aspects of human diversity.”

Rafferty gives no reason why we should regard transgenderism as a “normal aspect of human diversity.” He merely asserts it. Perhaps he believes in what is known as the “social model” of mental illness, which assumes that “illness” is not an inherent trait of persons but rather a result of the interaction between some atypical human trait and bad social arrangements. Often accompanying the social model is the belief that a person’s internal sense of gender can never be wrong provided it is sincere. As Rafferty puts it, “research substantiates that children who are prepubertal and assert an identity of [transgender or gender-diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance.‍”

Rafferty’s only citation for this claim is another article published by Kristina Olson. But all Olson shows in that article is that young children who exhibit cross-gender desires and behaviors are no less sincere in their ideas about gender as members of the opposite sex. Olson rules out that the children are “confused” about their gender. She conceptualizes confusion, however, not as failure to grasp objective reality (the usual sense of the word), but as inconsistency in one’s gender self-assessment as measured by preferences for playing with opposite-sex peers and their gender-“appropriate” toys. Further, Olson and her colleagues told the children—ages 5 to 12—“that people have outsides (their physical body) and insides (their feelings, thoughts, and mind). They were told that some people feel like they are boys on the outside, and some feel like they are girls on the outside, and that those people might feel the same way or different on the inside.” In other words, the researchers implanted into the children’s minds the idea that their (stereotype-based) gendered feelings were indicative of a real and fully autonomous inner self existing independently of their body.

Rafferty’s argument only works, then, if we allow the simplistic equation of “sincerity” with “knowledge.” Something is true because I feel it intensely and express it sincerely over time. This mode of thinking is thoroughly postmodernist, though it is not hard to envision why it has gained such a strong foothold in a country indebted to its Protestant origins. As the language of “affirming” and the taken-at-face-value professions of sentio ergo sum reveal, the contemporary gender movement is essentially sentimentalized Protestantism without a transcendent God.

What Rafferty never does is give us any reason why gender represents a unique case of child gnosis. For him as for other proponents of the “affirming” approach, an asserted gender that is different from the child’s sex is not just sincere but “authentic,” meaning somehow a mark of courage, even of precocious maturity. In The Gender Creative Child, Diane Ehrensaft calls young children who reject the sex they were “assigned at birth” the “leaders” of a “revolution.” In normal circumstances precisely the sincerity and tenacity of an inaccurate belief about reality would count as evidence of mental pathology. Here, however, it has come to count against pathology as a sign of health. Because what makes one “cisgender,” according to the new philosophical anthropology, is the fact that one “conforms” to the sex one was “assigned at birth,” it follows, for those who value “authenticity,” that non-transgender people are in fact defective, having failed to live up to their full humanity.  

I am frequently asked whether I think America’s liberal elites and policymakers really buy in to this theory of human nature and society, a theory that owes as much to queer theory and its anti-normativity posture as to the therapeutic turn in Western culture. My response is essentially the same as that given by Lionel Trilling in Sincerity and Authenticity when he writes: “it is characteristic of the intellectual life of our culture that it fosters a form of assent which does not involve actual credence.”

If these deeper assumptions indeed guide Rafferty’s thinking, the logical conclusion would be that mental and physical health for transgender people requires what one scholar-activist has called “the reconstruction of American society’s beliefs, assumptions, and norms associated with the binary sex/gender system.” The role of the physician, accordingly, is not to treat the individual patient but to change society in a way that—it is assumed—will prevent individuals from becoming patients in the first place. Whether a particular patient in fact turns out not to have needed the gender transition fades into the background, and aggressive promotion of “gender diversity” emerges as medicine’s chief goal.

Once these assumptions are granted, no principled obstacle remains to “gender affirming” medical interventions for minors. If an internally felt “identity” is the true locus of human dignity and autonomy, with the body being a mere vehicle piloted by the feeling self, then intervening in the processes of physical development on behalf of that self poses no serious ethical quandary. Indeed, failure to intervene would mean doing harm. The only thing that can legitimately stand between a young child’s desire for social or medical transition is a spontaneous change in the child’s own desires.

To be fair to Rafferty, glimmerings of this new ethical framework and its underlying metaphysics can already be found in the Dutch model. In a 2008 article explaining the paradigm shift, Peggy Cohen-Kettenis, Henriette Delemarre-van de Waal, and Louis Gooren pointed out that the principle of “do no harm” has traditionally been interpreted in light of another longstanding principle of medical ethics: in dubio abstine (in the face of doubt, abstain from acting). But if non-action means letting puberty take its natural course to the detriment of a person’s subjective psychological wellbeing, the Dutch authors wrote, then non-action means doing harm. The World Professional Association for Transgender Health’s seventh Standards of Care later summarized the new outlook in its remark that “Neither puberty suppression nor allowing puberty to occur is a neutral act.”

The AAP’s position, as discernable through the Rafferty statement, has been that any preference for achieving mind-body alignment in clinical treatment is in principle wrong, as it assumes that misalignment is pathological and inherently less preferable than alignment. Then as now, this position rests on a set of ideological, not scientific, propositions, chief among them that the body and its natural processes have no weight in determining standards of health and wellbeing and that the goal of medicine is helping the deep self achieve “authenticity.”

Medicine—not merely psychology but all branches of medicine—no longer means restoring the body to its natural functioning and helping the individual come to terms with reality. For the genderists, it has come to mean producing subjective satisfaction defined as fulfilling the patient’s present desires. This new understanding of “health” explains how Boston Children’s Hospital’s Dr. Frances Grimstad, a pediatrician who recently recorded a video message advertising “gender affirming hysterectomies” to teenage girls, is able to describe herself on Twitter, without a hint of irony, as a “trans reproductive health advocate.”

The AAP has come to see its role as an agent of radical social reform, not a professional organization of physicians and a gatekeeper of medical knowledge. Despite Moira Szilagyi’s complaint that AAP’s critics “mischaracterize it as pushing medical or surgical treatments on youth,” that is precisely what her organization has done. The reason, to put it simply, is that it has allowed a postmodern politics of identity to infiltrate and shape its scientific and medical judgment. Since 2018, and perhaps earlier, the AAP has embraced an ontology of the human person that cannot justify any obstacle, other than the child’s own desire, to the use of hormones and surgeries to achieve “authentic” selfhood. Considering the problem of iatrogenesis in social transition, moreover, the AAP cannot meaningfully claim that it was supporting “affirmation” but not medicalization.

Ultimately, AAP leadership will have to make a choice. Is the desire to reject one’s body as an alien imposition a natural and healthy expression of human diversity that turns patients into entitled customers of their doctors? Or is it an unfortunate condition that requires compassionate and reality-grounded care? If the latter, Moira Szilagyi should communicate clearly to AAP members that its previous approach was wrong, and that the only appropriate course of treatment for minors with gender issues is to start by doing all we can to help them learn to accept and feel comfortable in their bodies.

Organizations to Support

• Sex Matters

• Parents Defending Education

• Transgender Trend

• Genspect

• Foundation for Individual Rights and Expression (FIRE)

• Women’s Liberation Front (WoLF)

• LGB Alliance

• Fair Play for Women

• Society for Evidence-Based Gender Medicine

• Counterweight

• The Free Speech Union

• Heterodox Academy