The 92-year-old American Academy of Pediatrics (AAP) has 67,000 members, comprising primary-care pediatricians and physician specialists. Its policy positions, spanning topics from digital advertising that targets children to gun violence, carry considerable weight. In recent years, however, at least one of these positions has proven internally controversial, with some AAP members questioning the group’s strident advocacy of treating trans-identified children with a “gender-affirmative care model” (GACM).
According to the AAP, this means a model of care “oriented toward understanding and appreciating the youth’s gender experience.” But as a growing number of concerned clinicians, parents, trans “desisters,” and litigants have pointed out, what GACM usually signals is a reflexive, rubber-stamp approach to claims of gender distress from troubled children. As a result, a growing number of AAP members are asking difficult questions of the group’s leadership.
Back in 2018, when the AAP published its policy statement, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, few group members might have felt empowered to question it. During the late 2010s, gender activists were largely successful in advancing the narrative that an affirmation-based model was best for children; and that closely scrutinizing such an approach indicated transphobic attitudes that could put trans children at risk of depression and even suicide. But the tide has turned somewhat in recent years, with countries such as Sweden, Finland, France, and the UK stepping back from the gender-affirmative care model.
In July, Gender Identity Development Services—the world’s largest gender-identity clinic for children, located at the Tavistock Institute in London—was ordered to close, following an independent review that concluded its program of heavily medicalising child patients threatened their safety. Since then, a UK law firm has announced that hundreds of families are expected to join a class-action law suit against the Tavistock, as they allege their vulnerable youngsters were “misdiagnosed and placed on a damaging medical pathway.” The Tavistock is accused of “multiple failures in its duty of care”—including allegations that its doctors “recklessly prescribed puberty blockers with harmful side effects” and took an “unquestioning” approach to children who claimed to be transgender.
And yet even as the tide is turning in other countries, AAP President Moira Szilagyi recently reaffirmed the AAP’s 2018-era policy, and crowed that a group of critics within the AAP couldn’t effectively challenge the policy successfully at the AAP’s recent Leadership Conference. (In fact, this failure appears to be due in part to procedural rule changes intended to insulate Dr. Szilagyi and her allies from challenges—more on this below.) And so the AAP continues to endorse an affirmation model whereby “social transition” begins in kindergarten or grade one, with five-year olds being encouraged to inform adults of their preferred name and pronouns, and to seek entry into bathrooms corresponding to the opposite sex. Children aged between eight and 12 can be given puberty blockers and, following this, in their teen years, cross-sex hormones, followed by possible surgical procedures that alter their appearance, sex characteristics, and reproductive system. The age of consent for cross-sex hormones and surgeries varies depending on the state, but children as young as 13 are sometimes able to get their breasts removed. These steps often lead to the patient becoming permanently sterile and unable to achieve orgasm.
The belief that children should be aggressively rushed into such life-altering interventions is starkly at odds with the more conservative and holistic “watchful waiting” approach that leading therapists had been successfully using for years before “affirmation” became fashionable. Under the watchful waiting approach, clinicians will allow time to pass before they recommend medical intervention or therapy. During this interval, the child is observed and monitored. This protocol reflects research that suggests a clear majority of trans-identified children will desist from seeking medical transition, so long as they don’t receive interventions that push them along a transgender path.
An added complication is caused by the fact that a majority of gender-distressed children grow up to be lesbian, gay, or bisexual. If these children receive puberty suppressants, then their sexual development is blocked, which also may prevent them from gaining an understanding of their sexual orientation.
The precepts of gender-affirmative care—set out a decade ago by the World Professional Association for Transgender Health (WPATH), a loose network of professionals, clinicians, and trans people who advocate on matters related to transgender healthcare—generally discourage professionals from thoroughly questioning a child and his or her family about the possible sources of his or her self-identified transgender identity. These sources can include childhood trauma, autism, obsessive compulsive disorder, and depression. Indeed, “affirmed” patients often are encouraged to believe that their ancillary problems are mere artifacts of the discrimination and non-acceptance they endure from others, as well as the psychic ache caused by living in “the wrong body.”
It is now common for advocates of rapid “affirmation” to speak of trans identity as a sort of immutable soul-like state. According to the 2018 AAP policy statement (which the AAP admits to having been entirely conceptualized and drafted by a single author—Brown University Clinical Assistant Professor of Pediatrics Jason Rafferty), “children who are prepubertal and assert an identity of TGD [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender [i.e., not trans] and benefit from the same level of social acceptance.” Dr. Kerry McGregor, gender affirmative psychologist from the Gender Multispeciality Service in Boston Children’s Hospital, tells us that “a good portion of children do know [that they’re transgender] as early as seemingly from the womb.” Dr. Diane Ehrensaft, a clinical psychologist and leading advocate for the gender affirmative model of care, tells us that infants between the age of one and two years old can communicate about their gender.
According to Dr. Ehrensaft, a baby girl tearing barrettes out of her hair repeatedly is supposedly sending a “gender message” about her true identity as a trans boy. In 2012, Dr. Ehrensaft described a wide range of evolving categories, such as “gender taureses” (one gender on top, another on the bottom); “gender priuses” (a child who is, for example, 60 percent girl and 40 percent boy); “gender oreos,”whereby the child presents as one gender on the outside, but feels like another on the inside; and “gender smoothies,” whereby “they metaphorically take everything about gender, throw it in the blender, and press the ‘on’ button, creating a fusion of gender that is a mix of male, female, and other.” Children who first come out as gay and later identify as transgender, on the other hand, are labelled by Dr. Ehrensaft as “prototransgender.”
This kind of mystical understanding of gender may seem strange and esoteric. Yet Dr. Ehrensaft’s work was cited repeatedly in the 2018 AAP policy statement. And so it is worth asking how this kind of dubious advocacy and scholarship ended up informing the guidelines promoted by such an influential and prestigious group of medical professionals.
The AAP has a well-organised system by which geographical chapters, committees, and even solitary members can put forward resolutions that are voted on by the general membership. While these votes are non-binding, they can have a major impact on leadership decisions. Leaked information (some of which is described below) indicates that among the AAP rank and file there’s a mix of both pediatricians who are keen to support childhood medical transition, along with others who are concerned that “affirmation”-based care overemphasizes medication while discounting the value of psychotherapy.
In light of new evidence that raises fresh concerns with the gender-affirmative model, some AAP pediatricians have put forward resolutions asking the body to reconsider its stance. These include Resolution #33 from the AAP Annual Leadership Forum in 2021, which highlighted the low quality of medical evidence supporting treatment of trans-identified minors with hormones and surgeries. That resolution reportedly ranked fourth in affirmative votes from among almost 60 resolutions brought forward last year, with more than 80 percent of voting members apparently expressing support for the resolution.
While the AAP’s leadership has tried to present its members as unified, or nearly unified, in their embrace of the gender-affirmative approach, the truth is that different schools of thought have emerged in recent years. One of these is the so-called gender-exploratory approach, used by therapists who seek to promote a more holistic view of the individual. Many of these therapists have come together through the Gender Exploratory Therapy Association (GETA), of which I am a co-founder. We seek to provide families with access to therapists who offer a process that doesn’t push transition on people who are exploring their gender identity or struggling with their biological sex.
The main accusation levelled against GETA members—and, in fact, against anyone who doesn’t subscribe to the gender-affirmative model—is that they are somehow seeking to inflict “conversion therapy” upon trans-identified children. That term, when properly used, refers to the discredited practice by which gay men and women have been subject to quack therapies (or, in some cases, torture) branded as “cures” for gay desire. Thankfully, such barbarous practices were largely abandoned decades ago, and are now shunned and reviled by mainstream therapists. However, the term “conversion therapy” remains in policy parlance because it has been co-opted by activists seeking to tar anyone who expresses scepticism of a purely affirmation-based approach to gender. Broadly speaking, the claim is that a refusal to reflexively “affirm” a child’s beliefs about his or her gender identity is morally tantamount to a religious charlatan who claims he can turn a gay child straight through, say, electroshock therapy.
At best, this misuse of the term “conversion therapy” is ignorant; at worst, it’s a deliberate propaganda trick intended to defame therapists such as myself. Gender-exploratory therapists do indeed “affirm” the existence of individuals’ feelings and beliefs, as well as their wish to live as authentic beings. What we do not do is confirm these beliefs as based on fact, which is what the affirmation model effectively would require.
Therapists hold a position of responsibility, and it is typically not a therapist’s role to confirm any beliefs or emotions pertaining to the client. A therapist who confirms a client’s belief risks exerting undue influence on the client at a time when he or she is in an emotionally vulnerable state. It usually makes more sense for the therapist to hold neutral therapeutic space, so that the client can more easily assess his or her beliefs independently.
In applying this approach, many gender-exploratory therapists are interested in helping individuals explore how their unconscious motivations and past experiences might impact their relationship with their bodies, and with whatever sense of femininity or masculinity they might feel they have or don’t have. These therapists may also believe it is important to help an individual explore any unconscious homophobia the client might have; as sometimes a masculine girl who is attracted to girls could believe that she should be a boy rather than navigating her sexual orientation and accepting that she is a butch lesbian. As in many other therapeutic contexts, the primary focus in this kind of therapy is often to help build self-awareness and develop insight.
It isn’t just therapists who’ve felt the need to create new professional alliances in order to help families manage gender distress in a climate free of rigid, ideologically motivated prescriptions. Genspect, an organisation I founded in 2021, is an international alliance of professional groups, parents, trans people, and detransitioners in 18 countries, many of whom favour a body-affirmative approach over a gender-affirmative approach. The Society for Evidence-based Gender Medicine (SEGM), an international group of over 100 clinicians and researchers, has a similar mandate. The Gender Dysphoria Alliance focuses on people who detransition, regret their transition, or desist from it. Other groups in the field include 4thWaveNow and Canadian Gender Report (also known as GCCan), whose president, Grace Lidinsky-Smith, shared her story with Newsweek readers in 2021:
In my early 20s, I became depressed and gender dysphoric after years of obsessing over identity issues. Finally, I thought I saw my route forward: the total transformation of medical transition, to live as a man. I had the most supportive possible environment for transitioning: easy access to hormones, an affirming community and insurance coverage. What I didn't have was a therapist who could help me scrutinize the underlying issues I had before I undertook serious medical decisions. Instead, I was diagnosed with gender dysphoria and given the green light to start transition by my doctor on the first visit. I started my transformation with cross-sex hormones injections. Four months later, I had my breasts removed in the masculinizing surgical procedure known as "top surgery." The day I got my first testosterone shot, I wept with joy. I thought I had discovered my path to self-actualization as a transgender man. One year later, I would be curled in my bed, clutching my double-mastectomy scars and sobbing with regret.
In Europe, there is an even richer network of free-thinking specialists and groups that reject an affirmation-based model. These include the Clinical Advisory Network on Sex and Gender, Sex Matters, Transgender Trend, Thoughtful Therapists, Evidence-based Social Workers, Fair Play for Women, Standing for Women, and The Countess; as well as parent groups such as Bayswater Support Group, Gender Dysphoria Support Network, Our Duty, AMQG, La Petite Sirène, Amanda, and countless others around the world. All of these organizations took shape because their members felt that established groups such as the AAP were prioritizing a pre-scripted dogma instead of the needs of real gender-distressed human beings.
Back in 2018, AAP leaders might have been seen as credible when they declared, through their policy statement, that there’s a medical consensus to the effect that affirmation is the only ethical response to gender dysphoric youth. But this position is no longer tenable. In truth, it was no longer tenable even back in 2019, when the AAP refused to engage with a peer-reviewed critique offered by University of Toronto professor James Cantor, Director of the Toronto Sexuality Centre. His article, Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy, demonstrated that many of the claims made by Dr. Rafferty in his 2018 AAP policy statement were completely at odds with the information contained in the sources he’d cited.
Within the AAP itself, dissent is now more openly expressed. In an August 10th post on the AAP web site, the group’s president, Moira Szilagyi, claimed that an anti-affirmation resolution raised at this year’s leadership conference had been stymied because its supporters hadn’t been able to meet the requirements of “standard parliamentary procedures.” But those AAP “procedures” had been altered this year in a way that limited members’ abilities to comment on “unsponsored” resolutions such as this one—i.e., resolutions advanced by individuals, not AAP chapters. And many AAP members suspect that the clear purpose of this procedural manoeuvre was to prevent the formal recording of a 2022 resolution—Resolution #27—requesting a systematic review of the available evidence with a view toward updating the 2018 AAP policy statement.
Earlier this month, the plot thickened, when a newspaper reported on internal AAP documents indicating a rising tide of anger and resentment among the group’s rank-and-file. As it turns out, discussion of Resolution #27 has been fierce and widespread within both informal AAP communication channels and formal committees. Indeed, the AAP apparently will be going ahead with a process of reviewing the available evidence (which would presumably include the recent UK Independent Review of Gender Identity Services for Children and Young People, which found no convincing evidence that the benefit of hormones outweigh the associated risks for those newly emergent cohorts of gender dysphoric teenagers who often have co-morbid challenges such as ASD, ADHD, and anxiety disorders). But to date, this process has been cloaked in secrecy, and some insiders have already accused the AAP of preordaining an analysis that will re-confirm the 2018-era position.
However, AAP leaders may find that kind of manoeuvre impossible if more rank-and-file members become involved in the process. Fewer than 0.2 percent of AAP members typically engage with any resolution, and so a small number of clinicians have effectively been shaping the lives of many North American children. A 2021 AAP news release explained that the aforementioned Resolution #33, asking clinicians to consider alternatives to the medical approach to gender dysphoria, had been rejected because “only 57 out of 67,000 members supported it.” Yet this year, when a pro-medical-transition resolution was endorsed with the support of only 53 members, these 53 votes were described by the AAP as indicating “broad support.”
It’s no surprise that some AAP members now tell journalists that, as one recently put it, they “no longer trust the AAP.” Remember that when a similar climate of distrust emerged within the Gender Identity Development Service at Tavistock, such complaints were initially dismissed as mere grumblings from non-affirming gender heretics. Then came the recently conducted Cass Review, which vindicated the whistle-blowers, and resulted in the Tavistock being shut down completely. If the AAP keeps trying to suppress dissent, while insisting on a false consensus that never existed in the first place, its leadership may find themselves discredited and dismissed in similar fashion.
This is a companion discussion topic for the original entry at https://quillette.com/2022/08/23/challenge-to-affirmation-based-gender-dogma-at-american-academy-pediatrics/