In response to a Wall Street Journal op-ed that I co-authored criticizing the American Academy of Pediatrics’ approach to pediatric gender medicine, Moira Szilagyi, president of the AAP, has written that “gender-affirming care . . . doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.”
This is a welcome development, and marks a reversal of the AAP’s previous policy. That policy was announced in a 2018 Pediatrics article, whose lead author was Jason Rafferty; it argued that “watchful waiting” is akin to “conversion therapy” and should be avoided. “Watchful waiting” refers to an approach that emphasizes psychotherapy as a measure of first (and hopefully last) resort to help minors in distress feel comfortable in their bodies. Its premise, confirmed by 11 studies, is that the vast majority of children with gender dysphoria will desist by adolescence and feel comfortable enough in their bodies not to require medical transition. The Dutch researchers who developed pediatric transition explicitly warned against early transition. Yet transgender activists in the United States have criticized this model, insisting that because transgender identity (i.e., body rejection) is a normal and healthy aspect of human existence, mental health professionals should never steer patients toward a “cisgender” outcome.
If Szilagyi believes that medicalization is the wrong way to go “for the vast majority of children” with gender dysphoria, then this constitutes a de-facto repudiation of the Rafferty statement and the AAP’s previous policy. That Szilagyi is disinclined to make this reversal explicit is unfortunate, and further evidence that the AAP has not fully shaken loose of its capture by activists. But it should not deter medical practitioners from using, and parents of gender-dysphoric minors from seeking, an approach that relies on intensive talk therapy and resorts to hormones only in extreme situations, if ever.
Crucially, the AAP’s new position also raises serious concerns about the Biden administration’s proposed Title IX rules. If implemented, these would put enormous pressure on schools to defer uncritically to their students’ self-identification, often without parental knowledge or approval. Researchers and clinicians working in the area of pediatric gender medicine have observed that “social transition”—using a child’s preferred name and pronouns—carries serious risks of iatrogenesis, meaning an intervention that is itself the cause of illness. When a school treats a child as his or her stated identity, that school, whether intentionally or not, may be locking in a state of temporary distress or confusion and helping it congeal into an “identity.” Such a child faces much higher chances of going down the medical path. If Szilagyi is right, then the Biden administration’s proposed rules are a step in the wrong direction—with potentially devastating consequences.
Absent a centralized medical authority as one finds in European welfare states, the American medical profession is prone to rely on guidance from professional organizations like the AAP. Policymakers have done the same, often betraying ignorance of the gap between what these groups say and what the research actually shows. Because medical organizations have proven themselves vulnerable to capture by ideological elements who do not necessarily represent the majority of practitioners in the field, even a soft pronouncement like the one from Szilagyi this weekend should be treated as a victory for science, medical ethics, and child welfare.
Photo by Anna Moneymaker/Getty Images