Second opinion

The American Academy of Pediatrics reckons it got gender medicine right the first time, but buckles to pressure for a fresh review of the evidence

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UPDATED August 7 | The American Academy of Pediatrics (AAP) should include sceptics of the gender-affirming treatment approach as it updates treatment advice for gender dysphoria, according to paediatrician Dr. Julia Mason.

On August 3, The New York Times reported that the AAP had re-endorsed its 2018 affirmative-only position statement on dysphoria, but also decided to commission a systematic review, which is the gold standard for weighing the evidence for medical interventions. The 2018 policy was not preceded by a systematic review.

Dr. Mason, part of a small group of paediatricians which had been urging reform upon a seemingly resistant AAP over the last few years, welcomed the academy’s decision to order a systematic review, “as this is the best way to determine what treatments are truly helpful for our patients.”

However, she told GCN there was “a breakdown in trust in the AAP leadership” and noted the academy’s statement that it would ensure a transparent and inclusive policy update by inviting “members and other stakeholders to share input.”

Dr. Mason, a co-founder of the Society for Evidence-Based Gender Medicine (SEGM), suggested the academy invite some of the 23 AAP-Fellow paediatricians who co-authored her April 1 resolution #37 urging the leadership to align AAP treatment advice with the results of a systematic review.

That resolution says “the first and most fundamental principle of evidence-based medicine is that optimal clinical decision-making should be based on a systematic review of evidence”, which uses an up-front method to screen studies for bias or design shortcomings and prevents “cherry-picking” from the literature.

“Shockingly, a recently published National Institutes of Health study conducted by four of the most prominent gender clinics in the U.S. reported two suicides within the first year of gender-affirming hormone treatment of the 315 minors, which appears to be over 50 times higher than the rate of suicide in the general U.S. adolescent population. No study to date has reliably demonstrated reductions in completed suicides or serious suicide attempts post-transition. Thus, gender affirmation and medical transition are not an evidence-based method of medical transition”—Resolution #37, Dr. Julia Mason with 23 AAP Fellows as co-authors, 1 April 2023

Making the grade

GCN asked McMaster University’s Professor Gordon Guyatt, a pioneer of evidence-based medicine and the GRADE system for rating the quality of evidence, what signs might reassure sceptics that the AAP leaders intend the review to be rigorous and independent.

In reply, Prof. Guyatt posed three questions—

“Do they commission a credible independent group to do the review?

“At the protocol stage [when the method for the review is set out], do they make the protocol available for public scrutiny?

“Does the protocol specify that they will rate the certainty/quality of the evidence using the [widely adopted] GRADE approach?”

The AAP’s systematic review would be conducted by an external organisation, The Wall Street Journal reported. “The exact scope of the review has yet to be determined, but is expected to include an evaluation of medical interventions such as puberty blockers and hormones”, the Journal said.

Since 2019, systematic reviews in Finland, Sweden, England and the American state of Florida have found the evidence base for medicalised gender change with minors to be weak and uncertain. In each jurisdiction, the result has been more cautious policy restricting access to puberty blocker drugs and synthetic cross-sex hormones.

The AAP should use the findings of these international systematic reviews to carry out a timely, interim update of its 2018 policy, according to SEGM.

In a statement, SEGM said a proper systematic review commissioned by the AAP might take a year or longer, plus at least several months for the policy update process itself.

“In the meantime, tens of thousands of youth [in North America] will continue to be treated according to AAP’s [2018] non-evidence-based recommendations, exposing them to potentially non-beneficial or even harmful interventions,” said SEGM, which included with its statement a guide to systematic review.

The group Do No Harm, which campaigns against politicised medicine, said it would “closely monitor this [AAP review] to ensure it is robust and expansive in nature, unbiased, and thorough.”

“Given the finding of every existing systematic review to date that the evidence for ‘gender-affirming care’ is exceptionally weak, the AAP should immediately recommend extreme caution in the use of puberty blockers, cross-sex hormones and surgeries in treating youth gender dysphoria”—Leor Sapir, WSJ, 6 August 2023

The AAP’s 2018 position statement—“Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents”—did not begin with a systematic review and has been heavily criticised for its handling of the scientific literature on youth gender dysphoria.

In an unrebutted 2019 “fact-check”, clinical psychologist and researcher Dr. James M. Cantor argued that the AAP’s policy preference for medicalised gender-affirming care over the non-invasive watchful-waiting approach involved “a systematic exclusion and misrepresentation of entire literatures.”

In an August 4 AAP news article, chief executive officer Mark Del Monte said the academy’s leadership was “confident the principles presented in the original [2018] policy… remain in the best interest of children.”

All 16 AAP board members voted to reaffirm the 2018 policy at last week’s leadership conference in Itasca, Illinois, although Mr Del Monte said, “At the same time, the board recognized that additional detail [from a systematic review] would be helpful here.”

The AAP attributed its decision to seek a systematic review not to concern about the rigour of the 2018 policy but to “the board’s concerns about restrictions to access to health care with bans on gender-affirming care in more than 20 [American] states.”

Amid political tribalism, the Democratic Biden Administration cites the activist-tinged policies of medical societies such as the AAP to promote gender-affirming treatment, while Republican states invoke the results of European systematic reviews when seeking to restrict paediatric transition. Longstanding Democratic voters who oppose the medicalisation of gender non-conforming youth declare themselves “politically homeless”.

There has been criticism of the AAP board’s decision to reassert its policy giving gender-affirming care monopoly status before results come in from a proper systematic review.

This was “very clearly putting the cart before the horse,” Prof. Guyatt told the Times.

On Twitter, Dr. Cantor shared news of the AAP update with the comment, “Call me old fashioned, but I think doctors should review the research *before* passing policies about it.”