November 23, 2023 - 3:20pm

For years, the American Academy of Pediatrics (AAP) has attempted to suppress internal dissent on the issue of child gender transition by any means necessary, bending and breaking its own rules in the process.  

This summer, the Academy board voted to reaffirm its controversial 2018 policy statement endorsing puberty blockers, cross-sex hormones and surgeries for gender-distressed kids. It also promised to conduct a systematic review of the evidence — something the AAP had evidently not found necessary before endorsing gender-affirming care in the first place. At the time, I observed that this is how organisations start to walk back from a medical scandal: “Quietly, slowly — ideally so quietly and so slowly that no one notices they’ve retreated from shaky to solid ground at all.”

But it turns out I was too hasty. Rather than waiting for the systematic review of the evidence, the Academy has announced it will be issuing “practical guidance” on gender-affirming care for kids early next year. 

The new guidance is a rare bright spot for co-author Jason Rafferty, a paediatrician and child psychiatrist who has weathered a stormy autumn that saw him sued by two former patients. Rafferty was also featured in an unflattering piece in the Boston Globe, in which he described his approach to gender-affirming care as “affirming and validating the child’s sense of identity from day one through to the end”. Reporter Jennifer Block spells out what that means in practice: 

Rafferty told me patients who live with harms or regrets do not signal a failure of the affirmative care model. If a child or patient doesn’t like the effects of an intervention, or begins to feel different in their identity, then the provider continues to affirm by discontinuing treatment. ‘They’re not treatment failures if that’s what’s affirming,’ he said. 
- Jennifer Block

In other words, the solution to gender-affirming care gone wrong is more affirmation, more hormones, more surgeries.

Critics and young people who’ve come to see being affirmed in their transgender identity as a form of medical harm beg to differ. Just last month, FAIR in Medicine smuggled dissent into the heart of the Academy’s annual conference, renting a booth in the exhibition hall to bring paediatricians face-to-face with detransitioners. While some paediatricians were eager to learn more, others were furious to be confronted with the underside of gender-affirming care, “refus[ing] to look at any materials, responding with ‘I already know all that, I already know.’ They were sure they knew what we had to say, sure they’d been fully informed, sure that anyone who wanted to talk was a bigot and a transphobe and nothing more.” 

Rafferty and the American Academy of Pediatrics have fallen into what Megan McCardle termed “the Oedipus trap”. This holds that “there are some mistakes no one can live with, no matter how innocently they were made […] If you have made such a mistake, it is obviously better not to know you have done so.” 

Confronted with evidence of medical harm, regret, and detransition, organisations such the American Academy of Pediatrics and clinicians such as Dr. Rafferty have two options: plug their ears, cover their eyes, and charge straight ahead — or look at the evidence and consider changing course. In other words: fall into the trap, or dare to climb out.

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