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  • Leor Sapir | WSJ Opinion

Second Thoughts on ‘Gender-Affirming Care’

The American Academy of Pediatrics orders a scientific review. Will it be conducted honestly?

Leor Sapir | WSJ Opinion | August 6, 2023

The American Academy of Pediatrics said last week that it will commission a systematic review of the evidence for pediatric sex-trait modification, known euphemistically as “gender-affirming care.” This marks a turning point in the battle over the controversial medical protocol. To those who favor evidence-based rather than eminence-based medicine, it is a step in the right direction.

But it is a small step. Two key questions: Will the systematic review follow a transparent, impartial scientific process? And what should the AAP do in the meantime?

In explaining the decision to commission a systematic review, the AAP’s CEO, Mark Del Monte, said that the academy’s board “has confidence that the existing evidence is such that the current policy is appropriate. At the same time, the board recognized that additional detail would be helpful here.”

If the AAP’s position is that it is “confident” the systematic review will vindicate its position and merely add “additional detail,” that raises suspicions about the honesty and independence of the process and shows the need for strong guardrails against AAP influence over the inquiry.

The AAP is, first and foremost, a trade union. “Professional medical association” is a less apt description than “association of medical professionals.” Teachers unions care about education but give their own and their members’ interests priority over those of students. So too the AAP has strong incentives to defend its own interests and those of member doctors—especially those who have publicly endorsed or facilitated sex-trait modification—even when that is harmful to patients.

The AAP and prominent members have consistently assured policy makers and judges that sex-trait modification is safe and effective and based on strong science. Insurance companies have based their coverage decisions on these claims. Democrats have used them to cast opponents as bigots. The Biden administration regularly cites the AAP in its efforts to guarantee minors unfettered access to hormonal drugs and life-altering surgery. Parents have accepted AAP claims and agreed to allow doctors to disrupt their children’s natural puberty, flood their bodies with synthetic hormones, and amputate their healthy breasts.

Should we therefore expect AAP leadership to be genuinely curious about the findings of a systematic review? Should we trust that the AAP won’t try to influence the outcome by tinkering with the process?

Unlike narrative literature reviews, systematic reviews follow a transparent, reproducible methodology on the same body of research. Anyone who uses the same methodology should arrive at more or less the same result. The existing systematic reviews on the benefits and risks of puberty blockers and cross-sex hormones, conducted by health authorities in three European countries, all found “very low” quality evidence for these interventions.

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. This is a no-brainer; health authorities in the U.K., Norway, Sweden, Finland and France have done it. “There is not enough evidence to support the safety, clinical effectiveness and cost effectiveness to make the treatment routinely available at this time,” said the statement from England’s National Health Service.

Systematic reviews can take six to 18 months to complete. Because the AAP apparently recognizes the superiority of systematic reviews, it should defer, while the review process is under way, to the systematic reviews conducted by the U.K. National Institute for Health Care Excellence in 2020 and updated last week. A slew of new systematic reviews touching on a wide range of topics related to pediatric gender medicine is expected to come out in the U.K. well before the AAP systematic review is completed. When they do, the AAP should embrace their findings.

Last August the AAP president said that her organization’s policy was based on “the best science.” But if systematic reviews are the appropriate way to evaluate the evidence, and if every systematic review to date has found that the evidence is exceptionally weak, how can the AAP continue to maintain that its current approach is evidence-based? Mr. Del Monte was evasive on this point. The Europeans, he said, “engaged in their process, we’re engaging in our process.”

In a press release, the AAP has promised a “policy update process” that is “transparent and inclusive.” The AAP “will invite members and other stakeholders to share input.” Will those members include the pediatricians who have demanded that a systematic review be done? Will it include researchers who have found evidence of socially influenced transgender identity? Will “other stakeholders” include “detransitioners,” who were inappropriately prescribed drugs and surgery when they should have received only mental-health support? Will it include parents of children who thought they were transgender and wanted drugs and surgeries, but changed their minds and now feel better?

The organization’s consistent attempts to suppress debate on this sensitive issue, the recent remarks of its chief executive, and its profound conflict of interest as a trade association don’t inspire confidence that it will act scientifically and in the best interests of children and families.

Mr. Del Monte and the AAP can rest assured that the group’s actions will be carefully watched over the months ahead. If the AAP wants to regain the public’s trust, it must allow for a truly transparent and inclusive process, not one that involves only those who agree with its existing position. Above all, the AAP must commit itself to follow the science, wherever it leads.

Mr. Sapir is a fellow at the Manhattan Institute.

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