Advocacy over science: How youth gender medicine overran our institutions

The American Academy of Pediatrics (AAP) annual convention is an opportunity for pediatricians to network, exchange ideas and learn. Unfortunately, when it comes to youth gender medicine, misinformation was on the 2024 conference agenda. As a keynote speaker, the AAP chose U.S. Department of Health and Human Services Assistant Secretary for Health Rachel Levine, the highest-ranking transgender official in the Biden administration.

Levine’s invitation should cause concern to American families who want to know that the nation’s largest pediatrician group values evidence-based medicine. Levine has supported a misinformation campaign that has turned the U.S. into an international outlier in the use of the “gender-affirming” model of care, which recommends hormones and surgeries rather than psychotherapy as the first-line treatment for adolescent distress around puberty. 

Emails recently unsealed in a lawsuit revealed that in 2022, Levine pressured the World Association for Transgender Health to remove age minimums for gender surgeries from its “standards of care.”

Since 2017, a Manhattan Institute analysis of health insurance claims has shown, that more than 5,000 teenage girls had their breasts amputated as part of a “gender-affirming” procedure designed to help them achieve a male look. This includes 50 to 179 girls who were 12-and-a-half years old or younger at the time of surgery.  

These figures represent an undercount, as they do not include procedures performed at large health care systems like Kaiser Permanente (which is currently being sued by two young women who underwent “top surgery”). Yet these surgeries do not seem to pose a problem for those like Levine who believe the theory that “trans kids know who they are.”  

Levine’s invitation ought to also be a concern to AAP members who worry that homophobia and regressive sex stereotypes are a large component of what underlies “gender affirming” treatments. Incredibly, children who do not fit sex stereotypes and same-sex attracted adolescents are now given the idea they are “trans” and encouraged to perceive hormones and surgeries as a solution to the substantial difficulties that society imposes on gender non-conforming young people. It is unwise to promote this speculative narrative, since neither data nor logic supports the concept of a “trans child.”

What we need is open, respectful, and fact-based public dialogue regarding these issues. Unfortunately, that will not occur at the AAP’s primary peer-reviewed journal, Pediatrics. This formerly high-quality journal has been used to cheerlead for the “gender-affirming care” scheme rather than to provide a forum for rigorous scholarly debate. This distortion of science conveniently helps insulate the AAP from criticism and is a prime example of how ideological activism, even if well-meaning, destroys trust in medicine.   

Until recently, these large numbers of gender dysphoric teens would have been unheard of. I was in medicine for two decades without encountering a single trans-identified youth. Youth with other types of body-related distress were common, but only in the last decade did any substantial number claim they had been born in the wrong body and request hormones and surgeries to become their “authentic selves.”

What has occurred to cause young people so much distress with their biological sex? How did they come to believe so strongly in irreversible treatments with scant supporting evidence? 

Rather being humble and accurate about what we know and don’t know regarding how to approach these young people, those within AAP have condemned anyone who advocates for a cautious, evidence-based approach as “anti-trans.” They even attempted to have their conference moved out of Florida due to erroneous and self-aggrandizing perception that “hate” is why so many across the world recommend against these treatments.

Levine’s invitation to be keynote was not the only dubious milestone for the AAP this year. The AAP also promised to conduct a systematic review of the evidence for so-called “gender-affirming care” over 13 months ago. There is no indication that the review has begun.

Systematic reviews, the gold standard in medical evidence analysis, are the reason a growing number of countries now classify puberty blockers and cross-sex hormones as “an experimental practice” and impose restrictions on their use. The AAP has refused to answer questions from journalists on the matter and excluded voices urging caution from its convention.

AAP is now under investigation by state attorneys general and, along with the author of its 2018 policy statement on “gender-affirming care,” is a named defendant in a lawsuit by a young woman who says she suffered irreparable harm because of the APP’s fraudulent recommendations.

In his book, “Blind Spots, When Medicine Gets It Wrong, and What It Means for Our Health,” Marty Makary reveals many examples of the harms of medical hubris and groupthink. One is the AAP’s reckless 2000 guidelines on peanut avoidance. Without supporting evidence, the AAP put its institutional credibility behind untested theories. When parents followed the AAP’s bad advice to avoid giving infants and young children peanuts, there was an increase in the number and severity of peanut allergies. The U.S. now leads the world in peanut allergies, which are almost unheard of in much of the world. 

The AAP quietly reversed this foolishness in 2017 but failed to learn from the episode. In 2018, it concocted its even more harmful and less evidence-based statement promoting gender-affirming care. The statement, written by a single physician with minimal clinical experience, has been thoroughly debunked and was rated unfit for use by a recent systematic review of guideline quality. The Cass Review, the most comprehensive review of youth gender medicine to date, found the AAP recommendations to be among the world’s worst.

Most embarrassing for AAP, in June, private emails unsealed as part of a lawsuit showed that even the discredited leadership at World Association for Transgender Health had said the AAP recommendations have “a very weak methodology, [and were] written by [a] few friends who think the same.” 

As a psychiatrist, I have seen firsthand how “gender-affirming” treatment approaches cause harm to vulnerable youth. Gender=affirming care is well-intended activism posing as medical treatment. It has torn families apart and eroded public trust in our medical system.

Contrary to the slogans, these treatments are not lifesaving. The AAP’s decision to invite Levine as keynote speaker and its continued lack of transparency regarding the evidence for its recommendations signal that the AAP continues to prioritize misguided advocacy over science.  

Kristopher Kaliebe is a psychiatrist and expert on youth gender medicine and professor in the Psychiatry Department at the University of South Florida.